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Bittermann T, Yagan L, Kathawate RG, Weinberg EM, Peyster EG, Lewis JD, Levy C, Goldberg DS. Real-world evidence for factors associated with maintenance treatment practices among US adults with autoimmune hepatitis. Hepatology 2024:01515467-990000000-00908. [PMID: 38865589 DOI: 10.1097/hep.0000000000000961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 05/30/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND AND AIMS While avoidance of long-term corticosteroids is a common objective in the management of autoimmune hepatitis (AIH), prolonged immunosuppression is usually required to prevent disease progression. This study investigates the patient and provider factors associated with treatment patterns in US patients with AIH. APPROACH AND RESULTS A retrospective cohort of adults with the incident and prevalent AIH was identified from Optum's deidentified Clinformatics Data Mart Database. All patients were followed for at least 2 years, with exposures assessed during the first year and treatment patterns during the second. Patient and provider factors associated with corticosteroid-sparing monotherapy and cumulative prednisone use were identified using multivariable logistic and linear regression, respectively.The cohort was 81.2% female, 66.3% White, 11.3% Black, 11.2% Hispanic, and with a median age of 61 years. Among 2203 patients with ≥1 AIH prescription fill, 83.1% received a single regimen for >6 months of the observation year, which included 52.2% azathioprine monotherapy, 16.9% azathioprine/prednisone, and 13.3% prednisone monotherapy. Budesonide use was uncommon (2.1% combination and 1.9% monotherapy). Hispanic ethnicity (aOR: 0.56; p = 0.006), cirrhosis (aOR: 0.73; p = 0.019), osteoporosis (aOR: 0.54; p =0.001), and top quintile of provider AIH experience (aOR: 0.66; p = 0.005) were independently associated with lower use of corticosteroid-sparing monotherapy. Cumulative prednisone use was greater with diabetes (+441 mg/y; p = 0.004), osteoporosis (+749 mg/y; p < 0.001), and highly experienced providers (+556 mg/y; p < 0.001). CONCLUSIONS Long-term prednisone therapy remains common and unexpectedly higher among patients with comorbidities potentially aggravated by corticosteroids. The greater use of corticosteroid-based therapy with highly experienced providers may reflect more treatment-refractory disease.
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Affiliation(s)
- Therese Bittermann
- Division of Gastroenterology and Hepatology Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lina Yagan
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Ethan M Weinberg
- Division of Gastroenterology and Hepatology Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Eliot G Peyster
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - James D Lewis
- Division of Gastroenterology and Hepatology Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Cynthia Levy
- Department of Medicine, Division of Digestive Health & Liver Diseases, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - David S Goldberg
- Department of Medicine, Division of Digestive Health & Liver Diseases, Miller School of Medicine, University of Miami, Miami, Florida, USA
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Urias E, Tedesco NR, Burkholder DA, Moran IJ, Miller MJ, Jasty VSJ, Patil S, Zoellner S, Wijarnpreecha K, Chen VL. PNPLA3 risk allele is associated with risk of hepatocellular carcinoma but not decompensation in compensated cirrhosis. Hepatol Commun 2024; 8:e0441. [PMID: 38780253 PMCID: PMC11124711 DOI: 10.1097/hc9.0000000000000441] [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: 01/31/2024] [Accepted: 03/03/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND The PNPLA3-rs738409-G, TM6SF2-rs58542926-T, and HSD17B13-rs6834314-A polymorphisms have been associated with cirrhosis, hepatic decompensation, and HCC. However, whether they remain associated with HCC and decompensation in people who already have cirrhosis remains unclear, which limits the clinical utility of genetics in risk stratification as HCC is uncommon in the absence of cirrhosis. We aimed to characterize the effects of PNPLA3, TM6SF2, and HSD17B13 genotype on hepatic decompensation, HCC, and liver-related mortality or liver transplant in patients with baseline compensated cirrhosis. METHODS We conducted a single-center retrospective study of patients in the Michigan Genomics Initiative who underwent genotyping. The primary predictors were PNPLA3, TM6SF2, and HSD17B13 genotypes. Primary outcomes were either hepatic decompensation, HCC, or liver-related mortality/transplant. We conducted competing risk Fine-Gray analyses on our cohort. RESULTS We identified 732 patients with baseline compensated cirrhosis. During follow-up, 50% of patients developed decompensation, 13% developed HCC, 24% underwent liver transplant, and 27% died. PNPLA3-rs738409-G genotype was associated with risk of incident HCC: adjusted subhazard hazard ratio 2.42 (1.40-4.17), p=0.0015 for PNPLA3-rs738409-GG vs. PNPLA3-rs738409-CC genotype. The 5-year cumulative incidence of HCC was higher in PNPLA3-rs738409-GG carriers than PNPLA3-rs738409-CC/-CG carriers: 15.6% (9.0%-24.0%) vs. 7.4% (5.2%-10.0%), p<0.001. PNPLA3 genotype was not associated with decompensation or the combined outcome of liver-related mortality or liver transplant. TM6SF2 and HSD17B13 genotypes were not associated with decompensation or HCC. CONCLUSIONS The PNPLA3-rs738409-G allele is associated with an increased risk of HCC among patients with baseline compensated cirrhosis. People with cirrhosis and PNPLA3-rs738409-GG genotype may warrant more intensive HCC surveillance.
