Disparities in Hepatocellular Carcinoma Surveillance: Dissecting the Roles of Patient, Provider, and Health System Factors

Health disparities in cirrhosis care and liver transplantation

Morbidity and mortality from cirrhosis are substantial and increasing. Health disparities in cirrhosis and liver transplantation are reflective of inequities along the entire spectrum of chronic liver disease care, from screening and diagnosis to prevention and treatment of liver-related complications. The key populations experiencing disparities in health status and healthcare delivery include racial and ethnic minority groups, sexual and gender minorities, people of lower socioeconomic status and underserved rural communities. These disparities lead to delayed diagnosis of chronic liver disease and complications of cirrhosis (for example, hepatocellular carcinoma), to differences in treatment of chronic liver disease and its complications, and ultimately to unequal access to transplantation for those with end-stage liver disease. Calling out these disparities is only the first step towards implementing solutions that can improve health equity and clinical outcomes for everyone. Multi-level interventions along the care continuum for chronic liver disease are needed to mitigate these disparities and provide equitable access to care.

Racial/Ethnic Disparities and Immunotherapeutic Advances in the Treatment of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) remains one of the leading causes of death among many associated liver diseases. Various conventional strategies have been utilized for treatment, ranging from invasive surgeries and liver transplants to radiation therapy, but fail due to advanced disease progression, late screening/staging, and the various etiologies of HCC. This is especially evident within racially distinct populations, where incidence rates are higher and treatment outcomes are worse for racial/ethnic minorities than their Caucasian counterparts. However, with the rapid development of genetic engineering and molecular and synthetic biology, many novel strategies have presented promising results and have provided potential treatment options. In this review, we summarize past treatments, how they have shaped current treatments, and potential treatment strategies for HCC that may prove more effective in the future.

Clinician-Level Knowledge and Barriers to Hepatocellular Carcinoma Surveillance

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.

Pragmatic strategies to address health disparities along the continuum of care in chronic liver disease

Racial, ethnic, and socioeconomic disparities exist in the prevalence and natural history of chronic liver disease, access to care, and clinical outcomes. Solutions to improve health equity range widely, from digital health tools to policy changes. The current review outlines the disparities along the chronic liver disease health care continuum from screening and diagnosis to the management of cirrhosis and considerations of pre-liver and post-liver transplantation. Using a health equity research and implementation science framework, we offer pragmatic strategies to address barriers to implementing high-quality equitable care for patients with chronic liver disease.

Effectiveness of a nurse-led decision counselling programme on hepatocellular carcinoma screening uptake among patients with hepatitis B: A randomised controlled trial

BACKGROUND

The globally endemic hepatocellular carcinoma induced by hepatitis B highlights the need for an ultrasonography-based screening strategy to reduce the tumour burden. However, patient non-adherence due to unawareness and complex decisions in weighting uncertainties of hepatocellular carcinoma screening has continuously challenged its continuum.

OBJECTIVE

To examine the effectiveness and process of a nurse-led decision counselling programme for improving hepatocellular carcinoma screening among patients with hepatitis B.

DESIGN

Single-blind randomised controlled trial.

SETTING AND PARTICIPANTS

Between 12 March and 19 July 2021, 178 patients with hepatitis B were recruited from six inpatient wards of a university-affiliated hospital in northern China.

METHODS

Participants were randomly allocated to receive usual care (n = 89) or usual care plus a nurse-led decision counselling programme (n = 89). Underpinned by the preventive health model, the programme consisted of health education, tailored information, and values clarification exercises to elicit informed and value-based preferences for hepatocellular carcinoma screening. Screening barriers were explored and addressed through procedural problem-solving. Hepatocellular carcinoma screening rate at six months post-baseline was the primary outcome. Secondary outcomes (knowledge, perceptions, and decision conflicts regarding hepatocellular carcinoma screening) were measured at baseline (T0), immediately after the intervention (T1), and the six-month follow-up (T2). A Medical Research Council framework-guided process evaluation was conducted by drawing on data from intervention documentation, WeChat discussions, and interviews with stakeholders (n = 13).

RESULTS

With a mean age of 47.32 (8.78) years, participants mostly occupied rural residences (63.5 %). Compared with the control group, the intervention group had significantly higher hepatocellular carcinoma screening rates (75.6 % vs. 42.1 %, p < 0.001) and displayed greater improvements in the scores of hepatocellular carcinoma screening knowledge (β = 3.643, 95 % confidence interval [CI] = 3.030, 4.255), salience and coherence (β = 0.410, 95 % CI = 0.234, 0.586), response efficacy (β = 0.327, 95 % CI = 0.181, 0.473), and perceived susceptibility (β = 0.214, 95 % CI = 0.040, 0.388) at T1. Improvement in perceived susceptibility was not maintained, whereas a higher decrease of the decision conflict score was found at T2 (β = -4.156, 95 % CI = -7.851, -0.461). The process evaluation revealed potential intervention mechanisms and contextual factors affecting intervention effectiveness, such as living status and natural disasters.

