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Singal AG, Ng M, Kulkarni A. Advancing Surveillance Strategies for Hepatocellular Carcinoma: A New Era of Efficacy and Precision. J Clin Exp Hepatol 2024; 14:101448. [PMID: 38946864 PMCID: PMC11214318 DOI: 10.1016/j.jceh.2024.101448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 05/13/2024] [Indexed: 07/02/2024] Open
Abstract
Hepatocellular carcinoma (HCC) is one of the few cancers with a 5-year survival that has remained below 20%; however, prognosis differs by tumor stage at diagnosis. Curative treatment options among patients with early-stage HCC afford a median survival of 5-10 years. Accordingly, international society guidelines recommend semi-annual HCC surveillance in at-risk patients, including those with cirrhosis or high-risk chronic hepatitis B infection. Surveillance is associated with increased early-stage HCC detection and curative treatments, leading to reduced HCC-related mortality. Abdominal ultrasound has been the cornerstone for HCC surveillance for the past two decades, but recent data have highlighted its suboptimal sensitivity for early-stage HCC detection, particularly in patients with obesity and those with non-viral etiologies of liver disease. The combination of ultrasound plus alpha fetoprotein (AFP) has higher sensitivity for early-stage HCC detection than ultrasound alone, although the combination still misses over one-third of HCC at an early stage. Emerging imaging and blood-based biomarker strategies have promising data in biomarker phase 2 (case-control) and phase 3 (cohort) studies. Beyond ultrasound, Magnetic resonance imaging (MRI) is the best-studied imaging strategy, with superior sensitivity and specificity compared to ultrasound in a cohort study. Abbreviated MRI protocols have been proposed to address concerns about MRI radiological capacity, costs, and patient acceptance. Of biomarker strategies, GALAD (a panel including gender, age, AFP, AFP-L3, and DCP) is the best validated, with promising sensitivity for early-stage HCC detection in a national multi-center cohort study. Liquid biopsy biomarkers, including methylated DNA markers, have also shown promising accuracy in case-control studies. Abbreviated MRI and GALAD are now entering prospective trials that examine clinical outcomes such as early-stage HCC detection and screening-related harms, which are essential data to understand for adoption in clinical practice. As additional surveillance strategies become available, it will allow an era of precision surveillance in which optimal surveillance modalities are tailored to individual patient risk and expected test performance.
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Affiliation(s)
- Amit G. Singal
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Michelle Ng
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Anand Kulkarni
- Department of Hepatology, AIG Hospitals, Hyderabad, India
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Kristiansen MK, Larsen LP, Villadsen GE, Sørensen M. Clinical impact of MRI on indeterminate findings on contrast-enhanced CT suspicious of HCC. Scand J Gastroenterol 2024; 59:1075-1080. [PMID: 39061129 DOI: 10.1080/00365521.2024.2384952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 07/19/2024] [Accepted: 07/22/2024] [Indexed: 07/28/2024]
Abstract
OBJECTIVES In patients evaluated for hepatocellular carcinoma (HCC), magnetic resonance imaging (MRI) is often used secondarily when multiphase contrast-enhanced computed tomography (ceCT) is inconclusive. We investigated the clinical impact of adding MRI. MATERIALS AND METHODS This single-institution retrospective study included 48 MRI scans (44 patients) conducted from May 2016 to July 2023 due to suspicion of HCC on a multiphase ceCT scan. Data included medical history, preceding and subsequent imaging, histology when available, and decisions made at multidisciplinary team meetings. RESULTS In case of possible HCC recurrence, 63% of the MRI scans were diagnostic of HCC. For 80% of the negative MRI scans, the patients were diagnosed with HCC within a median of 165 days in the suspicious area of the liver. In case of possible de-novo HCC in patients with cirrhosis, 22% of the scans were diagnostic of HCC and 33% of the negative MRI scans were of patients diagnosed with HCC within a median of 109 days. None of the non-cirrhotic patients with possible de-novo HCC and negative MRI scans (64%) were later diagnosed with HCC, but 3/5 of the indeterminate scans were of patients diagnosed with HCC in a biopsy. CONCLUSIONS Secondary MRI to a multiphase ceCT scan suspicious of HCC is highly valuable in ruling out HCC in non-cirrhotic patients and in diagnosing HCC non-invasively in cirrhotic patients and patients with prior HCC. Patients with cirrhosis or prior HCC are still at high risk of having HCC if MRI results are inconclusive or negative.
