Letter to the Editor: Updates in Abbreviated MRI-Based HCC Surveillance.

The Veterans Health Administration provides care to more than 100,000 Veterans with cirrhosis. This implementation evaluation aimed to understand organizational resources and barriers associated with cirrhosis care. Clinicians across 145 Department of Veterans Affairs (VA) medical centers (VAMCs) were surveyed in 2022 about implementing guideline-concordant cirrhosis care. VA Corporate Data Warehouse data were used to assess VAMC performance on two national cirrhosis quality measures: HCC surveillance and esophageal variceal surveillance or treatment (EVST). Organizational factors associated with higher performance were identified using linear regression models. Responding VAMCs (n = 124, 86%) ranged in resource availability, perceived barriers, and care processes. In multivariable models, factors independently associated with HCC surveillance included on-site interventional radiology and identifying patients overdue for surveillance using a national cirrhosis population management tool ("dashboard"). EVST was significantly associated with dashboard use and on-site gastroenterology services. For larger VAMCs, the average HCC surveillance rate was similar between VAMCs using vs. not using the dashboard (47% vs. 41%), while for smaller and less resourced VAMCs, dashboard use resulted in a 13% rate difference (46% vs. 33%). Likewise, higher EVST rates were more strongly associated with dashboard use in smaller (55% vs. 50%) compared to larger (57% vs. 55%) VAMCs. Resources, barriers, and care processes varied across diverse VAMCs. Smaller VAMCs without specialty care achieved HCC and EVST surveillance rates nearly as high as more complex and resourced VAMCs if they used a population management tool to identify the patients due for cirrhosis care.

Chronic hepatitis B (CHB) infection remains a significant public health issue for Indigenous Australians, in particular for remote communities. To evaluate the spectrum of hepatitis B virus (HBV) care provided to a remote Aboriginal community. Measures studied included screening, seroprevalence, vaccination rates and efficacy, and HCC risk and surveillance adherence. A retrospective audit of HBV care received by all permanent residents currently attending a remote Aboriginal Health service. This study was endorsed by both the local Aboriginal Health service and the Aboriginal Health Council of South Australia. A total of 208 patients attended the clinic, of whom 52% (109) were screened for HBV. Of these, 12% (13) had CHB and 20% (22) had evidence of past infection. Similarly, of the 208 attending patients, complete vaccination was documented in 48% (99). Of the 33 patients with post-vaccination serology, 24% (8) had subtherapeutic (<10 IU/mL) levels of HBsAb. Subtherapeutic HBsAb was independently associated with higher Charlson Comorbidity scores (odds ratio=17.1; 95% confidence interval 1.2-243.3; P=0.036). Definitive breakthrough infection was identified in 6% (2) patients. One HBsAg positive patient was identified as needing HCC surveillance, but had not undertaken HCC surveillance. Opportunities to improve the quality of CHB care through increased HBV vaccination, screening and adherence to HCC surveillance were identified. High rates of subtherapeutic vaccine responses and documented breakthrough infection raises concerns about the effectiveness of current CHB vaccines in this population.

Is it time to refine HCC surveillance strategies in HCV cured patients?