CONCLUSION

The programme was effective in improving hepatocellular carcinoma screening and showed that nurses could play a decision counselling role in optimising the screening among patients with hepatitis B.

TRIAL REGISTRATION

ClinicalTrials.govNCT04659005. Registration date: 9 December, 2020.

TWEETABLE ABSTRACT

Nurse-led decision counselling improves hepatocellular carcinoma screening in patients with hepatitis B.

The impact of social risk factors on the presentation, treatment and survival of patients with hepatocellular carcinoma at an urban, academic safety-net hospital

BACKGROUND

Vulnerable populations have worse hepatocellular carcinoma (HCC) outcomes. We sought to understand if this could be mitigated at a safety-net hospital.

METHODS

A retrospective chart review of HCC patients was conducted (2007-2018). Stage at presentation, intervention and systemic therapy were analyzed (Chi-square for categorical variables and Wilcoxon tests for continuous variables) and median survival calculated by Kaplan-Meier method.

RESULTS

388 HCC patients were identified. Sociodemographic factors were similar for stage at presentation, except insurance status (diagnosis at earlier stages for commercial insurance and later stages for safety-net/no insurance). Higher education level and origin of mainland US increased intervention rates for all stages. Early-stage disease patients had no differences in receipt of intervention or therapy. Late-stage disease patients with higher education level had increased intervention rates. Median survival was not impacted by any sociodemographic factor.

CONCLUSION

Urban safety-net hospitals with a focus on vulnerable patient populations provide equitable outcomes and can serve as a model to address inequities in HCC management.

Is There Really a Difference in Outcomes between Men and Women with Hepatocellular Cancer?

Hepatocellular carcinoma (HCC) is a male-dominated disease. Currently, gender differences remain incompletely defined. Data from the state tumor registry were used to investigate differences in demographics, comorbidities, treatment patterns, and cancer-specific survival (HSS) among HCC patients according to gender. Additional analyses were performed to evaluate racial differences among women with HCC. 2627 patients with HCC were included; 498 (19%) were women. Women were mostly white (58%) or African American (39%)-only 3.8% were of another or unknown race. Women were older (65.1 vs. 61.3 years), more obese (33.7% vs. 24.2%), and diagnosed at an earlier stage (31.7% vs. 28.4%) than men. Women had a lower incidence of liver associated comorbidities (36.1% vs. 43%), and more often underwent liver-directed surgery (LDS; 27.5% vs. 22%). When controlling for LDS, no survival differences were observed between genders. African American women had similar HSS rates compared to white women (HR 1.14 (0.91,1.41), p = 0.239) despite having different residential and treatment geographical distributions. African American race and age >65 were predictive for worse HSS in men, but not in women. Overall, women with HCC undergo more treatment options-likely because of the earlier stage of the cancer and/or less severe underlying liver disease. However, when controlling for similar stages and treatments, HCC treatment outcomes were similar between men and women. African American race did not appear to influence outcomes among women with HCC as it did in men.

Surgical Eligibility Does Not Imply Surgical Equity: Recommendations for Curative Treatment in Patients With Stage I/II Pancreatic Head Adenocarcinoma Differ by Age and Race

OBJECTIVE

We sought to characterize differences in pancreatectomy recommendation rates to surgically eligible patients with pancreatic ductal adenocarcinoma of the pancreatic head across age and racial groups.

BACKGROUND

Pancreatectomy is not recommended in almost half of otherwise healthy patients with stage I/II pancreatic ductal adenocarcinoma lacking a surgical contraindication. We characterized differences in pancreatectomy recommendation among surgically eligible patients across age and racial groups.

METHODS

Non-Hispanic White (NHW) and Non-Hispanic Black (NHB) patients were identified in the National Cancer Database with clinical stage I/II pancreatic head adenocarcinoma, Charlson Comorbidity Index of 0 to 1, and age 40 to 89 years. Rates of surgery recommendation and overall survival (OS) by age and race were compared. A Pancreatectomy Recommendation Equivalence Point (PREP) was defined as the age at which the rate of not recommending surgery matched the rate of recommending and completing surgery. Marginal standardization was used to identify association of age and race with recommendation. OS was compared using Kaplan-Meier and Cox regression models.

RESULTS

Among 40,866 patients, 36,133 (88%) were NHW and 4733 (12%) were NHB. For the entire cohort, PREP was 79 years. PREP was 5 years younger in NHB patients than in NHW patients (75 vs 80 years). Adjusted rates of not recommending surgery were significantly higher for NHB than for NHW patients in each age group. After adjusting for surgery recommendation, we found no difference in OS between NHW and NHB patients (hazard ratio 0.98 [95% CI 0.94-1.02]).