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Affiliation(s)
| | - Lars Peter Larsen
- Department of Radiology, Aarhus University Hospital, Aarhus N, Denmark
| | | | - Michael Sørensen
- Department of Hepatology & Gastroenterology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Internal Medicine, Viborg Regional Hospital, Viborg, Denmark
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Bui H, Kumar NG, Singal AG, Boparai J, Mukhtar NA, Tran D, Saxena V, Balasubramanian S. Implementation of a Hepatocellular Carcinoma Surveillance Program in a Community-Based Integrated Health System in Patients With Hepatitis C Cirrhosis. Am J Gastroenterol 2024; 119:1506-1514. [PMID: 38334275 DOI: 10.14309/ajg.0000000000002704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 01/15/2024] [Indexed: 02/10/2024]
Abstract
INTRODUCTION Underutilization of hepatocellular cancer (HCC) surveillance has been reported, although data evaluating interventions to improve surveillance are sparse. We assessed the effect of a population-based HCC surveillance program on HCC surveillance utilization and outcomes. METHODS In this retrospective cohort study, we assessed preinclusion and postinclusion HCC surveillance patterns among 597 patients with hepatitis C virus cirrhosis enrolled in a program at an integrated health system between 2013 and 2020. Adequate surveillance was defined as at least 5 surveillance studies within 36 months pre-enrollment and postenrollment; a secondary outcome was proportion of time covered by surveillance over 36 months. Tumor size, stage, and receipt of curative therapy were compared between HCC detected on the first imaging examination (prevalent HCC) and surveillance-detected HCC (incident HCC). We performed Kaplan-Meier analysis and multivariable competing risk analysis to characterize the association between surveillance and mortality. RESULTS The surveillance program significantly improved surveillance completion (77.6% vs 5.0%, P < 0.001) and proportion time covered (80.9% vs 15.8%, P < 0.001). Compared with prevalent HCC, surveillance-detected cases were more likely unifocal (77.8% vs 44.8%, P < 0.001), early-stage (85.2% vs 44.8%, P < 0.001), with smaller maximum diameter (median 2.3 vs 3.2 cm), and more likely to undergo curative therapy (92.5% vs 72.4% P = 0.010). Survival was improved compared with prevalent cases hazard ratio (HR) 0.23 (0.11-0.51) after adjusting for age and Model for End Stage Liver Disease score. DISCUSSION Implementation of a population-based program resulted in significant improvement in HCC surveillance use and clinical outcomes among patients with hepatitis C virus cirrhosis. These findings may inform similar interventions by other healthcare systems.
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Affiliation(s)
- Hien Bui
- Pharmacology, Kaiser Permanente Northern California, California, USA
| | - Nikhilesh G Kumar
- Gastroenterology, Kaiser Permanente Northern California, California, USA
| | - Amit G Singal
- Department of Medicine, University of Texas Southwestern Medical Center, Texas, USA
| | - Jasdeep Boparai
- Hospital Based Service, Kaiser Permanente Northern California, California, USA
| | - Nizar A Mukhtar
- Gastroenterology, Kaiser Permanente Northern California, California, USA
| | - Don Tran
- Pharmacology, Kaiser Permanente Northern California, California, USA
| | - Varun Saxena
- Gastroenterology, Kaiser Permanente Northern California, University of California at San Francisco, California, USA
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Parikh ND, Jones P, Salgia R, Bhan I, Grinspan LT, Jou JH, Zhou K, Jalal P, Roccaro G, Rangnekar AS, Benhammou JN, Pillai A, Mehta N, Wedd J, Yang JD, Kim AK, Duarte-Rojo A, Oloruntoba OO, Tevar A, Au JS, Blain Y, Rao S, Catalano OA, Lewis S, Mendiratta-Lala M, King K, Sachdev L, Lee EW, Bruno J, Kamel I, Tolosa C, Kao K, Badawi T, Przybyszewski EM, Quirk L, Nathani P, Haydel B, Leven E, Wong N, Albertian R, Chen A, Aloor FZ, Mohamed IB, Elkheshen A, Marvil C, Issac G, Clinton JW, Woo SM, Yum J, Rieger E, Hutchison AL, Turner DA, Alsudaney M, Hernandez P, Xu Z, Khalid A, Barrick B, Wang B, Tapper EB, Hao W, Singal AG. Development and Validation of a Noninvasive Model for the Detection of High-Risk Varices in Patients with Unresectable HCC. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00678-5. [PMID: 39089513 DOI: 10.1016/j.cgh.2024.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 07/02/2024] [Accepted: 07/03/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND & AIMS Noninvasive variceal risk stratification systems have not been validated in patients with hepatocellular carcinoma (HCC), which presents logistical barriers for patients in the setting of systemic HCC therapy. We aimed to develop and validate a noninvasive algorithm for the prediction of varices in patients with unresectable HCC. METHODS We performed a retrospective cohort study in 21 centers in the United States including adult patients with unresectable HCC and Child-Pugh A5-B7 cirrhosis diagnosed between 2007 and 2019. We included patients who completed an esophagogastroduodonoscopy (EGD) within 12 months of index imaging but before HCC treatment. We divided the cohort into a 70:30 training set and validation set, with the goal of maximizing negative predictive value (NPV) to avoid EGD in low-risk patients. RESULTS We included 707 patients (median age, 64.6 years; 80.6% male; 74.0% White). Median time from HCC diagnosis to EGD was 47 (interquartile range, 114) days, with 25.0% of patients having high-risk varices. A model using clinical variables alone achieved an NPV of 86.3% in the validation cohort, whereas a model integrating clinical and imaging variables had an NPV 97.4% in validation. The clinical and imaging model would avoid EGDs in more than half of low-risk patients while misclassifying 7.7% of high-risk patients. CONCLUSIONS A model incorporating clinical and imaging data can accurately predict the absence of high-risk varices in patients with HCC and avoid EGD in many low-risk patients before the initiation of systemic therapy, thus expediting their care and avoiding treatment delays.