Hepatocellular carcinoma (HCC) is the third leading cause of death worldwide and one of the few cancers with a rising mortality in the United States. Given the stark contrast in treatment options and expected survival based on tumor stage at diagnosis, professional society guidelines recommend HCC surveillance in high-risk groups, including subsets with chronic HBV infection and those with cirrhosis from any etiology. These target populations, particularly those with cirrhosis, account for &amp;gt;90% of HCC in the Western world, as patients without chronic liver disease have a very low risk of developing HCC. The best data for HCC surveillance comes from a large randomized clinical trial among &amp;gt;18,00 patients with HBV infection from China; however, similar level I data does not exist supporting HCC surveillance in patients with cirrhosis. A meta-analysis of recent cohort studies highlights a consistent association between surveillance receipt and improved clinical outcomes in patients with cirrhosis, including early detection, curative treatment receipt, and overall survival. Despite these recommendations, most HCC continue to be diagnosed at an advanced stage. We will discuss failures in our current surveillance strategies that must be addressed to improve HCC surveillance effectiveness and reduce HCC mortality. First, most professional societies recommend ultrasound-based surveillance, which is operator dependent and has suboptimal sensitivity for early HCC detection – missing approximately half of early-stage HCC if used alone and approximately one-third if used in combination with AFP. Several imaging- and blood-based surveillance strategies (e.g., abbreviated MRI, GALAD, and methylated DNA marker panels) have promising accuracy for early-stage HCC detection, although large prospective validation in diverse patient cohorts are still needed. Second, HCC surveillance is underused in clinical practice, with a recent systematic review finding only one-fourth of at-risk patients are undergoing surveillance, with even lower estimates when considering consistent semi-annual surveillance over extended periods of time. Surveillance underuse is related to several patient- and provider-barriers, which must be addressed to increased utilization. Notably, some barriers appear to be specific to imaging-based surveillance so validation of blood-based biomarkers may also improve utilization and maximize surveillance effectiveness. Several inreach and outreach interventions have demonstrated efficacy to increase HCC surveillance, and studies are now needed to evaluate how best to implement these interventions in clinical practice. Although HCC continues to have a poor overall prognosis, there have been dramatic advances in all three of these areas, highlighting promise for improved outcomes in the near future. Citation Format: Amit Singal. Systematic approach to HCC surveillance in patients with cirrhosis [abstract]. In: Proceedings of the AACR Special Conference: Advances in the Pathogenesis and Molecular Therapies of Liver Cancer; 2022 May 5-8; Boston, MA. Philadelphia (PA): AACR; Clin Cancer Res 2022;28(17_Suppl):Abstract nr IA08.

IntroductionThe most efficient and cost-effective programme for HCC surveillance is the subject of ongoing debate. Current UK standard practice for HCC surveillance in high risk populations consists of 6 monthly...

&lt;div&gt;Abstract&lt;p&gt;Background. Hepatocellular carcinoma surveillance is underutilized, with &lt;25% of individuals with cirrhosis receiving surveillance exams as recommended. The epidemiology of cirrhosis and HCC in the US has also shifted in recent years, but little is known about recent trends in surveillance utilization. We characterized patterns of HCC surveillance by payer, cirrhosis etiology, and calendar year in insured individuals with cirrhosis. Methods. We conducted a retrospective cohort study of individuals with cirrhosis using claims data from Medicare, Medicaid, and private insurance plans in North Carolina. We included individuals ≥18 years with a first occurrence of an ICD-9/10 code for cirrhosis between January 1, 2010, and June 30, 2018. The outcome was HCC surveillance by abdominal ultrasound, computed tomography, or magnetic resonance imaging. We estimated 1- and 2-year cumulative incidences for HCC surveillance and assessed longitudinal adherence to surveillance by computing the proportion of time covered (PTC). Results. Among 46,052 individuals, 71% were enrolled through Medicare, 15% through Medicaid, and 14% through private insurance. The overall 1-year cumulative incidence of HCC surveillance was 49% and the 2-year cumulative incidence was 55%. For those with an initial screen in the first six months of their cirrhosis diagnosis, the median 2-year PTC was 67% (Q1, 38%; Q3, 100%). Conclusion. HCC surveillance initiation after cirrhosis diagnosis remains low, though it has improved slightly over time, particularly among individuals with Medicaid. Impact. This study provides insight into recent trends in HCC surveillance and highlights areas to target for future interventions, particularly among patients with non-viral etiologies.&lt;/p&gt;&lt;/div&gt;

IntroductionBSG guidelines for diagnosis and treatment of hepatocellular carcinoma (2003) advocate 6 monthly surveillance of high risk cirrhotic patients with abdominal ultrasonography and alfa-feto protein estimation.An audit of cirrhotic patients...

