Rate of hepatocellular carcinoma surveillance remains low for a large, real-life cohort of patients with hepatitis C cirrhosis
Sally Ann Tran1, An Le1, Changqing Zhao2, Joseph Hoang1, Lee Ann Yasukawa3, Susan Weber3,
Linda Henry1, Mindie H Nguyen1
Sally Ann Tran1, An Le1, Changqing Zhao2, Joseph Hoang1, Lee Ann Yasukawa3, Susan Weber3,
Linda Henry1, Mindie H Nguyen1
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Abstract
Background In patients with chronic hepatitis C (CHC) cirrhosis, imaging for hepatocellular carcinoma (HCC) is recommended every 6 months to maximise eligibility for curative treatment. The aim was to determine the adherence rate and outcomes among patients with CHC cirrhosis and whether the adherence rate has improved over time.
Methods
Background In patients with chronic hepatitis C (CHC) cirrhosis, imaging for hepatocellular carcinoma (HCC) is recommended every 6 months to maximise eligibility for curative treatment. The aim was to determine the adherence rate and outcomes among patients with CHC cirrhosis and whether the adherence rate has improved over time.
Methods
Retrospective cohort study of patients with CHC cirrhosis (n=2366) monitored for ≥1 year at Stanford University Medical Center between January 2001 and August 2015.
Results
Results
Overall demographics: mean age 54; 62.3% men; 48.3% Caucasian. 24.4% adherent to imaging every 6 months per European Association for the Study of the Liver 2000 and American Association for the Study of Liver Diseases (AASLD) 2011 criteria and 44% at least every 12 months per AASLD 2005 criteria. No significant change in adherence before and after 2011. Predictors of multivariable analysis of adherence were age >54 (OR 1.74, p<0.0001), Asian ethnicity (OR 2.23, p<0.0001), liver decompensation (OR 2.40, p<0.0001) and having ≥2 clinical visits per year (OR 1.33, p=0.01). During follow-up, 9.6% were diagnosed with HCC. Adherent patients were more likely to have smaller tumours (2.3 vs 3.3 cm, p=0.0020), be within the Milan criteria for liver transplants (73.2% vs 54.8%, p=0.006) and receive curative HCC treatment (43.6% vs 24.0%, p=0.005). On multivariable analysis, curative treatment (HR 0.32, p=0.001) and every 6-month imaging (HR 0.34, p=0.005), but not every 6–12 month imaging, were associated with reduced risk of mortality.
Conclusions
Conclusions
Adherence to HCC surveillance continues to be poor. Adherent patients with HCC were more likely to undergo curative treatment and have better survival. Research understanding barriers to surveillance is needed.
Summary box
What is already known about this subject?
Major liver disease societies recommend surveillance for hepatocellular carcinoma (HCC) in high-risk groups to maximise eligibility for curative treatment.
The American Association for the Study of Liver Diseases (AASLD) 2011 and European Association for the Study of the Liver (EASL) 2000 guidelines recommend HCC surveillance every 6 months.
The AASLD 2005 guideline recommends surveillance every 12 months.
What are the new findings?
In a large, real-life cohort of patients with chronic hepatitis C cirrhosis, only 24% underwent HCC surveillance every 6 months and only 44% had surveillance at least every 12 months.
Adherence rates remained poor over the 16 years of the study: the every 6 month surveillance rate was 20.5% before 2011 and 21.6% after 2011 (p=0.21).
The 5-year cumulative survival was 54.7% for the adherent (every 6-month imaging) group, compared with 6.5% for the non-adherent group (p<0.00001). Although every 6-month imaging reduced mortality by 66%, every 6–12 month imaging did not.
Besides age >54, Asian ethnicity and decompensation, more frequent clinic visits was associated with a 33% increase in every 6-month imaging.
How might it impact on clinical practice in the foreseeable future?
Further research to understand barriers to surveillance is needed, but our study suggests that just one additional clinic visit per year increases the likelihood of undergoing surveillance.
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