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Affiliation(s)
| | | | | | - Irun Bhan
- Massachusetts General Hospital, Boston, Massachusetts
| | | | - Janice H Jou
- Oregon Health Science University, Portland, Oregon
| | - Kali Zhou
- University of Southern California, Los Angeles, California
| | | | | | | | | | | | - Neil Mehta
- University of San Francisco, San Francisco, California
| | - Joel Wedd
- Virginia Commonwealth University, Richmond, Virginia
| | - Ju Dong Yang
- Cedars-Sinai Medical Center, Los Angeles, California
| | - Amy K Kim
- Johns Hopkins University, Baltimore, Maryland
| | | | | | - Amit Tevar
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | | | | | - Sara Lewis
- The Mount Sinai Hospital, New York, New York
| | | | - Kevin King
- University of Southern California, Los Angeles, California
| | - Lekha Sachdev
- Georgetown University, Washington, District of Columbia
| | - Edward W Lee
- University of California Los Angeles, Los Angeles, California
| | - Jill Bruno
- Virginia Commonwealth University, Richmond, Virginia
| | - Ihab Kamel
- Johns Hopkins University, Baltimore, Maryland
| | | | | | | | | | - Lisa Quirk
- University of Texas Southwestern, Dallas, Texas
| | | | | | - Emily Leven
- The Mount Sinai Hospital, New York, New York
| | - Nicole Wong
- Oregon Health Science University, Portland, Oregon
| | | | - Ariana Chen
- University of Southern California, Los Angeles, California
| | | | | | | | | | | | | | | | - Jung Yum
- University of California Los Angeles, Los Angeles, California
| | | | | | - Don A Turner
- Virginia Commonwealth University, Richmond, Virginia
| | | | | | - Ziyi Xu
- Johns Hopkins University, Baltimore, Maryland
| | | | | | - Bo Wang
- University of Michigan, Ann Arbor, Michigan
| | | | - Wei Hao
- University of Michigan, Ann Arbor, Michigan
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Shen J, Yang D, Zhou Y, Pei J, Wu Z, Wang X, Zhao K, Ding Y. Development of machine learning models for patients in the high intrahepatic cholangiocarcinoma incidence age group. BMC Geriatr 2024; 24:553. [PMID: 38918710 PMCID: PMC11197277 DOI: 10.1186/s12877-024-05154-3] [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: 12/19/2023] [Accepted: 06/17/2024] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND Intrahepatic cholangiocarcinoma (ICC) has a poor prognosis and is understudied. Based on the clinical features of patients with ICC, we constructed machine learning models to understand their importance on survival and to accurately determine patient prognosis, aiming to develop reference values to guide physicians in developing more effective treatment plans. METHODS This study used machine learning (ML) algorithms to build prediction models using ICC data on 1,751 patients from the SEER (Surveillance, Epidemiology, and End Results) database and 58 hospital cases. The models' performances were compared using receiver operating characteristic curve analysis, C-index, and Brier scores. RESULTS A total of eight variables were used to construct the ML models. Our analysis identified the random survival forest model as the best for prognostic prediction. In the training cohort, its C-index, Brier score, and Area Under the Curve values were 0.76, 0.124, and 0.882, respectively, and it also performed well in the test cohort. Kaplan-Meier survival analysis revealed that the model could effectively determine patient prognosis. CONCLUSIONS To our knowledge, this is the first study to develop ML prognostic models for ICC in the high-incidence age group. Of the ML models, the random survival forest model was best at prognosis prediction.
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Affiliation(s)
- Jie Shen
- Dept of hepatobiliary surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, 430060, China
| | - Dashuai Yang
- Dept of hepatobiliary surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, 430060, China
| | - Yu Zhou
- Dept of hepatobiliary surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, 430060, China
| | - Junpeng Pei
- Dept of hepatobiliary surgery, 521 Hospital of Norinco Group, Xi'an, Shaanxi, 710061, China
| | - Zhongkai Wu
- Dept of hepatobiliary surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, 430060, China
| | - Xin Wang
- Dept of hepatobiliary surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, 430060, China
| | - Kailiang Zhao
- Dept of hepatobiliary surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, 430060, China.
| | - Youming Ding
- Dept of hepatobiliary surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, 430060, China.
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Singal AG, Narasimman M, Daher D, Yekkaluri S, Liu Y, Lee M, Cerda V, Khan A, Seif El Dahan K, Kramer J, Gopal P, Murphy C, Hernaez R. Effectiveness of mailed outreach and patient navigation to promote HCC screening process completion: a multicentre pragmatic randomised clinical trial. Gut 2024:gutjnl-2024-332508. [PMID: 38839269 DOI: 10.1136/gutjnl-2024-332508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 05/22/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is plagued by failures across the cancer care continuum, leading to frequent late-stage diagnoses and high mortality. We evaluated the effectiveness of mailed outreach invitations plus patient navigation to promote HCC screening process completion in patients with cirrhosis. METHODS Between April 2018 and September 2021, we conducted a multicentre pragmatic randomised clinical trial comparing mailed outreach plus patient navigation for HCC screening (n=1436) versus usual care with visit-based screening (n=1436) among patients with cirrhosis at three US health systems. Our primary outcome was screening process completion over a 36-month period, and our secondary outcome was the proportion of time covered (PTC) by screening. All patients were included in intention-to-screen analyses. RESULTS All 2872 participants (median age 61.3 years; 32.3% women) were included in intention-to-screen analyses. Screening process completion was observed in 6.6% (95% CI: 5.3% to 7.9%) of patients randomised to outreach and 3.3% (95% CI: 2.4% to 4.3%) of those randomised to usual care (OR 2.05, 95% CI: 1.44 to 2.92). The intervention increased HCC screening process completion across most subgroups including age, sex, race and ethnicity, Child-Turcotte-Pugh class and health system. PTC was also significantly higher in the outreach arm than usual care (mean 37.5% vs 28.2%; RR 1.33, 95% CI: 1.31 to 1.35). Despite screening underuse, most HCC in both arms were detected at an early stage. CONCLUSION Mailed outreach plus navigation significantly increased HCC screening process completion versus usual care in patients with cirrhosis, with a consistent effect across most examined subgroups. However, screening completion remained suboptimal in both arms, underscoring a need for more intensive interventions. TRIAL REGISTRATION NUMBER NCT02582918.
