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Wong RJ, Jones PD, Niu B, Therapondos G, Thamer M, Kshirsagar O, Zhang Y, Pinheiro P, Kyalwazi B, Fass R, Khalili M, Singal AG. Clinician-Level Knowledge and Barriers to Hepatocellular Carcinoma Surveillance. JAMA Netw Open 2024; 7:e2411076. [PMID: 38743424 PMCID: PMC11094557 DOI: 10.1001/jamanetworkopen.2024.11076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 03/12/2024] [Indexed: 05/16/2024] Open
Abstract
Importance Surveillance for hepatocellular carcinoma (HCC) in patients with cirrhosis is underused. Identifying potentially modifiable factors to address barriers in HCC surveillance is critical to improve patient outcomes. Objective To evaluate clinician-level factors contributing to underuse of HCC surveillance in patients with cirrhosis. Design, Setting, and Participants This survey study included primary care clinicians (PCCs) and gastroenterology and hepatology clinicians at 5 safety-net health systems in the US. Clinicians were surveyed from March 15 to September 15, 2023, to assess knowledge, attitudes, beliefs, perceived barriers, and COVID-19-related disruptions in HCC surveillance in patients with cirrhosis. Data were analyzed from October to November 2023. Main Outcome and Measures HCC surveillance knowledge was assessed with 6 questions querying the respondent's ability to correctly identify appropriate use of HCC surveillance. Attitudes, perceived barriers, and beliefs regarding HCC surveillance and perceived impact of the COVID-19 pandemic-related disruptions with HCC surveillance were assessed with a series of statements using a 4-point Likert scale and compared PCCs and gastroenterology and hepatology clinicians. Results Overall, 347 of 1362 clinicians responded to the survey (25.5% response rate), among whom 142 of 237 (59.9%) were PCCs, 48 of 237 (20.3%) gastroenterology and hepatology, 190 of 236 (80.5%) were doctors of medicine and doctors of osteopathic medicine, and 46 of 236 (19.5%) were advanced practice clinicians. On HCC knowledge assessment, 144 of 270 (53.3%) scored 5 or more of 6 questions correctly, 37 of 48 (77.1%) among gastroenterology and hepatology vs 65 of 142 (45.8%) among PCCs (P < .001). Those with higher HCC knowledge scores were less likely to report barriers to HCC surveillance. PCCs were more likely to report inadequate time to discuss HCC surveillance (37 of 139 [26.6%] vs 2 of 48 [4.2%]; P = .001), difficulty identifying patients with cirrhosis (82 of 141 [58.2%] vs 5 of 48 [10.4%]; P < .001), and were not up-to-date with HCC surveillance guidelines (87 of 139 [62.6%] vs 5 of 48 [10.4%]; P < .001) compared with gastroenterology and hepatology clinicians. While most acknowledged delays during the COVID-19 pandemic, 62 of 136 PCCs (45.6%) and 27 of 45 gastroenterology and hepatology clinicians (60.0%) reported that patients with cirrhosis could currently complete HCC surveillance without delays. Conclusions and Relevance In this survey study, important gaps in knowledge and perceived barriers to HCC surveillance were identified. Effective delivery of HCC education to PCCs and health system-level interventions must be pursued in parallel to address the complex barriers affecting suboptimal HCC surveillance in patients with cirrhosis.