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Affiliation(s)
- Esteban Urias
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Nicholas R. Tedesco
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Daniel A. Burkholder
- Division of Gastroenterology and Hepatology, Houston Methodist Hospital, Houston, Texas, USA
| | - Isabel J. Moran
- Michigan State University College of Medicine, East Lansing, Michigan, USA
| | - Matthew J. Miller
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Venkata Sai J. Jasty
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Snehal Patil
- Department of Biostatistics and Center for Statistical Genetics, University of Michigan, Ann Arbor, Michigan, USA
| | - Sebastian Zoellner
- Department of Biostatistics and Center for Statistical Genetics, University of Michigan, Ann Arbor, Michigan, USA
| | - Karn Wijarnpreecha
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Arizona College of Medicine—Phoenix, Phoenix, Arizona, USA
| | - Vincent L. Chen
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
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Jonas MC, Sheu YS, Wright K, Peyton L, Bishop RC, Basra S, Sarwar F, Winn G, Chesbrough K. A care coordination program to support patients with hepatitis B virus at Kaiser Permanente Mid-Atlantic States. BMC Health Serv Res 2024; 24:482. [PMID: 38637807 PMCID: PMC11027294 DOI: 10.1186/s12913-024-10907-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 03/26/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND Eliminating hepatitis B virus (HBV) is a significant worldwide challenge requiring innovative approaches for vaccination, screening, disease management, and the prevention of related conditions. Programs that support patients in accessing needed clinical services can help optimize access to preventive services and treatment resources for hepatitis B. METHODS Here, we outline a coordinator-supported program (HBV Pathway) that connects patients infected with HBV to laboratory testing, imaging, and specialty care for treatment initiation and/or liver cancer surveillance (screening of high-risk patients for liver cancer). This study describes the HBV Pathway steps and reports sociodemographic factors of patients by initiation and completion. RESULTS Results showed a 72.5% completion rate (defined as completing all Pathway steps including the final specialty visit) among patients who initiated the Pathway. Differences in completion were observed by age, race, ethnicity, and service area, with higher rates for younger ages, Asian race, non-Hispanic ethnicity, and lower rates for patients within one service area. Of those who completed the specialty visit, 59.5% were referred for hepatocellular carcinoma surveillance. CONCLUSIONS The HBV Pathway offers dual benefits- care coordination support for patients to promote Pathway completion and a standardized testing and referral program to reduce physician burden. This program provides an easy and reliable process for patients and physicians to obtain updated clinical information and initiate treatment and/or liver cancer screening if needed.
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Affiliation(s)
- M Cabell Jonas
- Mid-Atlantic Permanente Research Institute, Mid-Atlantic Permanente Medical Group, Rockville, MD, USA.
| | - Yi-Shin Sheu
- Mid-Atlantic Permanente Research Institute, Mid-Atlantic Permanente Medical Group, Rockville, MD, USA
| | - Kara Wright
- Mid-Atlantic Permanente Research Institute, Mid-Atlantic Permanente Medical Group, Rockville, MD, USA
| | - Lauren Peyton
- Mid-Atlantic Permanente Research Institute, Mid-Atlantic Permanente Medical Group, Rockville, MD, USA
| | - R Clayton Bishop
- Mid-Atlantic Permanente Research Institute, Mid-Atlantic Permanente Medical Group, Rockville, MD, USA
| | - Sundeep Basra
- Mid-Atlantic Permanente Research Institute, Mid-Atlantic Permanente Medical Group, Rockville, MD, USA
| | - Fariha Sarwar
- Mid-Atlantic Permanente Research Institute, Mid-Atlantic Permanente Medical Group, Rockville, MD, USA
| | - Grace Winn
- Mid-Atlantic Permanente Research Institute, Mid-Atlantic Permanente Medical Group, Rockville, MD, USA
| | - Karen Chesbrough
- Mid-Atlantic Permanente Research Institute, Mid-Atlantic Permanente Medical Group, Rockville, MD, USA
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Curran C, Priest M, Datta S, Forrest EH, Stanley AJ, Barclay ST. Hepatocellular Carcinoma Risk Scores Predict Patients Under Surveillance at Low Risk of Benefit and High Risk of Harm. Dig Dis Sci 2023; 68:770-777. [PMID: 36376575 DOI: 10.1007/s10620-022-07731-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 10/11/2022] [Indexed: 02/08/2023]
Abstract