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Affiliation(s)
- Amit G Singal
- Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Manasa Narasimman
- Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Darine Daher
- Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Sruthi Yekkaluri
- Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Yan Liu
- Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, USA
| | - MinJae Lee
- Population and Data Sciences, UT Southwestern Medical, Dallas, Texas, USA
| | - Vanessa Cerda
- Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Aisha Khan
- Michael E. DeBakey Veterans Affairs Medical Center, Center for Innovations in Quality, Effectiveness and Safety and Baylor College of Medicine, Houston, Texas, USA
| | - Karim Seif El Dahan
- Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jennifer Kramer
- Michael E. DeBakey Veterans Affairs Medical Center, Center for Innovations in Quality, Effectiveness and Safety and Baylor College of Medicine, Houston, Texas, USA
| | - Purva Gopal
- Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Caitlin Murphy
- School of Public Health, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Ruben Hernaez
- Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, USA
- Gastroenterology and Hepatology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
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Singal AG, Parikh ND, Shetty K, Han SH, Xie C, Ning J, Rinaudo JA, Arvind A, Lok AS, Kanwal F. Natural History of Indeterminate Liver Nodules in Patients With Advanced Liver Disease: A Multicenter Retrospective Cohort Study. Am J Gastroenterol 2024:00000434-990000000-01151. [PMID: 38686922 DOI: 10.14309/ajg.0000000000002827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 03/11/2024] [Indexed: 05/02/2024]
Abstract
INTRODUCTION Indeterminate liver nodules (ILNs) are frequently encountered on diagnostic imaging after positive hepatocellular carcinoma (HCC) surveillance results, but their natural history remains unclear. METHODS We conducted a multicenter retrospective cohort study among patients with ≥1 newly detected LI-RADS 3 (LR-3) lesion ≥1 cm or LI-RADS 4 (LR-4) lesion of any size (per LI-RADS v2018) between January 2018 and December 2019. Patients were followed with repeat imaging at each site per institutional standard of care. Multivariable Fine-Gray models were used to evaluate associations between potential risk factors and patient-level time-to-HCC diagnosis, with death and liver transplantation as competing risks. RESULTS Of 307 patients with ILNs, 208 had LR-3 lesions, 83 had LR-4 lesions, and 16 had both LR-3 and LR-4 lesions. HCC incidence rates for patients with LR-3 and LR-4 lesions were 110 (95% CI 70-150) and 420 (95% CI 310-560) per 1,000 person-year, respectively. In multivariable analysis, incident HCC among patients with LR-3 lesions was associated with older age, thrombocytopenia (platelet count ≤150 ×10 9 /L), and elevated serum alpha-fetoprotein levels. Among those with LR-4 lesions, incident HCC was associated with a maximum lesion diameter >1 cm. Although most patients had follow-up computed tomography or magnetic resonance imaging, 13.7% had no follow-up imaging and another 14.3% had follow-up ultrasound only. DISCUSSION ILNs have a high but variable risk of HCC, with 4-fold higher risk in patients with LR-4 lesions than those with LR-3 lesions, highlighting a need for accurate risk stratification tools and close follow-up in this population.
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Affiliation(s)
- Amit G Singal
- Division of Digestive and Liver Diseases, University of Texas Southwestern, Dallas, Texas, USA
| | - Neehar D Parikh
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Kirti Shetty
- Division of Gastroenterology and Hepatology, University of Maryland, Baltimore, Maryland, USA
| | - Steven-Huy Han
- Pfleger Liver Institute, Vatche and Tamar Manoukian Division of Digestive Diseases, UCLA, Los Angeles, California, USA
| | - Cassie Xie
- Department of Biostatistics, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Jing Ning
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Ashwini Arvind
- Division of Digestive and Liver Diseases, University of Texas Southwestern, Dallas, Texas, USA
| | - Anna S Lok
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Fasiha Kanwal
- Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, USA
- VA HSR'D Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
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Daher D, Dahan KSE, Yekkaluri S, Gopal P, Rich NE, Parikh ND, Murphy CC, Singal AG. Proportion of Time Covered by Hepatocellular Carcinoma Surveillance in Patients With Cirrhosis. Am J Gastroenterol 2024; 119:875-882. [PMID: 37975606 PMCID: PMC11068493 DOI: 10.14309/ajg.0000000000002596] [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: 07/31/2023] [Accepted: 10/09/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION Hepatocellular carcinoma (HCC) surveillance is associated with improved early tumor detection, but effectiveness is limited by underuse. We characterized adherence to HCC surveillance using proportion of time covered (PTC) and estimated its association with clinical outcomes among patients with cirrhosis. METHODS We conducted a retrospective cohort study of patients diagnosed with HCC between January 2008 and December 2022 at 2 large US health systems. We characterized PTC by imaging in the 12 and 24 months before HCC diagnosis. We used multivariable logistic and Cox regression analyses to assess the association between PTC and early HCC detection, receipt of curative treatment, and overall survival. RESULTS Among 2,027 patients with HCC, 331 (51.4% Barcelona Clinic Liver Cancer 0/A) had been followed up for at least 12 months before diagnosis. The median PTC was 24.9% (interquartile range 1.1%-50.7%), with only 16.0% having semiannual imaging and 42.0% having annual surveillance. Semiannual and annual surveillance decreased to 6.3% and 29.6% when assessed over 24 months, although the median PTC remained unchanged at 24.9%. Receipt of gastroenterology/hepatology care had the strongest association with PTC, with median PTC of 36.7% and 3.8% for those with and without gastroenterology/hepatology care, respectively. PTC was independently associated with improved early HCC detection, curative treatment receipt, and overall survival. The median survival was 15.7, 26.8, and 32.7 months among those with PTC of <25% (n = 168 patients), PTC 25%-50% (n = 69 patients), and PTC >50% (n = 94 patients), respectively. DISCUSSION The proportion of time covered by HCC surveillance in patients with cirrhosis remains low, highlighting a need for multilevel interventions.
