PALO ALTO, CA — Even though hepatocellular carcinoma (HCC) surveillance in associated with improved survival, screening of cirrhosis patients is suboptimal, especially in primary care settings, according to recent surveys.
A recent study in JAMA Network Open argued that surveillance for hepatocellular carcinoma (HCC) in patients with cirrhosis is underused. “Identifying potentially modifiable factors to address barriers in HCC surveillance is critical to improve patient outcomes,’ wrote the researchers led by Stanford University School of Medicine and the VA Palo Alto, CA, Healthcare System.1
The study team sought to evaluate clinician-level factors contributing to underuse of HCC surveillance in patients with cirrhosis. Included in a survey were primary care clinicians (PCCs) and gastroenterology and hepatology clinicians at five safety-net health systems in the United States.
The researchers surveyed clinicians from March 15 to September 15, 2023, to assess knowledge, attitudes, beliefs, perceived barriers, and COVID-19-related disruptions in HCC surveillance in patients with cirrhosis. Data were analyzed from October to November 2023.
The study team assessed HCC surveillance knowledge with 6 questions querying the respondent’s ability to correctly identify appropriate use of HCC surveillance. At the same time, a series of statements using a 4-point Likert scale compared PCCs and gastroenterology and hepatology clinicians as to their attitudes, perceived barriers, and beliefs regarding HCC surveillance and perceived impact of the COVID-19 pandemic-related disruptions.
The overall survey had a 25.5% response rate — 142 of 237 (59.9%) were PCCs, 48 of 237 (20.3%) gastroenterology and hepatology, 190 of 236 (80.5%) were doctors of medicine and doctors of osteopathic medicine, and 46 of 236 (19.5%) were advanced practice clinicians.
On HCC knowledge assessment, 144 of 270 (53.3%) scored 5 or more of 6 questions correctly, 37 of 48 (77.1%) among gastroenterology and hepatology vs 65 of 142 (45.8%) among PCCs (P < .001).
“Those with higher HCC knowledge scores were less likely to report barriers to HCC surveillance,” the researchers noted. “PCCs were more likely to report inadequate time to discuss HCC surveillance (37 of) and26.6%] vs 2 of 48 [4.2%]; P = .001), difficulty identifying patients with cirrhosis (82 of 141 [58.2%] vs 5 of 48 [10.4%]; P < .001), and were not up-to-date with HCC surveillance guidelines (87 of 139 [62.6%] vs 5 of 48 [10.4%]; P < .001) compared with gastroenterology and hepatology clinicians. While most acknowledged delays during the COVID-19 pandemic, 62 of 136 PCCs (45.6%) and 27 of 45 gastroenterology and hepatology clinicians (60.0%) reported that patients with cirrhosis could currently complete HCC surveillance without delays.”
The study team concluded that their responses showed “important gaps in knowledge and perceived barriers to HCC surveillance were identified. Effective delivery of HCC education to PCCs and health system-level interventions must be pursued in parallel to address the complex barriers affecting suboptimal HCC surveillance in patients with cirrhosis.”
An earlier study led by University of North Carolina Chapel Hill researchers sought to evaluate current hepatitis C virus (HCV) and HCC surveillance practices and physician attitudes regarding HCC risk-stratification among primary care and subspecialty providers. Researchers from the VA Puget Sound Healthcare System in Seattle participated in the study, which was reported in Digestive Diseases and Sciences.2
Using the Tailored Design Method, the study team conducted a 34-item online survey among 7,654 North Carolina-licensed internal/family medicine or gastroenterology/hepatology physicians and advanced practice providers in 2022.
Covered in the survey were the domains of HCV treatment, cirrhosis diagnosis, HCC surveillance practices, barriers to surveillance, and interest in risk-stratification tools.
After exclusions, 266 responses were included in the final sample (response rate 3.8%). Results indicated that most respondents (78%) diagnosed cirrhosis using imaging and a minority, about 15%, used non-invasive blood-based tests and 31% used transient elastography.
“Compared to primary care providers, subspecialists were more likely to perform HCC surveillance every 6-months (vs annual) (98% vs 35%, p < 0.0001),” the researchers pointed out. “Most respondents (80%) believed there were strong data to support HCC surveillance, but primary care providers did not know which liver disease patients needed surveillance. Most providers (> 70%) expressed interest in potential solutions to improve HCC risk-stratification.”
The authors concluded that, in the statewide survey, “there were great knowledge gaps in HCC surveillance among PCPs and most respondents expressed interest in strategies to increase appropriate HCC surveillance.”
- Wong RJ, Jones PD, Niu B, Therapondos G, Thamer M, Kshirsagar O, Zhang Y, Pinheiro P, Kyalwazi B, Fass R, Khalili M, Singal AG. Clinician-Level Knowledge and Barriers to Hepatocellular Carcinoma Surveillance. JAMA Netw Open. 2024 May 1;7(5):e2411076. doi: 10.1001/jamanetworkopen.2024.11076. PMID: 38743424; PMCID: PMC11094557.
- Moon AM, Swier RM, Lane LM, Barritt AS 4th, Sanoff HK, Olshan AF, Wheeler SB, Ioannou GN, Kim NJ, Hagan S, Vutien P, Benefield T, Henderson LM. Statewide Survey of Primary Care and Subspecialty Providers on Hepatocellular Carcinoma Risk-Stratification and Surveillance Practices. Dig Dis Sci. 2024 Apr 23. doi: 10.1007/s10620-024-08442-5. Epub ahead of print. PMID: 38652392.