AIMS Surveillance for hepatocellular carcinoma (HCC) is recommended for patients with cirrhosis. Multiple risk scores aim to stratify HCC risk, potentially allowing individualized surveillance strategies. We sought to validate four risk scores and quantify the consequences of surveillance via the calculation of numbers needed to benefit (NNB) and harm (NNH) according to classification by risk score strata. METHODS Data were collected on 482 patients with cirrhosis during 2013-2014, with follow-up until 31/12/2019. Risk scores (aMAP, Toronto risk index, ADRESS HCC, HCC risk score) were derived from index clinic results. The area under the receiving operating characteristic curve (AUC) was calculated for each. Additionally, per-risk strata, NNB was calculated as total surveillance ultrasounds per surveillance diagnosed early HCC (stage 0/A) and NNH as total ultrasounds performed per false positive (abnormal surveillance with normal follow-up imaging). RESULTS 22 (4.6%) patients developed HCC. 77% (17/22) were diagnosed through surveillance, of which 13/17 (76%) were early stage. There were 88 false positives and no false negatives (normal surveillance result however subsequent HCC detection). Overall NNB and NNH were 241 and 36, respectively. No score was significantly superior using AUC. Patients classified as low risk demonstrated no surveillance benefit (AMAP, THRI) or had a high NNB of > 300/900 (ADRESS HCC, HCC risk score), with low NNH (24-38). CONCLUSION Given the lack of benefit and increased harm through false positives in low-risk groups, a risk-based surveillance strategy may have the potential to reduce patient harm and increase benefit from HCC surveillance. CLINICAL TRIALS REGISTRATION This was not a clinical trial and the study was not pre-registered.
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Affiliation(s)
- Chris Curran
- Department of Gastroenterology, Queen Elizabeth University Hospital, 1345 Govan Rd, Glasgow, G51 4TF, UK.
- , Flat 2/2, 53 Dalnair Street, Glasgow, G3 8SQ, UK.
| | - Matthew Priest
- Department of Gastroenterology, Queen Elizabeth University Hospital, 1345 Govan Rd, Glasgow, G51 4TF, UK
| | - Shouren Datta
- Department of Gastroenterology, Queen Elizabeth University Hospital, 1345 Govan Rd, Glasgow, G51 4TF, UK
| | - Ewan H Forrest
- Department of Gastroenterology, Glasgow Royal Infirmary, 84 Castle St, Glasgow, G4 0SF, UK
- College of Medical, Veterinary & Life Sciences, University of Glasgow, Wolfson Medical School Building, University Avenue, Glasgow, G12 8QQ, UK
| | - Adrian J Stanley
- Department of Gastroenterology, Glasgow Royal Infirmary, 84 Castle St, Glasgow, G4 0SF, UK
- College of Medical, Veterinary & Life Sciences, University of Glasgow, Wolfson Medical School Building, University Avenue, Glasgow, G12 8QQ, UK
| | - Stephen T Barclay
- Department of Gastroenterology, Glasgow Royal Infirmary, 84 Castle St, Glasgow, G4 0SF, UK
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Bittermann T, Lewis JD, Levy C, Goldberg DS. Sociodemographic and geographic differences in the US epidemiology of autoimmune hepatitis with and without cirrhosis. Hepatology 2023; 77:367-378. [PMID: 35810446 PMCID: PMC9829924 DOI: 10.1002/hep.32653] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/17/2022] [Accepted: 07/04/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND AIMS Data on the epidemiology of autoimmune hepatitis (AIH) in the United States are limited. This study investigated the sociodemographic and geographic factors associated with AIH incidence and prevalence with and without cirrhosis. APPROACH AND RESULTS In a retrospective cohort of adults in the Optum Clinformatics Data Mart (2009-2018), we identified AIH cases using a validated claims-based algorithm. Incidence and prevalence were compared between sociodemographic subgroups. Logistic regression evaluated the association of US Census Division with AIH incidence and the factors associated with incident AIH with cirrhosis. From 2009 to 2018, the age- and sex-standardized prevalence of AIH in the Optum cohort was 26.6 per 100,000 persons with an incidence of 4.0 per 100,000 person-years. AIH incidence increased earlier among Hispanics (age 50-59 years) and later among Asians (≥80 years). Adjusted AIH incidence was higher in the Mountain Division (odds ratio [OR] 1.17) and lower in the Pacific (OR 0.68), Middle Atlantic (OR 0.81), and West North Central Divisions (OR 0.86 vs. East North Central; p < 0.001). Male sex (OR 1.31, p = 0.003), Black race (OR 1.32, p = 0.022), and Hispanic ethnicity (OR 1.37 vs. non-Hispanic White, p = 0.009) were associated with incident AIH with cirrhosis. Incident AIH with cirrhosis was greater in the West South Central Division (OR 1.30 vs. South Atlantic; p = 0.008). CONCLUSIONS AIH epidemiology differs according to sociodemographic and geographic factors in the United States. Studies are needed to determine the genetic, epigenetic, and environmental factors underlying the heterogeneity in AIH risk and outcomes.