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Affiliation(s)
- Darine Daher
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Karim Seif El Dahan
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Sruthi Yekkaluri
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Purva Gopal
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Nicole E. Rich
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Neehar D. Parikh
- Department of Internal Medicine, University of Michigan, Ann Arbor MI
| | | | - Amit G. Singal
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
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Wagle NS, Park S, Washburn D, Ohsfeldt R, Kum HC, Singal AG. Racial and Ethnic Disparities in Hepatocellular Carcinoma Treatment Receipt in the United States: A Systematic Review and Meta-Analysis. Cancer Epidemiol Biomarkers Prev 2024; 33:463-470. [PMID: 38252039 PMCID: PMC10990826 DOI: 10.1158/1055-9965.epi-23-1236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 12/13/2023] [Accepted: 01/16/2024] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND Racial and ethnic disparities in hepatocellular carcinoma (HCC) prognosis exist, partly related to differential failures along the cancer care continuum. We characterized racial and ethnic disparities in treatment receipt among patients with HCC in the United States. METHODS We searched Medline, Embase, and CINAHL databases to identify studies published between January 2012 and March 2022 reporting HCC treatment receipt among adult patients with HCC, stratified by race or ethnicity. We calculated pooled odds ratios for HCC treatment using random effects models. RESULTS We identified 15 studies with 320,686 patients (65.8% White, 13.9% Black, 10.4% Asian, and 8.5% Hispanic). Overall, 33.2% of HCC patients underwent any treatment, and 22.7% underwent curative treatment. Compared with White patients, Black patients had lower odds of any treatment (OR 0.67, 95% CI 0.55-0.81) and curative treatment (OR 0.74, 95% CI 0.71-0.78). Similarly, Hispanic patients had lower pooled odds of curative treatment (OR 0.79, 95% CI 0.73-0.84). CONCLUSIONS There were significant racial and ethnic disparities in HCC treatment receipt, with Black patients having lower odds of receiving any and curative treatment while Hispanic patients having lower odds of curative treatment. IMPACT Racial and ethnic differences in treatment receipt serve as an intervention target to reduce disparities in HCC prognosis.
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Affiliation(s)
- Nikita Sandeep Wagle
- Population Informatics Lab, Texas A&M University, College Station, Texas
- Department of Health Policy and Management, School of Public Health, Texas A&M, Health Science Center, College Station, Texas
| | - Sulki Park
- Department of Health Policy and Management, School of Public Health, Texas A&M, Health Science Center, College Station, Texas
- Department of Industrial and Systems Engineering, Texas A&M University, College, Station, Texas
| | - David Washburn
- Population Informatics Lab, Texas A&M University, College Station, Texas
- Department of Health Policy and Management, School of Public Health, Texas A&M, Health Science Center, College Station, Texas
| | - Robert Ohsfeldt
- Population Informatics Lab, Texas A&M University, College Station, Texas
- Department of Health Policy and Management, School of Public Health, Texas A&M, Health Science Center, College Station, Texas
| | - Hye-Chung Kum
- Population Informatics Lab, Texas A&M University, College Station, Texas
- Department of Health Policy and Management, School of Public Health, Texas A&M, Health Science Center, College Station, Texas
- Department of Industrial and Systems Engineering, Texas A&M University, College, Station, Texas
| | - Amit G Singal
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas
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Narasimman M, Hernaez R, Cerda V, Lee M, Yekkaluri S, Khan A, Sood A, Gurley T, Quirk L, Liu Y, Kramer JR, Lee SC, Tiro JA, Murphy CC, Singal AG. Financial Burden of Hepatocellular Carcinoma Screening in Patients With Cirrhosis. Clin Gastroenterol Hepatol 2024; 22:760-767.e1. [PMID: 37544418 DOI: 10.1016/j.cgh.2023.07.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 07/12/2023] [Accepted: 07/24/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND The overall value of hepatocellular carcinoma screening is defined by the balance of benefits and harms. Studies have only reported physical harms with none describing financial harms. METHODS We conducted a multicenter pragmatic randomized clinical trial of hepatocellular carcinoma screening outreach among 2872 patients with cirrhosis from March 2018 to April 2021. Patients with positive or indeterminate results and matched patients with negative results completed surveys at baseline and at follow-up measuring financial harms via Cancer Self-Administered Questionnaire and financial burden via Comprehensive Score for Financial Toxicity Functional Assessment of Chronic Illness Therapy. Univariable and multivariable longitudinal regression analyses were performed to compare changes in financial harms across groups: true positive, true negative, false positive, and indeterminate. Semistructured interviews were conducted in a subset of patients, sampled by center and test result. RESULTS Of 311 patients who completed at least 1 follow-up survey (75% response rate), 37 had true positive, 133 true negative, 64 false positive, and 77 indeterminate results. Financial harms increased in true positive and false positive patients with no significant changes noted among those with true negative or indeterminate results. At follow-up, 21.8% of patients reported moderate-severe financial burden, which was not significantly associated with test results. Semistructured interviews revealed variation in the frequency and severity of financial harms based on test results, with increased harm in those with false positive results. CONCLUSIONS Financial harms of hepatocellular carcinoma screening vary by test result and can pose a barrier that must be considered when determining the optimal screening program.
