Hepatocellular carcinoma surveillance suboptimal in cirrhosis patients
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Recommended surveillance for hepatocellular carcinoma is too low in patients with cirrhosis, especially those treated by internists or family doctors, according to a new study.
Risk for hepatocellular carcinoma (HCC) is elevated in patients with cirrhosis, and most cases are diagnosed at an advanced stage. Guidelines from consensus conferences and professional organizations have called for regular surveillance for HCC in cirrhosis patients.
Researchers performed a population-based cohort study using data from Medicare patients in the Surveillance, Epidemiology, and End Results (SEER) Registry to determine the use of HCC surveillance in this group. Patients were categorized as receiving regular surveillance (annual alpha-fetaprotein [AFP] test or ultrasound during at least two of the three years before HCC diagnosis), inconsistent surveillance (at least one AFP test or ultrasound for surveillance during the three years before HCC diagnosis) or no surveillance. Results will appear in the July Hepatology.
Overall, study authors identified 1,873 HCC patients with a previous diagnosis of cirrhosis. Mean age at diagnosis of HCC was 74.9 years, 65.7% of patients were men, and 81.8% were white. In the three years before HCC was diagnosed, 17% of patients underwent regular surveillance, 38% received inconsistent surveillance and 45% received no surveillance. Among a subset of 541 patients who had received a cirrhosis diagnosis at least three years before their HCC diagnosis, 29% got routine surveillance, 33% got inconsistent surveillance and 38% got no surveillance. Approximately 52% of patients who received regular surveillance had both AFP tests and ultrasound, while 46% received only an AFP test and 2% received only ultrasound.
Regular surveillance was associated with living in an urban area and having a higher income. Patients seen by a gastroenterologist/hepatologist or by a physician with an academic affiliation were 4.5-fold and 2.8-fold more likely to receive regular surveillance, respectively, than those who were seen by an internist or a family practitioner only.
The authors acknowledged that surveillance tests could have been misclassified and that tests could have been ordered but not performed, among other limitations. They also pointed out that rates of surveillance may be improving, because the study used data from 1994 to 2002 while the two most important guidelines on HCC management were released in 2001 and 2005. Nevertheless, they concluded that rates of recommended HCC surveillance are low in patients with established cirrhosis, and that physician specialty and practice type are strongly associated with surveillance.
“Future studies are needed to evaluate the knowledge, attitudes, and barriers for HCC surveillance and to develop appropriate, targeted interventions to increase the dissemination of this practice,” they wrote.