Objective: This study aimed to determine the adherence rate of HCC surveillance in CHB patients at the largest tertiary hospital in Southern Thailand and identify patient and physician factors that influence it. Materials and Methods: This retrospective cohort study included patients with CHB who were followed up for more than 1 year between 2011 and 2019 at a tertiary care hospital in Thailand. Patients diagnosed with HCC within 6 months of their first visit were excluded. The rate of adherence with HCC surveillance was calculated using percentage of time up-to-date with HCC surveillance (PTUDS). Results: The mean age of 531 eligible patients at the time HCC surveillance started was 55.5 ± 9.26 years. The most common indications for surveillance were male over 40 years of age (41.2%), female over 50 years of age (28.9%), and cirrhosis (22.6%). The median PTUDS was 70.6% (interquartile range 55.1 – 81.4%). The highest PTUDS was for cirrhosis (74.0%). For physicians’ subspecialties, the median PTUDS was 71.8% for gastroenterologists (IQR 58.3 – 81.6%) and 41.7% for internists (IQR 31.4 – 65.8%). Factors associated with increased PTUDS by multivariable analysis were having ≥2 clinical visits per year (±18.4%, p&lt;0.001), civil servant reimbursement (±8.81%, p=0.001), cirrhosis (±6.06%, p=0.003), and being follow-up by gastroenterologists (±20.4%, p&lt;0.001). Conclusion: The adherence with surveillance program in patients with CHB being followed up at a tertiary care setting in Thailand was good. This finding underscores the importance of education regarding indications for HCC surveillance, particularly in patients without cirrhosis.

<h3>Introduction</h3> The British Society of Gastroenterology (BSG) recommends, if HCC surveillance is offered, 6 monthly ultrasound-scan with serum AFP.¹ We aim to evaluate our screening practice in liver cirrhosis patients and compare it with the BSG guidelines. <h3>Methodology</h3> Retrospectively, all patients with liver disease who admitted to gastroenterology ward between January 2020 and Jun 2020 at Royal Lancaster Infirmary were assessed. Stages of liver cirrhosis were taken into consideration with the presence of decompensated liver disease signs and the underlying cause of liver cirrhosis.² Data collected from Electronic-Patients Record included any blood test, ultrasound, and endoscopy report. We analysed the data by using One-Way ANOVA on SPSS. <h3>Results</h3> Total number of hepatology admissions during the study period was 183 patients with 65% (n=119) known to have liver cirrhosis. 74% were male (n=137) of total admissions and only forty-six female patients. Among individuals with liver cirrhosis, twenty-seven patients had Child-Pugh (A) liver cirrhosis with Fifty and forty-two had Child-Pugh (B) and (C) respectively. Admission with decompensated Alcoholic liver Cirrhosis was higher in male patients 69% (n=47) compare to female patients of only 30% (n=21) (p= 0.001). None of the patients had autoimmune or metabolic liver disease as main cause of cirrhosis (p= 0.0001). Oesophageal varices were diagnosed in thirty-one patients (26%) predominantly males (n=22). HCC surveillance with Ultrasound occurred in 85% (n=102) whereas only 73 patients (61.3%) had AFP checked. The ANOVA results suggest the HCC surveillance differs significantly between different stages of liver cirrhosis (Child-Pugh A, B and C) (F3,359 = 6.11, p= 0.003). Male patients had more robust HCC surveillance (M=37.61, SD=23.46, n=13) in comparison to Female patients with liver cirrhosis (M=13.38, SD = 8.60, n = 13). This was statistically significant, t (24) = 2.06, (p= 0.0009). <h3>Conclusion</h3> More than two third of Hepatology admissions have liver cirrhosis, however, the study period was during the first COVID-19 wave, yet the adherence to the BSG in HCC surveillance guidelines was achieved in 85% and 61.3% with USS and AFP respectively. Significant improvement is required; hence, we recommend adding checklist and proforma to the patients’ record as this may improve our practice. <h3>References</h3> Taylor EJ, Jones RL, Guthrie AJ, Rowe IA. Modelling the benefits and harms of surveillance for hepatocellular carcinoma: Information to support informed choices. <i>Hepatology</i> 2017;<b>66</b>:1546–1555. Roskilly A, Rowe IA. Surveillance for hepatocellular carcinoma. <i>Clinical Medicine</i> 2018;<b>18</b>:66–69.