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Affiliation(s)
- Therese Bittermann
- Division of Gastroenterology & Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Biostatistics and Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - James D. Lewis
- Division of Gastroenterology & Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Biostatistics and Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Cynthia Levy
- Division of Digestive Health and Liver Disease, University of Miami Miller School of Medicine, Miami, FL
| | - David S. Goldberg
- Division of Digestive Health and Liver Disease, University of Miami Miller School of Medicine, Miami, FL
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Dawkins A, Nelson LW, Gulati V, Stepp A, Chapelin F, Khurana A. Interobserver Agreement Between Primary Sonographers and Secondary Overreaders for Screening and Surveillance Liver Ultrasounds Using Ultrasound Liver Imaging Reporting and Data System. Ultrasound Q 2022; 38:116-123. [PMID: 35678479 DOI: 10.1097/ruq.0000000000000566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
ABSTRACT The authors aim to identify if primary sonographers and secondary reviewers, both radiologists and sonographers, are likely to assign the same Ultrasound Liver Imaging Reporting and Data System (US LI-RADS) scores for liver surveillance ultrasounds. Institutional review board approval was obtained. Sonographers were familiarized with US LI-RADS via radiologist-led lectures. Three sonographers prospectively scored 170 screening examinations using US LI-RADS recommendations. Scans were retrospectively rescored by a fourth sonographer and a radiologist, both of whom were blinded to the original scores. Results were analyzed with weighted and nonweighted Cohen kappa statistical analysis methods. There was near-perfect agreement between primary and secondary sonographers and primary sonographer and radiologist (kappa of 0.87 and 0.92, respectively) for US LI-RADS category (cat) scores. However, only substantial and moderate agreements were noted for visualization (vis) scores between primary and secondary sonographers and primary sonographer and radiologist (weighted kappa of 0.73 and 0.48, respectively). There was vis score disagreement between the primary sonographer and radiologist in 60 (35.3%) cases. In 35 (20%) cases, the radiologist assigned a lower/more conservative vis score. There was vis score disagreement between the primary and secondary reviewing sonographers in 30 (17.6%) cases. In 12 (7%) cases, the secondary sonographer assigned a more conservative vis score. Although a good degree of concordance was noted between the groups, radiologists will need to generate their own US LI-RADS scoring to accurately reflect their impression and appropriately steer management.
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Affiliation(s)
- Adrian Dawkins
- Department of Radiology, University of Kentucky Lexington, KY
| | - Leslie W Nelson
- Department of Radiology, University of Kentucky Lexington, KY
| | - Vaibhav Gulati
- Imaging Associates at National Heart Institute, New Delhi, India
| | - Angela Stepp
- Department of Radiology, University of Kentucky Lexington, KY
| | - Fanny Chapelin
- Department of Biomedical Engineering, University of Kentucky, Lexington, KY
| | - Aman Khurana
- Department of Radiology, University of Kentucky Lexington, KY
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Lee B, Keyes E, Rachocki C, Grimes B, Chen E, Vittinghoff E, Ladabaum U, Somsouk M. Increased Colorectal Cancer Screening Sustained with Mailed Fecal Immunochemical Test Outreach. Clin Gastroenterol Hepatol 2022; 20:1326-1333.e4. [PMID: 34280552 DOI: 10.1016/j.cgh.2021.07.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 07/07/2021] [Accepted: 07/13/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Reports of mailed fecal immunochemical test (FIT) outreach effectiveness over time are minimal. We aimed to better evaluate a mailed FIT program with longitudinal metrics. METHODS A total of 10,771 patients aged 50 to 75 years not up-to-date with colorectal cancer screening were randomized to intervention or usual care. The intervention arm received an advanced notification call and informational postcard prior to a mailed FIT. Usual care was at the discretion of the primary care provider. Patients were followed for up to 2.5 years. The primary outcome was the difference in cumulative proportion of completed FIT screening between arms. Screening was further examined with the proportion of time up-to-date, consistency of adherence, and frequency of abnormal FIT. RESULTS The cumulative proportion of FIT completion was higher in the outreach intervention (73.2% vs 55.1%; P < .001). The proportion of time covered by screening was higher in the intervention group (46.8% vs 27.3%; Δ19.6%; 95% confidence interval, 18.2%-20.9%). Patients assigned to FIT outreach were more likely to consistently complete FITs (2 completed of 2 offered) (50.1% vs 21.8%; P < .001). However, for patients who did not complete the FIT during the first cycle, only 17.1% completed a FIT during the second outreach cycle. The number and overall proportion of abnormal FIT was significantly higher in the outreach intervention (6.9% Outreach vs 4.1% Usual Care; P < .01). CONCLUSIONS Organized mailed FIT outreach significantly increased colorectal cancer screening over multiple years in this safety-net health system. Although mailing was overall effective, the effect was modest in patients who did not complete FIT in first cycle of intervention. (ClincialTrials.gov, NCT02613260).
