Use of Surveillance for Hepatocellular Carcinoma Among Patients With Cirrhosis in the United States

Abstract

Background Surveillance for hepatocellular carcinoma (HCC) in patients with cirrhosis is recommended but may not be performed. The extent and determinants of HCC surveillance are unknown. Methods We conducted a population-based US cohort study of those over 65 years of age to examine utilization and determinants of pre-diagnosis surveillance in patients with HCC who were previously diagnosed with cirrhosis. Patients diagnosed with HCC during 1994-2002 were identified from the linked Surveillance, Epidemiology, and End-Results registry-Medicare databases. We identified alpha-fetoprotein and ultrasound tests performed for HCC surveillance, and examined factors associated with surveillance. Results We identified 1,873 HCC patients with a prior diagnosis of cirrhosis. In the 3 years before HCC, 17% received regular surveillance and 38% received inconsistent surveillance. In a subset of 541 patients in whom cirrhosis was recorded for 3 or more years prior to HCC, only 29% received routine surveillance and 33% inconsistent surveillance. Among all patients who received regular surveillance, approximately 52% received both alpha-fetoprotein and ultrasound, 46% received alpha-fetoprotein only, and 2% received ultrasound only. Patients receiving regular surveillance were more likely to have lived in urban areas and had higher incomes than those who did not receive surveillance. Before diagnosis, approximately 48% of patients were seen by a gastroenterologist/hepatologist or by a physician with an academic affiliation; they were approximately 4.5-fold and 2.8-fold, respectively, more likely to receive regular surveillance than those seen by a primary care physician only. Geographic variation in surveillance was observed and explained by patient and physician factors. Conclusions Less than 20% of patients with cirrhosis who developed HCC received regular surveillance. Gastroenterologists/hepatologists or physicians with an academic affiliation are more likely to perform surveillance.

Patient‐reported barriers are associated with lower hepatocellular carcinoma surveillance rates in patients with cirrhosis

“…(12,13) However, most studies evaluating HCC surveillance correlates have primarily focused on patient sociodemographic and clinical characteristics. (7,14) The effect of theory-based, patient-reported psychosocial factors on HCC surveillance completion has not been quantified. A better understanding of patient knowledge, attitudes, and barriers, particularly among low-income minorities, is crucial to develop and implement effective interventions to improve HCC surveillance rates.…”

Role of Surveillance in Prevention of Hepatocellular Carcinoma

“…Patients were approximately 4.5-fold and 2.8-fold, respectively, more likely to receive regular surveillance than those seen by a primary care physician only. 26 In a systemic review, surveillance rates were significantly higher among patients followed in subspecialty gastroenterology clinics compared to those followed in primary care clinics (51.7% vs. 16.9%, p < 0.001). 27 There has been a study conducted to understand failure rates in surveillance.…”

Worse Outcomes among African Americans with Liver Cancer: What Might Cause the Disparity?

“…Among a population of roughly 1,800 cirrhotic patients in the SEER database with an eventual diagnosis of HCC between 1994 and 2002, Davila, et al found that a smaller percentage of black patients received any screening as compared to white patients (40.8% versus 53.3%) [10]. "Any screening" in this case was defined as ever having an AFP level measured or an abdominal ultrasound.…”

“…Black patients with cirrhosis receive less surveillance for HCC than other racial groups particularly nonHispanic Caucasians [10]. Perhaps as a consequence, African Americans have more advanced tumor stage at diagnosis and receive definitive surgical treatment less often than other racial groups.…”