Hepatocellular carcinoma surveillance may be associated with potential psychological harms in patients with cirrhosis

Abstract

Background and Aims: The value of HCC surveillance is determined by the balance between benefits and harms; however, no studies have enumerated psychological harms. Approach and Results: We fielded surveys measuring psychological harms to patients with cirrhosis in a multicenter randomized trial of HCC surveillance outreach. All patients with positive or indeterminate surveillance results and matched patients with negative results were invited to complete surveys measuring (1) depression through the Patient Health Questionnaire-ninth version, (2) anxiety through State-Trait Anxiety Inventory, (3) HCC-specific worry through Psychological Consequences Questionnaire, and (4) decisional regret. Patients were classified into 4 groups: true positive (TP), false positive (FP), indeterminate, and true negative (TN). Multivariable longitudinal regression analysis using the generalized estimating equation method was performed to compare the means of measures across groups. We conducted 89 semistructured interviews in a subset of patients stratified by health system and test results. Of 2872 patients in the trial, 311 completed 1+ follow-up survey (63 FP, 77 indeterminate, 38 TP, and 133 TN). Moderate depression decreased in TN patients, increased in TP, and had intermittent but mild increases in those with FP and indeterminate results. High anxiety temporarily increased in patients with TP results but resolved over time and was stable in those with FP and indeterminate results. Decisional regret was low and did not differ across groups. In semistructured interviews, patients reported apprehension, anxiety, emotional distress, and coping related to HCC surveillance. Conclusions: Psychological harms of HCC surveillance appear mild but differ by test result. Future research should determine the impact of psychological harms on the value of HCC surveillance programs.

AASLD Practice Guidance on prevention, diagnosis, and treatment of hepatocellular carcinoma

“…To date, few data exist on surveillance harms, including few data quantifying psychological or financial harms. [62,63] Available data suggest HCC surveillance harms that are due to false positives and indeterminate tests occur in ∼10% of patients with cirrhosis and most harms are mild in severity. [56] Therefore, the benefit of HCC surveillance appears to outweigh potential harms.…”

“…The overall value of HCC surveillance programs must balance surveillance benefits against potential physical, financial, and psychological harms (Figure 4). To date, few data exist on surveillance harms, including few data quantifying psychological or financial harms 62,63 . Available data suggest HCC surveillance harms that are due to false positives and indeterminate tests occur in ∼10% of patients with cirrhosis and most harms are mild in severity 56 .…”

Proportion of Time Covered by Hepatocellular Carcinoma Surveillance in Patients With Cirrhosis

“…First, the study is subject to ascertainment bias for imaging not performed at our health systems; however, this was minimized by review of outside clinical records as available. Second, our study did not assess overdiagnosis or screening-related harms, which are informative when assessing the overall value of surveillance programs (40–43). Although risk of overdiagnosis in HCC may be small given its high incidence-to-mortality ratio, this can still occur in patients with high competing risk of mortality such as those with Child-Pugh C cirrhosis.…”

Hepatocellular Carcinoma Screening in a Contemporary Cohort of At-Risk Patients

“…Understanding the true benefit of HCC screening is important for determining its overall value, considering potential physical, financial, and psychological harms. 12 , 13 Delayed evaluation of the risk-to-benefit ratio has led to controversies in other cancer screening programs, including prostate cancer, colorectal cancer in older individuals, and breast cancer in younger women. Here, we aimed to characterize the benefits of HCC screening after considering lead-time and length-time biases in a contemporary cohort of patients.…”