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Affiliation(s)
- Briton Lee
- School of Medicine, University of California San Francisco, San Francisco, California
| | - Erin Keyes
- Division of Gastroenterology, University of California San Francisco, San Francisco, California
| | | | - Barbara Grimes
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | - Ellen Chen
- San Francisco Health Network, San Francisco, California
| | | | - Uri Ladabaum
- Division of Gastroenterology, Stanford University, Palo Alto, California
| | - Ma Somsouk
- Division of Gastroenterology, University of California San Francisco, San Francisco, California.
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Ah Hwang J, Wook Kang T, Hye Min J, Kon Kim Y, Hyun Kim S, Hyun Sinn D, Kim K. Association between intensity of imaging surveillance and clinical outcomes in patients with hepatocellular carcinoma. Eur J Radiol 2022; 151:110328. [DOI: 10.1016/j.ejrad.2022.110328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 04/10/2022] [Accepted: 04/16/2022] [Indexed: 11/15/2022]
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Woolen SA, Singal AG, Davenport MS, Troost JP, Khalatbari S, Mittal S, Siddiqui S, Fobar A, Morris J, Odewole M, Tapper EB, Pillai A, Parikh ND. Patient Preferences for Hepatocellular Carcinoma Surveillance Parameters. Clin Gastroenterol Hepatol 2022; 20:204-215.e6. [PMID: 33618022 PMCID: PMC9150784 DOI: 10.1016/j.cgh.2021.02.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 02/01/2021] [Accepted: 02/15/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND AIMS Professional societies recommend abdominal ultrasound (US) with or without alpha fetoprotein (AFP) for hepatocellular cancer (HCC) surveillance; however, there are several emerging surveillance modalities, including abbreviated MRI and blood-based biomarker panels. Most studies have focused on provider perspectives for surveillance logistics, but few have assessed patient preferences. We aimed to measure preferences among patients with cirrhosis regarding HCC surveillance modalities. METHODS We conducted a choice-based conjoint survey to patients with cirrhosis at four institutions. Participants were provided 15 scenarios in which they were asked to choose surveillance modalities based on five test attributes: benefits, i.e. sensitivity for early HCC (range: 35-95%), physical harm, i.e. false positives requiring additional testing (range: 10-40%), financial harm, i.e. out-of-pocket costs (range: $10-100), test logistics and convenience, i.e. duration of testing (range: 10-60 min). Hierarchical Bayes discrete choice conjoint analysis was used to derive attribute importance, and preference shares were determined by simulation. RESULTS In total 91% (182/199) of approached patients consented to participate in the study and 98% (n=179) successfully completed the survey. Surveillance benefits (importance: 51.3%, 95%CI: 49.0-53.4%) were valued more than risk of physical harm (importance: 7.6%, 95%CI 7.0-8.2%), financial harm (importance: 15.2%, 95%CI 14.0-16.3%), convenience (importance: 9.3%, 95%CI 8.5-10.1%) and test logistics (importance: 16.7%, 95%CI 15.4-18.1%). Based on simulations including all possible tests, patients preferred abbreviated MRI (29.0%), MRI (23.3%), or novel blood-based biomarkers (20.9%) to ultrasound alone (3.4%) or with AFP (8.8%). CONCLUSIONS Patients with cirrhosis prioritize early HCC detection over potential surveillance-related harms or inconvenience.