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Affiliation(s)
- Manasa Narasimman
- Department of Internal Medicine, UT Southwestern Medical Center and Parkland Health Hospital System, Dallas, Texas
| | - Ruben Hernaez
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Vanessa Cerda
- Peter O'Donnell Jr. School of Public Health, UT Southwestern Medical Center and Parkland Health Hospital System, Dallas, Texas
| | - MinJae Lee
- Peter O'Donnell Jr. School of Public Health, UT Southwestern Medical Center and Parkland Health Hospital System, Dallas, Texas
| | - Sruthi Yekkaluri
- Department of Internal Medicine, UT Southwestern Medical Center and Parkland Health Hospital System, Dallas, Texas
| | - Aisha Khan
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Anubha Sood
- Peter O'Donnell Jr. School of Public Health, UT Southwestern Medical Center and Parkland Health Hospital System, Dallas, Texas
| | - Tami Gurley
- Peter O'Donnell Jr. School of Public Health, UT Southwestern Medical Center and Parkland Health Hospital System, Dallas, Texas
| | - Lisa Quirk
- Department of Internal Medicine, UT Southwestern Medical Center and Parkland Health Hospital System, Dallas, Texas
| | - Yan Liu
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Jennifer R Kramer
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Simon Craddock Lee
- Peter O'Donnell Jr. School of Public Health, UT Southwestern Medical Center and Parkland Health Hospital System, Dallas, Texas
| | - Jasmin A Tiro
- Peter O'Donnell Jr. School of Public Health, UT Southwestern Medical Center and Parkland Health Hospital System, Dallas, Texas
| | - Caitlin C Murphy
- Peter O'Donnell Jr. School of Public Health, UT Southwestern Medical Center and Parkland Health Hospital System, Dallas, Texas
| | - Amit G Singal
- Department of Internal Medicine, UT Southwestern Medical Center and Parkland Health Hospital System, Dallas, Texas.
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11
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Daher D, Seif El Dahan K, Rich NE, Tayob N, Merrill V, Huang DQ, Yang JD, Kulkarni AV, Kanwal F, Marrero J, Parikh N, Singal AG. Hepatocellular Carcinoma Screening in a Contemporary Cohort of At-Risk Patients. JAMA Netw Open 2024; 7:e248755. [PMID: 38683607 PMCID: PMC11059036 DOI: 10.1001/jamanetworkopen.2024.8755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 02/26/2024] [Indexed: 05/01/2024] Open
Abstract
Importance Cohort studies demonstrating an association of hepatocellular carcinoma (HCC) screening with reduced mortality are prone to lead-time and length-time biases. Objective To characterize the clinical benefits of HCC screening, adjusting for lead-time and length-time biases, in a diverse, contemporary cohort of at-risk patients. Design, Setting, and Participants This retrospective cohort study of patients with HCC was conducted between January 2008 and December 2022 at 2 large US health systems. Data analysis was performed from September to November 2023. Main Outcomes and Measures The primary outcome was screen-detected HCC, defined by abnormal screening-intent abdominal imaging or α-fetoprotein level within 6 months before diagnosis. Cox regression analysis was used to characterize differences in overall survival between patients with screen-detected and non-screen-detected HCC; lead-time and length-time adjustments were calculated using the Duffy parametric formula. Results Among 1313 patients with HCC (mean [SD] age, 61.7 [9.6] years; 993 male [75.6%]; 739 [56.3%] with Barcelona Clinic Liver Cancer stage 0/A disease), HCC was screen-detected in 556 (42.3%) and non-screen detected in 757 (57.7%). Patients with screen-detected HCC had higher proportions of early-stage HCC (393 patients [70.7%] vs 346 patients [45.7%]; risk ratio [RR], 1.54; 95% CI, 1.41-1.70) and curative treatment receipt (283 patients [51.1%] vs 252 patients [33.5%]; RR, 1.52; 95% CI, 1.34-1.74) compared with patients with non-screen-detected HCC. The screen-detected group had significantly lower mortality, which persisted after correcting for lead-time bias (hazard ratio, 0.75; 95% CI, 0.65-0.87) in fully adjusted models. Both groups had similar tumor doubling times (median [IQR], 3.8 [2.2-10.7] vs 5.6 [1.7-11.4] months) and proportions of indolent tumors (28 patients [35.4%] vs 24 patients [38.1%]; RR, 0.93; 95% CI, 0.60-1.43). Adjustment for length-time bias decreased survival estimates, although 3-year and 5-year survival for patients with screen-detected HCC remained longer than that for patients with non-screen-detected HCC. Conclusions and Relevance The findings of this cohort study suggest that HCC screening is associated with reduced mortality even after accounting for lead-time and length-time biases. However, these biases should be considered in future studies.
