Suboptimal Surveillance for and Knowledge of Hepatocellular Carcinoma Among Primary Care Providers

Abstract

Background & Aims A large proportion of patients with cirrhosis are seen only by their primary care provider (PCP). Surveillance for hepatocellular carcinoma (HCC) therefore depends on PCPs in these cases. We aimed to assess PCP knowledge and practice of HCC surveillance. Methods We contacted a random sample of 1000 North Carolina PCPs by mail. All received an introductory letter, followed by a 12-item questionnaire addressing HCC surveillance knowledge and practice. Results Three hundred ninety-one PCPs (39%) completed the survey; 89% saw patients with cirrhosis in their practice, but only 45% screened for HCC. Among PCPs who screened, the most common methods were ultrasound analysis and measurement of [α] fetoprotein (66%). Reasons for surveillance included supported by evidence (72%), recommended by medical societies (42%), and malpractice liability for not surveilling (26%). Of PCPs who did not screen, 84% referred to gastroenterologists for surveillance decisions, 24% were unaware of recommendations, 8% were uncertain of the benefits, and 8% were concerned over cost. Hepatic resection and liver transplantation were identified as effective therapies by 67% and 56% of PCPs, but all other effective therapies were identified by less than half (transarterial chemoembolization by 42%, radiofrequency ablation by 35%, sorafenib by 26%). Ability to identify at least 1 effective therapy was independently associated with surveillance (odds ratio, 2.1; 95% confidence interval, 1.1−4.0) Conclusions Most PCPs see patients with cirrhosis, but only a minority screen for HCC. PCP knowledge of effective HCC therapy options is suboptimal. Efforts to enlist PCPs in HCC surveillance may be best served by increasing their knowledge of effective therapies.

Identifying barriers to hepatocellular carcinoma surveillance in a national sample of patients with cirrhosis

“…We found lower surveillance rates for black patients and patients with nonalcoholic hepatitis, alcohol‐induced liver disease, and cryptogenic cirrhosis . Further work is needed to determine whether lower surveillance rates in these populations are related to physician biases versus patient adherence . Because of the need for detailed medical record review for HCC stage, we only had stage data on a small subset of patients; and the data suggested that a similar percentage of patients were within Milan criteria at HCC diagnosis based on the PTUDS category.…”

“…Operationally, long‐term HCC surveillance is a multistep process that requires clinician recognition of cirrhosis, clinician awareness of guidelines, test ordering, and patient adherence with test completion (http://onlinelibrary.wiley.com/doi/10.1002/hep.28765/suppinfo). There are data to suggest that initial diagnosis of cirrhosis and subsequent triggering of surveillance by primary care is suboptimal, likely related to poor knowledge of and adherence to surveillance guidelines . Yet even among gastroenterologists/hepatologists aware of AASLD and EASL guidelines in the United States and Europe, surveillance rates remain low .…”

Provider, Patient, and Practice Factors Shape Hepatitis B Prevention and Management by Primary Care Providers

“…The limitations of the study include use of provider self-report and survey response rates of 40%, though this response rate is comparable to other previously reported provider survey studies. 13, 20, 21 Provider self-report tends to overestimate adherence to quality of care guidelines. 22 However, the suboptimal rates of HBV screening, HBV vaccination, and HCC surveillance observed in this study suggest that many providers candidly acknowledged that they did not consistently implement screening and management practices for all appropriate patients.…”

Hepatocellular Carcinoma From Epidemiology to Prevention: Translating Knowledge into Practice

“…8 First, providers must be knowledgeable about HCC risk factors and the target patient population for whom prevention and/or surveillance is recommended. 9 Second, providers must accurately identify patients with cirrhosis and refer eligible patients for primary prevention or HCC surveillance. Third, the healthcare system must have sufficient capacity to schedule and deliver surveillance tests; patients must comply with provider recommendations.…”