CONCLUSIONS

PREP of NHB patients was 5 years younger than NHW patients, and in every age group, the rate of not recommending pancreatectomy was higher in NHB patients. Age and race disparities in treatment recommendations may contribute to shorter longevity of NHB patients.

Physician- and patient-reported barriers to hepatocellular carcinoma surveillance: A nationwide survey

Hepatocellular carcinoma (HCC) surveillance rates are suboptimal. We aimed to identify HCC surveillance barriers from both physician's and patient's perspectives and assess the effectiveness of physician education using social networks. A nationwide survey with 513 physicians and another single-center survey with 315 HCC-risk patients were conducted. Barriers to suboptimal surveillance were identified using univariate and multivariate logistic regression analysis. We educated 143 physicians by sending brief notes on HCC surveillance guidelines via social networks and re-evaluated their knowledge after 60 days using t test. Surveys showed 458 (86.3%), 254 (47.8%), and 225 (42.4%) physicians recommended surveillance in patients with cirrhosis, at-risk hepatitis B virus, and hepatitis C virus infection, respectively. Only 228 (42.9%) and 241 (38.0%) respondents adhered to recommended surveillance tools and interval, respectively. The main surveillance barriers among physicians were the lack of knowledge and resource limitations. The lack of a doctor's prescription was identified as a major barrier by patient' perspectives (odds ratio 1.4, 95% CI: 1.1-1.8, P = .024). Education via social networks enhanced physicians' knowledge, with pre- and post-education scores for guideline awareness of 63.0% versus 84.3% (P < .001) and for surveillance indication and tools of 40.0% versus 63.0% (P = .001), and 42.0% versus 59.3% (P = .015), respectively. Physicians' knowledge gap is a primary barrier for adherence to HCC surveillance protocols. Brief education via social networks shows effectiveness at increasing physicians' knowledge of HCC surveillance.

Disparities in risk of advanced stage liver cancer and mortality by race and ethnicity

BACKGROUND

In the United States liver cancer is the 5th and 7th most common cause of cancer related-death among men and women, respectively. Compared to other racial/ethnic groups in the U.S. Asian and Pacific Islander populations experience the highest incidence rates of liver cancer, but little is known about disparities in risk of advanced stage disease or risk of liver cancer mortality across these heterogenous populations. All statistical tests were 2-sided.

METHODS

In a population-based cohort of 60,146 patients 20-79 years of age diagnosed with liver cancer from 2004-2018 identified through the Surveillance, Epidemiology and End Results Program, we examined associations between race/ethnicity, including specific Asian and Pacific Islander subgroups, and risk of advanced stage liver cancer and liver cancer-specific mortality.

RESULTS

Compared to non-Hispanic White patients, non-Hispanic Black, Filipino, and Laotian patients had 30%-85% elevated odds of being diagnosed with stage IV liver cancer, while Hispanic, Vietnamese, and Chinese patients had 7-33% lower odds of being diagnosed with stage IV liver cancer (all p-values <0.05). Additionally, non-Hispanic Black, Kampuchean, and Laotian patients had 6-22% elevated hazards of liver cancer-specific mortality, and Hispanic, Vietnamese, Chinese, and Korean patients had 3-27% lower hazards of liver cancer-specific mortality (all p-values <0.05).

CONCLUSIONS

Substantial variations in risk of advanced stage liver cancer and in risk of liver cancer mortality were observed by race and ethnicity including considerable heterogeneity across individuals broadly defined as Asians and Pacific Islanders. Further efforts to understand the contributors to these disparities are needed in order to inform potential targeted screening and treatment interventions.

Hepatocellular carcinoma surveillance, incidence, and tumor doubling times in patients cured of hepatitis C

Background

Hepatocellular carcinoma (HCC) incidence and mortality vary by race/ethnicity and both are higher in Black patients than in Whites. For HCC surveillance, all cirrhotic patients are advised to undergo lifelong twice‐annual abdominal imaging. We investigated factors associated with surveillance and HCC incidence in a diverse HCC risk group, cirrhotic patients recently cured of hepatitis C virus (HCV) infection.

Methods

In this observational cohort study, all participants (n = 357) had advanced fibrosis/cirrhosis and were cured of HCV with antiviral treatment. None had Liver Imaging Reporting and Data System (LI‐RADS) 2–5 lesions prior to HCV cure. Ultrasound, computed tomography, and/or magnetic resonance imaging were used for surveillance.

