Hepatocellular Carcinoma Screening and Surveillance: Practice Guidelines and Real-Life Practice.

Chapter 2: Diagnosis and surveillance

Hepatocellular carcinoma surveillance: The road ahead.

HCC surveillance improves early detection, curative treatment receipt, and survival in patients with cirrhosis: A meta-analysis

International Liver Cancer Association (ILCA) White Paper on Biomarker Development for Hepatocellular Carcinoma

We assessed the impact of the COVID-19 pandemic on hepatocellular carcinoma (HCC) surveillance among individuals with HCV diagnosed with cirrhosis in British Columbia (BC), Canada. We used data from the British Columbia Hepatitis Testers Cohort (BC-HTC), including all individuals in the province tested for or diagnosed with HCV from 1 January 1990 to 31 December 2015, to assess HCC surveillance. To analyse the impact of the pandemic on HCC surveillance, we used pre-policy (January 2018 to February 2020) and post-policy (March to December 2020) periods. We conducted interrupted time series (ITS) analysis using a segmented linear regression model and included first-order autocorrelation terms. From January 2018 to December 2020, 6546 HCC screenings were performed among 3429 individuals with HCV and cirrhosis. The ITS model showed an immediate decrease in HCC screenings in March and April 2020, with an overall level change of -71 screenings [95% confidence interval (CI): -105.9, -18.9]. We observed a significant decrease in HCC surveillance among study participants, regardless of HCV treatment status and age group, with the sharpest decrease among untreated HCV patients. A recovery of HCC surveillance followed this decline, reflected in an increasing trend of 7.8 screenings (95% CI: 0.6, 13.5) per month during the post-policy period. There was no level or trend change in the number of individuals diagnosed with HCC. We observed a sharp decline in HCC surveillance among people living with HCV and cirrhosis in BC following the COVID-19 pandemic control measures. HCC screening returned to pre-pandemic levels by mid-2020.

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Hepatocellular carcinoma diagnosis and surveillance: Socioeconomic factors don’t seem to matter, unless you are an immigrant

Introduction: Hepatocellular carcinoma (HCC) surveillance detects early stage cancer, increases curative options and improves survival. Practice guidelines recommend HCC screening every 6 months in this population. Our previous study of adherence to HCC surveillance was not optimal. Our goal was to assess the improvement in adherence to HCC surveillance guidelines among patients with cirrhosis after implementation of QI measures. Methods: Previous study of adherence to HCC surveillance guidelines at Northwell Health Hepatology practice in 2016 (January 1st to December 31st) showed that routine surveillance every 6 months was 36%, and inconsistent surveillance was 60% (mean 10 ± 3 months). We retrospectively reviewed HCC surveillance among patients with cirrhosis after implementation of dedicated patient education and monthly reminder to health care providers. Patients with cirrhosis having visits between January 1st 2017 and March 1st 2018 were included in this follow-up study. Records were reviewed for demographics, liver disease, surveillance modality, interval and results. Prior HCC was excluded. Results: A total of 933 patients were included. Demographics and surveillance modalities are listed in table 1 and 2 respectively. Eighty six percent had routine surveillance every 6 months; 14% had inconsistent surveillance (range 8 to 12 months, mean 10 ± 2 months). Mean surveillance interval was 6 ± 2 months. Thirty six de novo HCC (3.9%) were detected, the majority had alcohol associated liver disease (56%). Eighty nine percent were single tumors (n=32), 11% multifocal (n=4), none were metastatic. All met Milan criteria for liver transplantation (OLT). Twenty (56%) were referred to OLT, 12 (33%) underwent resection and 4 (11%) radiofrequency ablation. Conclusion: Our study illustrates that implementation of QI measures improve HCC surveillance. In our population, 3.9% of patients with cirrhosis were detected with de novo HCC by routine surveillance. The majority were single tumors, early cancers and eligible for curative therapy, including resection and OLT. There was a marked improvement in adherence to standard HCC surveillance from previous study in 2016 of 36% to 86% following implementation of our QI measures. Our study shows that QI measures by patient education and physician reminders increase adherence to practice guidelines significantly and improve quality of patient care.922_A Figure 1. Patient Demographics and Characteristics.922_B Figure 2. Hepatocellular Carcinoma (HCC) Surveillance Modality.

Hepatocellular carcinoma screening is associated with survival benefit in silico but needs confirmation in an in vivo analysis.