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Affiliation(s)
- Sean A. Woolen
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - Amit G. Singal
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas,North American Liver Cancer Consortium
| | - Matthew S. Davenport
- Department of Radiology, Michigan Medicine, Ann Arbor, Michigan,Department of Urology, Michigan Medicine, Ann Arbor, Michigan
| | - Jonathan P. Troost
- Michigan Institute for Clinical and Health Research, Michigan Medicine, Ann Arbor, Michigan
| | - Shokoufeh Khalatbari
- Michigan Institute for Clinical and Health Research, Michigan Medicine, Ann Arbor, Michigan
| | - Sukul Mittal
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas
| | - Sehar Siddiqui
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan
| | - Austin Fobar
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan
| | - Jason Morris
- Center for Liver Disease, University of Chicago, Chicago, Illinois
| | - Mobolaji Odewole
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas
| | - Elliot B. Tapper
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan
| | - Anjana Pillai
- North American Liver Cancer Consortium,Center for Liver Disease, University of Chicago, Chicago, Illinois
| | - Neehar D. Parikh
- North American Liver Cancer Consortium,Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan
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Renzulli M, Dajti E, Ierardi AM, Brandi N, Berzigotti A, Milandri M, Rossini B, Clemente A, Ravaioli F, Marasco G, Azzaroli F, Carrafiello G, Festi D, Colecchia A, Golfieri R. Validation of a standardized CT protocol for the evaluation of varices and porto-systemic shunts in cirrhotic patients. Eur J Radiol 2021; 147:110010. [PMID: 34801322 DOI: 10.1016/j.ejrad.2021.110010] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 10/19/2021] [Accepted: 10/26/2021] [Indexed: 12/18/2022]
Abstract
PURPOSE The aim of the present study was to propose and validate a standardized CT protocol for evaluating all the types of portosystemic collaterals (P-SC), including gastroesophageal varices and spontaneous portosystemic shunts (SPSS), and to evaluate the prognostic role of portal hypertension CT features for the prediction of the hepatic decompensation risk in cirrhotic patients. METHODS A retrospective cohort study of 184 advanced chronic liver disease who underwent CT scan between January 2014 and December 2017. Patients with an interval > 6 months between the imaging, elastometric, endoscopic and biochemical evaluation were excluded, as well as patients with previous transjugular intrahepatic portosystemic shunt (TIPS), liver transplantation (LT) or terminal medical conditions. Data on liver disease history, co-morbidities, endoscopic and radiologic findings were collected. The incidence of hepatic decompensation and other events, such as portal vein thrombosis, HCC, TIPS placement, LT, death, and its cause, were also recorded. The procedure was performed at baseline and after the administration of contrast agent using a multiphasic technique and bolus tracking. Two senior radiologists working in different centres and a non-expert radiologist reviewed all CT examinations, to evaluate both intra-observer and inter-observer variability of the CT protocol and to obtain an external validation. The radiological variables were evaluated using both univariate and adjusted multivariate competing risk regression models. RESULTS Both intra-observer and inter-observer agreement were excellent in detection and measurement of almost all types of P-SC. The presence of SPSS, a spleen diameter > 16 cm, a portal vein diameter > 17 mm and the presence of ascites resulted independent predictors of decompensation-free survival for cirrhotic patients and were incorporated in an easy-to-use score (AUROC = 0.799, p-value = 0.732) which can the risk of decompensation at 5 years, ranking it as low (11.3%), moderate (35.6%) or high (70.8%). CONCLUSIONS The CT protocol commonly performed during the HCC surveillance program for cirrhotic patients is valid for detecting all types of P-SC. The radiological score identified to predict the decompensation-free survival for cirrhotic patients could be an easy-to-use clinical tool.
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Affiliation(s)
- Matteo Renzulli
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, Bologna, Italy.
| | - Elton Dajti
- Department of Medical and Surgical Sciences (DIMEC), IRCCS, University of Bologna, Via Massarenti 9, Bologna 40138, Italy
| | - Anna Maria Ierardi
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano Milan, Italy
| | - Nicolò Brandi
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, Bologna, Italy
| | - Annalisa Berzigotti
- Hepatology, University Clinic for Visceral Surgery and Medicine, Inselspital, University of Bern, Bern, Switzerland
| | - Matteo Milandri
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, Bologna, Italy
| | - Benedetta Rossini
- Department of Medical and Surgical Sciences (DIMEC), IRCCS, University of Bologna, Via Massarenti 9, Bologna 40138, Italy
| | - Alfredo Clemente
- Radiology and Radiotherapy Unit, Department of Precision Medicine, University of Campania "L. Vanvitelli", 80138 Naples, Italy
| | - Federico Ravaioli
- Department of Medical and Surgical Sciences (DIMEC), IRCCS, University of Bologna, Via Massarenti 9, Bologna 40138, Italy