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Affiliation(s)
- Darine Daher
- Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Karim Seif El Dahan
- Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Nicole E. Rich
- Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Nabihah Tayob
- Department of Data Science, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Vincent Merrill
- Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Daniel Q. Huang
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ju Dong Yang
- Department of Internal Medicine, Cedars Sinai Medical Center, Los Angeles, California
| | - Anand V. Kulkarni
- Department of Hepatology and Liver Transplantation, AIG Hospitals, Hyderabad India
| | - Fasiha Kanwal
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Jorge Marrero
- Department of Internal Medicine, University of Pennsylvania, Philadelphia
| | - Neehar Parikh
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Amit G. Singal
- Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
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12
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Cheo FY, Lim CHF, Chan KS, Shelat VG. The impact of waiting time and delayed treatment on the outcomes of patients with hepatocellular carcinoma: A systematic review and meta-analysis. Ann Hepatobiliary Pancreat Surg 2024; 28:1-13. [PMID: 38092430 PMCID: PMC10896687 DOI: 10.14701/ahbps.23-090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/27/2023] [Accepted: 08/30/2023] [Indexed: 02/06/2024] Open
Abstract
Hepatocellular carcinoma (HCC) is the sixth most diagnosed cancer worldwide. Healthcare resource constraints may predispose treatment delays. We aim to review existing literature on whether delayed treatment results in worse outcomes in HCC. PubMed, Embase, The Cochrane Library, and Scopus were systematically searched from inception till December 2022. Primary outcomes were overall survival (OS) and disease-free survival (DFS). Secondary outcomes included post-treatment mortality, readmission rates, and complications. Fourteen studies with a total of 135,389 patients (delayed n = 25,516, no delay n = 109,873) were included. Age, incidence of male patients, Child-Pugh B cirrhosis, and Barcelona Clinic Liver Cancer Stage 0/A HCC were comparable between delayed and no delay groups. Tumor size was significantly smaller in delayed versus no delay group (mean difference, -0.70 cm; 95% confidence interval [CI]: -1.14, 0.26; p = 0.002). More patients received radiofrequency ablation in delayed versus no delay group (OR, 1.22; 95% CI: 1.16, 1.27; p < 0.0001). OS was comparable between delayed and no delay in HCC treatment (hazard ratio [HR], 1.13; 95% CI: 0.99, 1.29; p = 0.07). Comparable DFS between delayed and no delay groups (HR, 0.99; 95% CI: 0.75, 1.30; p = 0.95) was observed. Subgroup analysis of studies that defined treatment delay as > 90 days showed comparable OS in the delayed group (HR, 1.04; 95% CI: 0.93, 1.16; p = 0.51). OS and DFS for delayed treatment were non-inferior compared to no delay, but might be due to better tumor biology/smaller tumor size in the delayed group.
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Affiliation(s)
- Feng Yi Cheo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Kai Siang Chan
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Vishal Girishchandra Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
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13
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Daher D, Seif El Dahan K, Cano A, Gonzales M, Ransom C, Jaurez E, Carranza O, Quirk L, Morgan T, Gopal P, Patel MS, Lieber S, Louissaint J, Cotter TG, VanWagner LB, Yang JD, Parikh ND, Yopp A, Rich NE, Singal AG. Hepatocellular Carcinoma Surveillance Patterns and Outcomes in Patients With Cirrhosis. Clin Gastroenterol Hepatol 2024; 22:295-304.e2. [PMID: 37573986 PMCID: PMC11415236 DOI: 10.1016/j.cgh.2023.08.003] [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: 05/19/2023] [Revised: 07/18/2023] [Accepted: 08/02/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND & AIMS Hepatocellular carcinoma (HCC) surveillance is associated with improved early detection and reduced mortality, although practice patterns and effectiveness vary in clinical practice. We aimed to characterize HCC surveillance patterns in a large, diverse cohort of patients with HCC. METHODS We conducted a retrospective cohort study of patients diagnosed with HCC between January 2008 and December 2022 at 2 large US health systems. We recorded imaging receipt in the year before HCC diagnosis: ultrasound plus α-fetoprotein (AFP), ultrasound alone, multiphasic contrast-enhanced computed tomography (CT)/magnetic resonance imaging (MRI), and no liver imaging. We used multivariable logistic and Cox regression analysis to compare early tumor detection, curative treatment receipt, and overall survival between surveillance strategies. RESULTS Among 2028 patients with HCC (46.7% Barcelona Clinic Liver Cancer stage A), 703 (34.7%) had ultrasound plus AFP, 293 (14.5%) had ultrasound alone, 326 (16.1%) had multiphasic CT/MRI, and 706 (34.8%) had no imaging in the year before HCC diagnosis. Over the study period, proportions without imaging were stable, whereas use of CT/MRI increased. Compared with no imaging, CT/MRI and ultrasound plus AFP, but not ultrasound alone, were associated with early stage HCC detection and curative treatment. Compared with ultrasound alone, CT/MRI and ultrasound plus AFP were associated with increased early stage detection. CONCLUSIONS HCC surveillance patterns vary in clinical practice and are associated with differing clinical outcomes. While awaiting data to determine if CT or MRI surveillance can be performed in a cost-effective manner in selected patients, AFP has a complementary role to ultrasound-based surveillance, supporting its adoption in practice guidelines.