Results

At a median follow‐up of 40 months [interquartile range (IQR) = 28–48], the median percentage of time up‐to‐date with surveillance was 49% (IQR) = 30%–71%. The likelihood of receiving a first surveillance examination was not significantly associated with race/ethnicity, but was higher for patients with more advanced cirrhosis, for example, bilirubin [odds ratio (OR) = 3.8/mg/dL, p = 0.002], private insurance (OR = 3.4, p = 0.006), and women (OR = 2.3, p = 0.008). The likelihood of receiving two or three examinations was significantly lower for non‐Hispanic Blacks and Hispanics versus non‐Hispanic Whites (OR = 0.39, and OR = 0.40, respectively, p < 0.005 for both) and for patients with higher platelet counts (OR = 0.99/10,000 cells/µl, p = 0.01), but higher for patients with private insurance (OR = 2.8, p < 0.001). Incident HCC was associated with higher bilirubin (OR = 1.7, p = 0.02) and lower lymphocyte counts (OR = 0.16, p = 0.01).

Conclusions

Contrary to best practices, HCC surveillance was associated with sociodemographic factors (insurance status and race/ethnicity) among patients cured of HCV. Guideline‐concordant surveillance is needed to address healthcare disparities.

Rates and Predictors of Undergoing Different Hepatocellular Carcinoma Screening Tests in Patients With Cirrhosis

INTRODUCTION

We aimed to assess rates and predictors of hepatocellular carcinoma (HCC) screening among patients with cirrhosis.

METHODS

We reviewed electronic health records of 11,361 patients with cirrhosis from 11 U.S. Veterans Health Administration facilities for receipt of HCC screening in the 6 months preceding October 1, 2019.

RESULTS

Nearly half of the cohort (46%) received HCC screening over a 6-month period. Screening rates and modalities (ultrasound, computed tomography, magnetic resonance imaging, serum alpha fetoprotein) varied by facility. Screening was associated with race/ethnicity, body mass index ≥ 25, cirrhosis etiology, thrombocytopenia, Fibrosis-4 ≥ 3.25, and lower Model for End-Stage Liver Disease-Sodium.

DISCUSSION

HCC screening rates varied by facility. Higher risk patients were more likely to receive screening.

Patients with hepatocellular carcinoma from more rural and lower-income households have more advanced tumor stage at diagnosis and significantly higher mortality

BACKGROUND

Patients from rural and low-income households may have suboptimal access to liver disease care, which may translate into worse HCC outcomes. The authors provide a comprehensive update of HCC incidence and outcomes among US adults, focusing on the effect of rural geography and household income on tumor stage and mortality.

METHODS

The authors retrospectively evaluated adults with HCC using Surveillance, Epidemiology, and End Results data from 2004 to 2017. HCC incidence was reported per 100,000 persons and was compared using z-statistics. Tumor stage at diagnosis used the Surveillance, Epidemiology, and End Results staging system and was evaluated with multivariate logistic regression. HCC mortality was evaluated using Kaplan-Meier and multivariate Cox proportional hazards methods.

RESULTS

HCC incidence plateaued for most groups, with the exception of American Indians/Alaska Natives (2004-2017: APC, 4.17%; P < .05) and patients in the lowest household income category (<$40,000; 2006-2017: APC, 2.80%; P < .05). Compared with patients who had HCC in large metropolitan areas with a population >1 million, patients in more rural regions had higher odds of advanced-stage HCC at diagnosis (odds ratio, 1.10; 95% CI, 1.00-1.20; P = .04) and higher mortality (hazard ratio, 1.05; 95% CI, 1.01-1.08; P = .02). Compared with the highest income group (≥$70,000), patients with HCC who earned <$40,000 annually had higher odds of advanced-stage HCC (odds ratio, 1.15; 95% CI, 1.01-1.32; P = .03) and higher mortality (hazard ratio, 1.23; 95% CI, 1.16-1.31; P < .001).

CONCLUSIONS

Patients from rural regions and lower-income households had more advanced tumor stage at diagnosis and significantly higher HCC mortality. These disparities likely reflect suboptimal access to consistent high-quality liver disease care, including HCC surveillance.

Understanding Gaps in the Hepatocellular Carcinoma Cascade of Care: Opportunities to Improve Hepatocellular Carcinoma Outcomes

Hepatocellular carcinoma (HCC) is a leading cause of morbidity and mortality. Existing studies have highlighted significant disparities in HCC outcomes, particularly among vulnerable populations, including ethnic minorities, safety-net populations, underinsured patients, and those with low socioeconomic status and high risk behaviors. The majority of these studies have focused on HCC surveillance. Although HCC surveillance is one of the most important first steps in HCC monitoring and management, it is only one step in the complex HCC cascade of care that evolves from surveillance to diagnosis and tumor staging that leads to access to HCC therapies. In this current review, we explore the disparities that exist along this complex HCC cascade of care and further highlight potential interventions that have been implemented to improve HCC outcomes. These interventions focus on patient, provider, and system level factors and provide a potential framework for health systems to implement quality improvement initiatives to improve HCC monitoring and management.