To evaluate rates and predictors of retention into hepatocellular carcinoma (HCC) surveillance beyond initial screening among underserved cirrhosis patients. Although initial HCC screening among cirrhosis patients remains low, few studies have evaluated retention to HCC surveillance beyond initial screening. We retrospectively evaluated all consecutive adults with cirrhosis from 2014 to 2017 at a single underserved safety net hospital system to determine rates of HCC surveillance at 6 months and at 1 year beyond initial screening. Rates of HCC surveillance was stratified by sex, race/ethnicity, and etiology of liver disease. Multivariate Cox proportional hazards models evaluated predictors of retention into HCC surveillance. Among 235 cirrhosis patients [hepatitis C virus: 35.7%, hepatitis B virus (HBV): 15.7%, alcoholic cirrhosis: 36.2%, nonalcoholic steatohepatitis (NASH): 8.1%], mean age of cirrhosis diagnosis was 54.2±8.9 years. Overall, 74.8% received initial screening within 1 year of cirrhosis diagnosis. Among those who completed initial screening, 47.6% [95% confidence interval (CI), 41.4-54.2) received second surveillance within 1 year. On multivariate analyses, patients with NASH and HBV were significantly more likely to receive second HCC surveillance compared with hepatitis C virus, HBV (hazard ratio, 2.32; 95% CI, 1.18-4.56; P=0.014) and NASH (hazard ratio, 2.49; 95% CI, 1.22-5.11; P=0.012). No sex or race-specific/ethnicity-specific differences in HCC surveillance retention were observed. Although overall rates of initial HCC screening among cirrhosis patients is nearly 75%, retention into continued HCC surveillance is poor, with less than half of patients undergoing subsequent HCC surveillance. Cirrhosis patients with HBV and NASH were more likely to be retained into HCC surveillance.

Surveillance for Hepatocellular Carcinoma: Current Best Practice and Future Direction.

Neighborhood opportunity is associated with completion of hepatocellular carcinoma surveillance prior to the diagnosis of hepatocellular carcinoma in patients with cirrhosis

Hepatocellular Carcinoma: Still in Search of Evidence-Based Care

Disparities in receipt of hepatocellular carcinoma (HCC) surveillance contribute to disparities in overall survival outcomes. We aim to evaluate disparities in receipt of routine HCC surveillance among patients with cirrhosis in a large urban safety-net hospital. Consecutive adults (age≥18) with cirrhosis from July 1, 2014, to December 31, 2015, were retrospectively evaluated to determine rates of receiving appropriate HCC surveillance within 6months and 1year after diagnosis of cirrhosis. Rates of HCC surveillance were stratified by sex, race/ethnicity, and liver disease etiology. Multivariate Cox proportional hazards models were utilized to evaluate for predictors of receiving appropriate HCC surveillance. Among 157 cirrhosis patients enrolled [hepatitis C virus (HCV): 29.9%, hepatitis B virus: 13.4%, alcoholic cirrhosis: 44.6%, nonalcoholic steatohepatitis (NASH): 8.9%], mean age of cirrhosis diagnosis was 53.8±9.0years. Among these patients, 49% received (n=77) HCC surveillance within 6months and 78% (n=123) were surveyed within 1year of cirrhosis diagnosis. On multivariate analyses, patients with NASH cirrhosis were significantly less likely to receive HCC surveillance compared with chronic HCV cirrhosis patients (HR 0.44, 95% CI 0.19-0.99, p<0.05). No significant sex-specific or race/ethnicity-specific disparities in receipt of HCC surveillance were observed. Among a diverse safety-net hospital population, sub-optimal HCC surveillance rates were observed: Only 49% of cirrhosis patients received HCC surveillance within 6months, and 78% of cirrhosis patients received HCC surveillance within 1year. Differences in rates of HCC screening by liver disease etiology were observed.

Hepatocellular carcinoma (HCC) surveillance in patients with cirrhosis is associated with improved survival. Provision of HCC surveillance is low in the US, particularly in primary care settings. To evaluate current hepatitis C virus (HCV) and HCC surveillance practices and physician attitudes regarding HCC risk-stratification among primary care and subspecialty providers. Using the Tailored Design Method, we delivered a 34-item online survey to 7654 North Carolina-licensed internal/family medicine or gastroenterology/hepatology physicians and advanced practice providers in 2022. We included the domains of HCV treatment, cirrhosis diagnosis, HCC surveillance practices, barriers to surveillance, and interest in risk-stratification tools. We performed descriptive analyses to summarize responses. Tabulations were weighted based on sampling weights accounting for non-response and inter-specialty comparisons were made using chi-squared or t test statistics. After exclusions, 266 responses were included in the final sample (response rate 3.8%). Most respondents (78%) diagnosed cirrhosis using imaging and a minority used non-invasive tests that were blood-based (~ 15%) or transient elastography (31%). Compared to primary care providers, subspecialists were more likely to perform HCC surveillance every 6-months (vs annual) (98% vs 35%, p < 0.0001). 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. In this statewide survey, there were great knowledge gaps in HCC surveillance among PCPs and most respondents expressed interest in strategies to increase appropriate HCC surveillance.