&lt;div&gt;Abstract&lt;p&gt;Background. Hepatocellular carcinoma surveillance is underutilized, with &lt;25% of individuals with cirrhosis receiving surveillance exams as recommended. The epidemiology of cirrhosis and HCC in the US has also shifted in recent years, but little is known about recent trends in surveillance utilization. We characterized patterns of HCC surveillance by payer, cirrhosis etiology, and calendar year in insured individuals with cirrhosis. Methods. We conducted a retrospective cohort study of individuals with cirrhosis using claims data from Medicare, Medicaid, and private insurance plans in North Carolina. We included individuals ≥18 years with a first occurrence of an ICD-9/10 code for cirrhosis between January 1, 2010, and June 30, 2018. The outcome was HCC surveillance by abdominal ultrasound, computed tomography, or magnetic resonance imaging. We estimated 1- and 2-year cumulative incidences for HCC surveillance and assessed longitudinal adherence to surveillance by computing the proportion of time covered (PTC). Results. Among 46,052 individuals, 71% were enrolled through Medicare, 15% through Medicaid, and 14% through private insurance. The overall 1-year cumulative incidence of HCC surveillance was 49% and the 2-year cumulative incidence was 55%. For those with an initial screen in the first six months of their cirrhosis diagnosis, the median 2-year PTC was 67% (Q1, 38%; Q3, 100%). Conclusion. HCC surveillance initiation after cirrhosis diagnosis remains low, though it has improved slightly over time, particularly among individuals with Medicaid. Impact. This study provides insight into recent trends in HCC surveillance and highlights areas to target for future interventions, particularly among patients with non-viral etiologies.&lt;/p&gt;&lt;/div&gt;

Low surveillance receipt in cirrhotic patients with cured HCV: Where are the barriers?

IntroductionHepatocellular carcinoma (HCC) is the third leading cause of cancer-related mortality worldwide, posing a significant public health burden. Early diagnosis and effective treatment options are crucial for improving the curative effect and quality of life of patients. However, the detection of early-stage HCC remains challenging due to its strong compensatory function. HCC surveillance is an evidence-based practice with sufficient evidence. Numerous studies have demonstrated that HCC surveillance effectively increases early diagnosis rates and improves survival rates among liver cancer patients. Yet, its utilisation in clinical practice remains limited, at approximately 24%. Given the pivotal role clinicians play in HCC surveillance, their implementation barriers are more likely to lead to underutilisation of surveillance. This study aims to identify the barriers to implementing HCC surveillance guidelines among clinicians, subsequently developing and optimising efficient implementation strategies to enhance adherence to these guidelines.Methods and analysisThis study will be carried out at hospitals within the Yunnan Infectious Diseases Specialist Alliance. Focusing on promoting clinicians’ implementation of HCC surveillance, the study pursues two objectives: (1) Under the guidance of the Consolidated Framework for Implementation Research, semistructured interviews and a literature review will be conducted to analyse the barriers clinicians face in implementing HCC surveillance guidelines; (2) Employing the preparation and optimisation phase of the Multiphase Optimisation Strategy framework, effective implementation strategies will be developed and optimised to enhance clinicians’ implementation of HCC surveillance. The primary outcome measure is fidelity, assessed through rigorous patient-reported data collection methods. Statistical analyses will include independent samples t-tests, χ2 tests, Wilcoxon rank sum tests and multiple logistic regression analyses, performed using R V.4.4.1. The statistical significance level will be set at 0.05.Ethics and disseminationThis study has been approved by the Ethics Committee of the Kunming Third People’s Hospital (KSLL20230711005). Participants will provide informed consent before taking part in the study. Results will be published in peer-reviewed journals in open-access formats, and anonymised data will be made available.Trial registration numberChiCTR2300071570.

Background & AimHCC has significantly improved outcomes when detected early. Guidelines recommend biannual surveillance with ultrasound (US) and/or AFP in at-risk individuals. This survey aimed to describe HCC surveillance adherence/practices amongst the NHS hospitals in the UK.MethodsAn electronic survey was sent to 79 NHS hospitals via the British Association for the Study of the Liver distribution list. The responses were captured from July 2021 to January 2022. Centres were divided into hepato-pancreato-biliary (HPB) and non-HPB centres, depending on whether the hospital undertakes major liver surgeries.ResultsA total of 39 (49.3%) centres responded: 15 HPB and 24 non-HPB centres from across the UK. HCC surveillance eligibility criteria were universally applied, but heterogeneous approaches occur outside these criteria. Eighty per cent of patients undergoing surveillance were estimated to have cirrhosis. Eighty-five per cent of centres do 6-monthly US and AFP requested by clinicians and liver clinical nurse specialists. Compliance was estimated at 80% but not routinely audited. In most centres, general sonographers and/or radiologists perform surveillance US scans without a standard reporting template, although structured reporting was viewed as desirable by the majority. Poor views on US are approached heterogeneously, with patients variably offered ongoing US, CT, or MRI with different protocols.ConclusionMost responding NHS hospitals follow 6-monthly HCC surveillance guidance. Data recording is variable, with limited routine data collection regarding compliance, yield, and quality. Surveillance US is mostly performed by non-HPB specialists without standardised reporting. There is an inconsistent approach to poor views with US surveillance. Even in a universal healthcare system such as NHS, which is free at the point of care, delivery of HCC surveillance has not improved over the last decade and remains variable.