| | - Giovanni Marasco
- Department of Medical and Surgical Sciences (DIMEC), IRCCS, University of Bologna, Via Massarenti 9, Bologna 40138, Italy
| | - Francesco Azzaroli
- Department of Medical and Surgical Sciences (DIMEC), IRCCS, University of Bologna, Via Massarenti 9, Bologna 40138, Italy
| | - Gianpaolo Carrafiello
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano Milan, Italy
| | - Davide Festi
- Department of Medical and Surgical Sciences (DIMEC), IRCCS, University of Bologna, Via Massarenti 9, Bologna 40138, Italy
| | - Antonio Colecchia
- Unit of Gastroenterology, Borgo Trento University Hospital of Verona, Verona, Italy
| | - Rita Golfieri
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, Bologna, Italy
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11
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Chen VL, Yeh ML, Yang JD, Leong J, Huang DQ, Toyoda H, Chen YL, Guy J, Maeda M, Tsai PC, Huang CF, Yasuda S, Le AK, Dang H, Giama NH, Ali HA, Zhang N, Wang X, Jun DW, Tseng CH, Hsu YC, Huang JF, Dai CY, Chuang WL, Zhu Q, Dan YY, Schwartz M, Roberts LR, Yu ML, Nguyen MH. Effects of Cirrhosis and Diagnosis Scenario in Metabolic-Associated Fatty Liver Disease-Related Hepatocellular Carcinoma. Hepatol Commun 2021; 5:122-132. [PMID: 33437906 PMCID: PMC7789832 DOI: 10.1002/hep4.1606] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/02/2020] [Accepted: 08/08/2020] [Indexed: 12/15/2022] Open
Abstract
Metabolic-associated fatty liver disease (MAFLD) is a major cause of liver-related complications, including hepatocellular carcinoma (HCC). While MAFLD-related HCC is known to occur in the absence of cirrhosis, our understanding of MAFLD-related HCC in this setting is limited. Here, we characterize MAFLD-related HCC and the impact of cirrhosis and screening on survival. This was a multicenter, retrospective, cohort study of MAFLD-related HCC. MAFLD was defined based on the presence of race-adjusted overweight, diabetes, or both hypertension and dyslipidemia in the absence of excess alcohol use or other underlying cause of liver disease. The primary outcome of interest was overall survival, and the primary dependent variables were cirrhosis status and prior HCC screening. We used Kaplan-Meier methods to estimate overall survival and Cox proportional hazards models and random forest machine learning to determine factors associated with prognosis. This study included 1,382 patients from 11 centers in the United States and East/Southeast Asia. Cirrhosis was present in 62% of patients, but under half of these patients had undergone imaging within 12 months of HCC diagnosis. Patients with cirrhosis were more likely to have early stage disease but less often received curative therapy. After adjustment, cirrhosis was not associated with prognosis, but the presence of cancer-related symptoms at diagnosis was associated with poorer prognosis. Conclusion: Cirrhosis was not associated with overall survival in this cohort of MAFLD-related HCC, while diagnosis in the presence of symptoms was associated with poorer prognosis. The HCC surveillance rate in patients with MAFLD-related HCC was disappointingly low in a multicenter cohort.
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Affiliation(s)
- Vincent L Chen
- Division of GastroenterologyUniversity of Michigan Health SystemAnn ArborMIUSA
| | - Ming-Lun Yeh
- Hepatobiliary DivisionKaohsiung Medical University HospitalKaohsiungTaiwan.,Hepatitis Research CenterCollege of MedicineKaohsiung Medical UniversityKaohsiungTaiwan.,Center for Cancer ResearchKaohsiung Medical UniversityKaohsiungTaiwan
| | - Ju Dong Yang
- Comprehensive Transplant CenterCedars Sinai Medical CenterLos AngelesCAUSA
| | - Jennifer Leong
- Division of Liver DiseasesRecanati/Miller Transplantation InstituteIcahn School of MedicineNew YorkNYUSA
| | - Daniel Q Huang
- Division of Gastroenterology and HepatologyDepartment of MedicineNational University Health SystemSingaporeSingapore.,Department of MedicineNational University of SingaporeSingaporeSingapore
| | - Hidenori Toyoda
- Department of GastroenterologyOgaki Municipal HospitalOgakiJapan
| | - Yao-Li Chen
- Department of SurgeryChanghua Christian HospitalChanghuaTaiwan
| | - Jennifer Guy
- Division of Gastroenterology and HepatologyCalifornia Pacific Medical CenterSan FranciscoCA
| | - Mayumi Maeda
- Division of Gastroenterology and HepatologyStanford University Medical CenterStanfordCA
| | - Pei-Chien Tsai
- Hepatobiliary DivisionKaohsiung Medical University HospitalKaohsiungTaiwan.,Hepatitis Research CenterCollege of MedicineKaohsiung Medical UniversityKaohsiungTaiwan.,Center for Cancer ResearchKaohsiung Medical UniversityKaohsiungTaiwan
| | - Chung-Feng Huang
- Hepatobiliary DivisionKaohsiung Medical University HospitalKaohsiungTaiwan.,Hepatitis Research CenterCollege of MedicineKaohsiung Medical UniversityKaohsiungTaiwan.,Center for Cancer ResearchKaohsiung Medical UniversityKaohsiungTaiwan
| | - Satoshi Yasuda
- Department of GastroenterologyOgaki Municipal HospitalOgakiJapan
| | - An K Le
- Division of Gastroenterology and HepatologyStanford University Medical CenterStanfordCA
| | - Hansen Dang
- Division of Gastroenterology and HepatologyStanford University Medical CenterStanfordCA
| | - Nasra H Giama
- Department of Gastroenterology and HepatologyMayo ClinicRochesterMN
