Study finds poor compliance with cirrhosis surveillance recommendations

A study conducted by researchers at the Baylor College of Medicine found that fewer than 20% of patients with hepatocellular carcinoma (HCC) preceded by cirrhosis were monitored for the development of cancer. Full findings of this study are published in the July issue of Hepatology, a journal of the American Association for the Study of Liver Diseases (AASLD).

According to the National Cancer Institute, HCC is the fourth most common cancer in the world. In the U.S., 22,620 new cases of HCC were diagnosed and 18,160 deaths due to this disease occurred in 2009. Most patients with HCC are diagnosed at an advanced stage of disease when survival is poor, but if patients are diagnosed early, survival rates improve considerably. The AASLD recommend HCC surveillance in patients with cirrhosis who are at high risk of developing HCC. However, population-based studies in the U.S. indicate that only 11% of patients with HCC are diagnosed early enough to receive potentially curative treatments.

Given the escalating incidence of HCC-related deaths, the extent of HCC surveillance in clinical practice is unclear. The study team evaluated HCC surveillance in 1,873 patients diagnosed with HCC who had a prior diagnosis of cirrhosis during 1994-2002 using data obtained from the linked Surveillance, Epidemiology, and End-Results (SEER) -Medicare claims. Several potential determinants of HCC surveillance, including patient, clinical, and physician factors were also examined. The mean age at HCC diagnosis was 74.9 years and most patients were male (65.7%). The largest proportion of patients was white, followed by Hispanic, Asian, and black. Approximately 37% had a recorded diagnosis of cirrhosis for more than 2-years prior to their HCC diagnosis. The mean number of physician visits within the 3-years prior to HCC was 67.9.

Patients were categorised into three mutually exclusive groups as receiving regular surveillance (had an annual serum alpha-fetoprotein (AFP) and/or ultrasound test, the most commonly used modalities for HCC surveillance, during at least 2 of the 3 years prior to HCC diagnosis), inconsistent surveillance (had one or more AFP or ultrasound tests for surveillance purposes during the 3 years prior to HCC diagnosis but did not meet the criteria for regular surveillance), or no surveillance. Among 541 patients diagnosed with cirrhosis 3 or more years prior to HCC diagnosis, only 29% received routine surveillance, 33% inconsistent surveillance, while 38% had no surveillance.

Patients who were younger, Asian, diagnosed during more recent years, living in zip codes with higher income or education or in urban areas were more likely to have received regular surveillance than other groups. Women were also more likely to receive regular surveillance.

There was a distinct association between surveillance and physician characteristics. Patients seen by a gastroenterologist or hepatologist only or in combination with an internal medicine or family practice physician were 2.8 and 4.5 times, respectively, more likely to receive regular surveillance than patients seen by an internal medicine or family practice physician only. Patients whose primary physician had an academic affiliation were over 3 times more likely to receive regular surveillance than patients seen by physicians in solo practice.

'Findings from this study suggest that recommendations to monitor cirrhosis patients who are at risk for HCC have not been well adopted into clinical practice. In this population-based study, fewer than 20% of HCC patients with previously recorded cirrhosis received the recommended regular surveillance,' concluded study leader Jessica Davila, Ph.D. '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.'