Integrated Multi-center Regional Liver Cancer Tumor Board May Improve Access, Quality and Timeliness of Care for Patients With Hepatocellular Carcinoma

Abstract

Introduction: Hepatocellular Carcinoma (HCC) is the most rapidly increasing cause of cancer death in the United States. Curative treatments with better prognosis are available for patients when detected early. Therefore, timeliness of initiation of HCC therapy after diagnosis is of essence. In July 2012, a Veterans Integrated Service Network (VISN) wide HCC tumor board (TB) was created using the Specialty Care Access Network-Extension for Community (SCAN-ECHO) program. A shared network space was created for tumor board schedules, submission templates, educational materials and procedure protocols. Standardization of HCC screening, diagnosis, surveillance, imaging protocols, staging, treatment and palliation (with end of life care processes) was implemented. Liver cancer educational programs and yearly summits were developed with local leaders and national experts as faculty. This retrospective study examines the impact of the creation of this HCC TB on advanced directives, tumor staging and timeliness of therapy. Methods: A cross-sectional chart review was performed on all patients diagnosed with HCC from 2010-2016 in five centers in VISN 3 (NY/NJ). Patients diagnosed before and after July 2012 (introduction of HCC TB) were compared with respect to time from HCC diagnosis to first therapy, documentation of tumor staging at diagnosis, and establishment of advanced directives within 90 days of HCC diagnosis. Results: A total of 261 HCC patients were included in this study. 55 (21%) of these patients were diagnosed before July 2012 or pre-HCC Tumor Board (TB) and 206 patients were diagnosed with HCC Tumor Board in place. The median time from diagnosis of HCC to initial therapy decreased from 36 days pre-HCC TB to 25 days with HCC TB (p=0.022, Mann Whitney U Test). The frequency of tumor staging at diagnosis increased from 69% in the pre-HCC TB group to 83% with the HCC TB in place (p=0.023, Chi-Square). Similarly, the number of patients with advanced directives discussed within 90 days of HCC diagnosis improved from 44% pre-HCC TB to 67% with HCC TB (p=0.003, Chi-Square). Conclusion: The creation of a SCAN ECHO VISN wide multi-disciplinary HCC Tumor Board was associated with a shortened time from HCC diagnosis to first treatment, a higher frequency of tumor staging prior to therapy and increased number of patients having a discussion regarding advanced directives within 90 days of their diagnosis. This initiative is now being spread nationally with survival outcomes data forthcoming.Table: Table. Pre-HCC Tumor Board vs HCC Tumor Board: Impact on Timeliness and Quality of Care