| | - Hamdi A Ali
- Department of Gastroenterology and HepatologyMayo ClinicRochesterMN
| | - Ning Zhang
- Department of Gastroenterology and HepatologyMayo ClinicRochesterMN
| | - Xiaozhong Wang
- Division of Gastroenterology and HepatologyTraditional Chinese Medicine Hospital of Xinjiang Uyghur Autonomous RegionUrumqiChina
| | - Dae Won Jun
- Division of GastroenterologyHanyang University Medical CenterSeoulRepublic of Korea
| | - Cheng-Hao Tseng
- Division of Gastroenterology and HepatologyE-Da Cancer Hospital/I-Shou UniversityKaohsiungTaiwan
| | - Yao-Chun Hsu
- Division of Gastroenterology and HepatologyE-Da Cancer Hospital/I-Shou UniversityKaohsiungTaiwan
| | - Jee-Fu Huang
- Hepatobiliary DivisionKaohsiung Medical University HospitalKaohsiungTaiwan.,Hepatitis Research CenterCollege of MedicineKaohsiung Medical UniversityKaohsiungTaiwan.,Center for Cancer ResearchKaohsiung Medical UniversityKaohsiungTaiwan
| | - Chia-Yen Dai
- Hepatobiliary DivisionKaohsiung Medical University HospitalKaohsiungTaiwan.,Hepatitis Research CenterCollege of MedicineKaohsiung Medical UniversityKaohsiungTaiwan.,Center for Cancer ResearchKaohsiung Medical UniversityKaohsiungTaiwan
| | - Wan-Long Chuang
- Hepatobiliary DivisionKaohsiung Medical University HospitalKaohsiungTaiwan.,Hepatitis Research CenterCollege of MedicineKaohsiung Medical UniversityKaohsiungTaiwan.,Center for Cancer ResearchKaohsiung Medical UniversityKaohsiungTaiwan
| | - Qiang Zhu
- Division of Gastroenterology and HepatologyShandong Provincial Hospital Affiliated to Shandong UniversityJinanChina
| | - Yock Young Dan
- Division of Gastroenterology and HepatologyDepartment of MedicineNational University Health SystemSingaporeSingapore.,Department of MedicineNational University of SingaporeSingaporeSingapore
| | - Myron Schwartz
- Division of Liver DiseasesRecanati/Miller Transplantation InstituteIcahn School of MedicineNew YorkNYUSA
| | - Lewis R Roberts
- Comprehensive Transplant CenterCedars Sinai Medical CenterLos AngelesCAUSA
| | - Ming-Lung Yu
- Hepatobiliary DivisionKaohsiung Medical University HospitalKaohsiungTaiwan.,Hepatitis Research CenterCollege of MedicineKaohsiung Medical UniversityKaohsiungTaiwan.,Center for Cancer ResearchKaohsiung Medical UniversityKaohsiungTaiwan
| | - Mindie H Nguyen
- Division of Gastroenterology and HepatologyStanford University Medical CenterStanfordCA
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12
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Abstract
Hepatocellular carcinoma (HCC) is increasing in prevalence and is the third leading cause of cancer-related death worldwide. Unlike other malignancies, HCC can be diagnosed with dynamic imaging with very high accuracy, and tissue diagnosis is not needed for cancer therapy. There is a unique role of established as well as developing biomarkers in diagnosis, prognosis, and management of HCC. Sequencing HCC tumors has yielded substantial insights into HCC tumor biology and has raised the possibility of precision oncology in which therapy decisions are guided by cancer genetics. However, it is not ready for prime time yet.
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Affiliation(s)
- Vincent L Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, 3912 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Pratima Sharma
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, 3912 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
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13
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Chen VL, Parikh ND. Author response to Letter to the Editor: 'Chronological change in alpha-foetoprotein levels in hepatocellular carcinoma after eradication of hepatitis C virus'. Liver Int 2020; 40:2307. [PMID: 32687626 DOI: 10.1111/liv.14612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Affiliation(s)
- Vincent L Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Neehar D Parikh
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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14
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Fukumoto T, Minami T, Tateishi R, Koike K. Chronological change in alpha-fetoprotein levels in hepatocellular carcinoma after eradication of hepatitis C virus. Liver Int 2020; 40:2305-2306. [PMID: 32463966 DOI: 10.1111/liv.14544] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 05/19/2020] [Indexed: 12/21/2022]
Affiliation(s)
- Tsuyoshi Fukumoto
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tatsuya Minami
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Ryosuke Tateishi
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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15
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Da Fonseca LG, Forner A. Adherence and quality are key for a beneficial HCC surveillance. Liver Int 2020; 40:751-753. [PMID: 32255572 DOI: 10.1111/liv.14421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 02/23/2020] [Indexed: 02/13/2023]
Affiliation(s)
- Leonardo G Da Fonseca
- Clinical Oncology, Instituto do Cancer do Estado de Sao Paulo, University of Sao Paulo, Sao Paulo, Brazil
| | - Alejandro Forner
- Liver Unit, Barcelona Clinic Liver Cancer (BCLC) group, Hospital Clinic Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
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