To evaluate the feasibility of simulated abbreviated MRI (AMRI) with second shot arterial phase (SSAP) for HCC surveillance and diagnosis. A total of 129 consecutive patients (age, 58.8 ± 11.4 years; male, 71.3%) underwent gadoxetic acid-enhanced MRI using a modified injection protocol for HCC evaluation from July 2017 to February 2018. The modified injection protocol consisted of routine dynamic imaging (6 mL) and SSAP imaging (4 mL). Two radiologists independently reviewed two AMRI sets: AMRI without SSAP (surveillance set) and AMRI with SSAP (diagnosis set). A modified version of the Liver Imaging Reporting and Data System (LI-RADS) for the diagnosis set was devised by referring to contrast-enhanced ultrasound LI-RADS. Sixty-seven patients with HCC and 62 patients without HCC were included. In the surveillance set, sensitivity and specificity for the detection of patients with HCC were 95.5% and 96.8%, and 94.0% and 96.8% in reviewers 1 and 2, respectively. In the diagnosis set, the scores of most HCCs (76/78, 97.4%) were consistent between LI-RADS of full-protocol and modified LI-RADS of AMRI with SSAP protocol. When the HCC surveillance and diagnosis strategy was changed from strategy 1 (AMRI without SSAP) to strategy 2 (AMRI with SSAP), the recall rate significantly decreased from 52.7 to 3.9% (p < 0.001). The modified LI-RADS score of the AMRI with SSAP protocol showed high agreement with the LI-RADS score of the full protocol. The HCC surveillance and diagnosis strategy using the AMRI with SSAP protocol reduced the recall rate. These results may enable to diagnose HCC simultaneously with surveillance. • A modified version of LI-RADS was devised for the diagnostic algorithm using AMRI with the second shot arterial phase (SSAP) by referring to CEUS LI-RADS. • The modified LI-RADS scores using AMRI with SSAP showed a high concordance rate with the conventional LI-RADS score using full-protocol MRI. • The recall rate significantly decreased when the HCC surveillance and diagnosis strategy was changed from strategy 1 (AMRI without SSAP; surveillance then recall test) to strategy 2 (AMRI with SSAP; simultaneous surveillance and diagnosis).

HCC surveillance is recommended by liver professional societies but lacks broad acceptance by several primary care and cancer societies due to limitations in the existing data. We convened a diverse multidisciplinary group of cancer screening experts to evaluate current and future paradigms of HCC prevention and early detection using a rigorous Delphi panel approach. The experts had high agreement on 21 statements about primary prevention, HCC surveillance benefits, HCC surveillance harms, and the evaluation of emerging surveillance modalities. The experts agreed that current data have methodologic limitations as well as unclear generalizability to Western populations. Although a randomized clinical trial of surveillance versus no surveillance is unlikely feasible, they concurred that alternative designs, such as a comparison of 2 surveillance modalities, could provide indirect evidence of surveillance efficacy. The panel acknowledged the presence of surveillance harms, but concurred the overall value of surveillance appears high, particularly given a greater emphasis on benefits over harms by both patients and clinicians. The experts underscored the importance of a framework for measuring both benefits and harms when evaluating emerging surveillance strategies. The panel acknowledged performance metrics of emerging methods may differ from other cancer screening programs given differences in populations, including higher risk of cancer development and competing risk of morality, and differences in diagnostic workflow in patients at risk of HCC. These data provide insights into the perceived value of HCC surveillance in an era of emerging blood- and imaging-based surveillance strategies.