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Affiliation(s)
- Robert J. Wong
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine and Gastroenterology Section, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
| | - Patricia D. Jones
- Division of Digestive Health and Liver Diseases, University of Miami School of Medicine and Jackson Memorial Health System, Miami, Florida
| | - Bolin Niu
- Division of Gastroenterology and Hepatology, MetroHealth Hospital and Health System, Cleveland, Ohio
| | | | - Mae Thamer
- Medical Technology and Practice Patterns Institute, Bethesda, Maryland
| | - Onkar Kshirsagar
- Medical Technology and Practice Patterns Institute, Bethesda, Maryland
| | - Yi Zhang
- Medical Technology and Practice Patterns Institute, Bethesda, Maryland
| | - Paulo Pinheiro
- Division of Epidemiology and Population Health Sciences, University of Miami School of Medicine, Miami, Florida
| | - Beverly Kyalwazi
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Ronnie Fass
- Division of Gastroenterology and Hepatology, MetroHealth Hospital and Health System, Cleveland, Ohio
| | - Mandana Khalili
- Division of Gastroenterology and Hepatology, University of California San Francisco and Zuckerberg San Francisco General Hospital, San Francisco
| | - Amit G. Singal
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center and Parkland Health, Dallas
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Okushin K, Tateishi R, Hirakawa S, Tachimori H, Uchino K, Nakagomi R, Yamada T, Nakatsuka T, Minami T, Sato M, Fujishiro M, Hasegawa K, Eguchi Y, Kanto T, Yoshiji H, Izumi N, Kudo M, Koike K. The impact of COVID-19 on the diagnosis and treatment of HCC: analysis of a nationwide registry for advanced liver diseases (REAL). Sci Rep 2024; 14:2826. [PMID: 38310156 PMCID: PMC10838269 DOI: 10.1038/s41598-024-53199-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 01/29/2024] [Indexed: 02/05/2024] Open
Abstract
The number of cancer cases diagnosed during the coronavirus disease 2019 (COVID-19) pandemic has decreased. This study investigated the impact of the pandemic on the clinical practice of hepatocellular carcinoma (HCC) using a novel nationwide REgistry for Advanced Liver diseases (REAL) in Japan. We retrieved data of patients initially diagnosed with HCC between January 2018 and December 2021. We adopted tumor size as the primary outcome measure and compared it between the pre-COVID-19 (2018 and 2019) and COVID-19 eras (2020 and 2021). We analyzed 13,777 patients initially diagnosed with HCC (8074 in the pre-COVID-19 era and 5703 in the COVID-19 era). The size of the maximal intrahepatic tumor did not change between the two periods (mean [SD] = 4.3 [3.6] cm and 4.4 [3.6] cm), whereas the proportion of patients with a single tumor increased slightly from 72.0 to 74.3%. HCC was diagnosed at a similar Barcelona Clinic Liver Cancer stage. However, the proportion of patients treated with systemic therapy has increased from 5.4 to 8.9%. The proportion of patients with a non-viral etiology significantly increased from 55.3 to 60.4%. Although the tumor size was significantly different among the etiologies, the subgroup analysis showed that the tumor size did not change after stratification by etiology. In conclusion, the characteristics of initially diagnosed HCC remained unchanged during the COVID-19 pandemic in Japan, regardless of differences in etiology. A robust surveillance system should be established particularly for non-B, non-C etiology to detect HCC in earlier stages.
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Affiliation(s)
- Kazuya Okushin
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
- Department of Infection Control and Prevention, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Ryosuke Tateishi
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Shinya Hirakawa
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Endowed Course for Health System Innovation, Keio University School of Medicine, Tokyo, Japan
| | - Hisateru Tachimori
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Endowed Course for Health System Innovation, Keio University School of Medicine, Tokyo, Japan
| | - Koji Uchino
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Ryo Nakagomi
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Tomoharu Yamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Takuma Nakatsuka
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Tatsuya Minami
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Masaya Sato
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Kiyoshi Hasegawa
- Hepato-Biliary-Pancreatic Surgery Division, Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yuichiro Eguchi
- Liver Center, Saga University Hospital, Saga University, Saga, Japan
| | - Tatsuya Kanto
- The Research Center for Hepatitis and Immunology, National Center for Global Health and Medicine, Chiba, Japan
| | - Hitoshi Yoshiji
- Department of Gastroenterology, Nara Medical University, Kashihara, Nara, Japan
| | - Namiki Izumi
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, Musashino, Japan
| | - Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
- Kanto Central Hospital, Tokyo, Japan
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Rogal SS, Taddei TH, Monto A, Yakovchenko V, Patton H, Merante M, Spoutz P, Chia L, Yudkevich J, Aytaman A, Rabiee A, John BV, Blechacz B, Cai CX, Gilles H, Shah AS, McCurdy H, Puri P, Jou J, Mazhar K, Dominitz JA, Anwar J, Morgan TR, Ioannou GN. Hepatocellular Carcinoma Diagnosis and Management in 2021: A National Veterans Affairs Quality Improvement Project. Clin Gastroenterol Hepatol 2024; 22:324-338. [PMID: 37460005 PMCID: PMC10788380 DOI: 10.1016/j.cgh.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/16/2023] [Accepted: 07/02/2023] [Indexed: 08/13/2023]
Abstract
BACKGROUND & AIMS The coronavirus disease-2019 pandemic profoundly disrupted preventative health care services including cancer screening. As the largest provider of cirrhosis care in the United States, the Department of Veterans Affairs (VA) National Gastroenterology and Hepatology Program aimed to assess factors associated with hepatocellular carcinoma (HCC) stage at diagnosis, treatment, and survival. METHODS Veterans with a new diagnosis of HCC in 2021 were identified from electronic health records (N = 2306). Structured medical record extraction was performed by expert reviewers in a 10% random subsample of Veterans with new HCC diagnoses. Factors associated with stage at diagnosis, receipt of treatment, and survival were assessed using multivariable models. RESULTS Among 199 patients with confirmed HCC, the average age was 71 years and most (72%) had underlying cirrhosis. More than half (54%) were at an early stage (T1 or T2) at diagnosis. Less-advanced liver disease, number of imaging tests adequate for HCC screening, HCC diagnosis in the VA, and receipt of VA primary care were associated significantly with early stage diagnosis. HCC-directed treatments were administered to 145 (73%) patients after a median of 37 days (interquartile range, 19-54 d) from diagnosis, including 70 (35%) patients who received potentially curative treatments. Factors associated with potentially curative (vs no) treatments included HCC screening, early stage at diagnosis, and better performance status. Having fewer comorbidities and better performance status were associated significantly with noncurative (vs no) treatment. Early stage diagnosis, diagnosis in the VA system, and receipt of curative treatment were associated significantly with survival. CONCLUSIONS These results highlight the importance of HCC screening and engagement in care for HCC diagnosis, treatment, and survival while demonstrating the feasibility of developing a national quality improvement agenda for HCC screening, diagnosis, and treatment.
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Affiliation(s)
- Shari S Rogal
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.
| | - Tamar H Taddei
- VA Connecticut Healthcare System, West Haven, Connecticut; Section of Digestive Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Alexander Monto
- San Francisco VA Health Care System, San Francisco, California
| | - Vera Yakovchenko
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Heather Patton
- Gastroenterology Section, Jennifer Moreno VA San Diego Healthcare System, San Diego, California
| | - Monica Merante
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Patrick Spoutz
- Pharmacy Benefits Management, Veterans Integrated Service Network 20, Vancouver, Washington
| | - Linda Chia
- Pharmacy Benefits Management, Veterans Integrated Service Network 20, Vancouver, Washington
| | - Jennifer Yudkevich
- VA New York Harbor Healthcare System, Brooklyn Campus, Brooklyn, New York
| | - Ayse Aytaman
- VA New York Harbor Healthcare System, Brooklyn Campus, Brooklyn, New York; SUNY Health Science Center Brooklyn, Brooklyn, New York
| | - Atoosa Rabiee
- Washington DC VA Medical Center, Washington, District of Columbia
| | - Binu V John
- Division of Gastroenterology and Hepatology, Miami VA Healthcare System, Miami, Florida; Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Boris Blechacz
- Department of Gastroenterology and Hepatology, VA South Texas Health Care System, San Antonio, Texas
| | - Cindy X Cai
- Department of Gastroenterology and Hepatology, VA Loma Linda Healthcare System, Loma Linda, California; Loma Linda University, Loma Linda, California; Department of Internal Medicine, University of California, Riverside, Riverside, California
| | - HoChong Gilles
- Division of Gastroenterology and Hepatology, Central Virginia VA Healthcare System, Richmond, Virginia
| | - Anand S Shah
- Division of Gastroenterology, Joseph Maxwell Cleland Atlanta VA Medical Center, Decatur, Georgia; Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | | | - Puneet Puri
- Division of Gastroenterology and Hepatology, Central Virginia VA Healthcare System, Richmond, Virginia; Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Janice Jou
- VA Portland Healthcare System, Portland, Oregon; Division of Gastroenterology and Hepatology, Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Khurram Mazhar
- VA North Texas Health Care System, Dallas, Texas; Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jason A Dominitz
- VA Puget Sound Health Care System, Seattle, Washington; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Washington
| | - Jennifer Anwar
- Gastroenterology Section, VA Long Beach Healthcare System, Long Beach, California
| | - Timothy R Morgan
- Gastroenterology Section, VA Long Beach Healthcare System, Long Beach, California; Division of Gastroenterology, Department of Medicine, University of California, Irvine, California
| | - George N Ioannou
- VA Puget Sound Health Care System, Seattle, Washington; Division of Gastroenterology, University of Washington School of Medicine, Seattle, Washington
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