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Affiliation(s)
- Darine Daher
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Karim Seif El Dahan
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Alva Cano
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Michael Gonzales
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Crystal Ransom
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Erik Jaurez
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Osiris Carranza
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Lisa Quirk
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Todd Morgan
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Purva Gopal
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Madhukar S Patel
- Department of Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Sarah Lieber
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Jeremy Louissaint
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Thomas G Cotter
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Lisa B VanWagner
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Ju Dong Yang
- Department of Internal Medicine, Cedars Sinai Medical Center, Los Angeles, California
| | - Neehar D Parikh
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Adam Yopp
- Department of Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Nicole E Rich
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Amit G Singal
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas.
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14
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Stanneart J, Nunez KG, Sandow T, Gimenez J, Fort D, Hibino M, Cohen AJ, Thevenot PT. Imaging Delay Following Liver-Directed Therapy Increases Progression Risk in Early- to Intermediate-Stage Hepatocellular Carcinoma. Cancers (Basel) 2024; 16:212. [PMID: 38201639 PMCID: PMC10777927 DOI: 10.3390/cancers16010212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/19/2023] [Accepted: 12/27/2023] [Indexed: 01/12/2024] Open
Abstract
Hepatocellular carcinoma (HCC) remains one of the leading causes of cancer-related deaths in the world. Patients with early-stage HCC are treated with liver-directed therapies to bridge or downstage for liver transplantation (LT). In this study, the impact of HCC care delay on HCC progression among early-stage patients was investigated. Early-stage HCC patients undergoing their first cycle of liver-directed therapy (LDT) for bridge/downstaging to LT between 04/2016 and 04/2022 were retrospectively analyzed. Baseline variables were analyzed for risk of disease progression and time to progression (TTP). HCC care delay was determined by the number of rescheduled appointments related to HCC care. The study cohort consisted of 316 patients who received first-cycle LDT. The HCC care no-show rate was associated with TTP (p = 0.004), while the overall no-show rate was not (p = 0.242). The HCC care no-show rate and HCC care delay were further expanded as no-show rates and rescheduled appointments for imaging, laboratory, and office visits, respectively. More than 60% of patients experienced HCC care delay for imaging and laboratory appointments compared to just 8% for office visits. Multivariate analysis revealed that HCC-specific no-show rates and HCC care delay for imaging (p < 0.001) were both independently associated with TTP, highlighting the importance of minimizing delays in early-stage HCC imaging surveillance to reduce disease progression risk.
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Affiliation(s)
- Jordin Stanneart
- University of Queensland Medical School, Brisbane, QLD 4072, Australia;
| | - Kelley G. Nunez
- Institute of Translational Research, Ochsner Health System, New Orleans, LA 70121, USA; (K.G.N.); (M.H.)
| | - Tyler Sandow
- Interventional Radiology, Ochsner Health System, New Orleans, LA 70121, USA; (T.S.); (J.G.)
| | - Juan Gimenez
- Interventional Radiology, Ochsner Health System, New Orleans, LA 70121, USA; (T.S.); (J.G.)
| | - Daniel Fort
- Center for Applied Health Services Research, Ochsner Health System, New Orleans, LA 70121, USA;
| | - Mina Hibino
- Institute of Translational Research, Ochsner Health System, New Orleans, LA 70121, USA; (K.G.N.); (M.H.)
| | - Ari J. Cohen
- Multi-Organ Transplant Institute, Ochsner Health System, New Orleans, LA 70121, USA;
- Faculty of Medicine, University of Queensland, Brisbane, QLD 4072, Australia
| | - Paul T. Thevenot
- Institute of Translational Research, Ochsner Health System, New Orleans, LA 70121, USA; (K.G.N.); (M.H.)
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15
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Narasimman M, Hernaez R, Cerda V, Lee M, Sood A, Yekkaluri S, Khan A, Quirk L, Liu Y, Kramer JR, Craddock Lee S, Murphy CC, Tiro JA, Singal AG. Hepatocellular carcinoma surveillance may be associated with potential psychological harms in patients with cirrhosis. Hepatology 2024; 79:107-117. [PMID: 37401857 DOI: 10.1097/hep.0000000000000528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 06/06/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND AND AIMS The value of HCC surveillance is determined by the balance between benefits and harms; however, no studies have enumerated psychological harms. APPROACH AND RESULTS We fielded surveys measuring psychological harms to patients with cirrhosis in a multicenter randomized trial of HCC surveillance outreach. All patients with positive or indeterminate surveillance results and matched patients with negative results were invited to complete surveys measuring (1) depression through the Patient Health Questionnaire-ninth version, (2) anxiety through State-Trait Anxiety Inventory, (3) HCC-specific worry through Psychological Consequences Questionnaire, and (4) decisional regret. Patients were classified into 4 groups: true positive (TP), false positive (FP), indeterminate, and true negative (TN). Multivariable longitudinal regression analysis using the generalized estimating equation method was performed to compare the means of measures across groups. We conducted 89 semistructured interviews in a subset of patients stratified by health system and test results. Of 2872 patients in the trial, 311 completed 1+ follow-up survey (63 FP, 77 indeterminate, 38 TP, and 133 TN). Moderate depression decreased in TN patients, increased in TP, and had intermittent but mild increases in those with FP and indeterminate results. High anxiety temporarily increased in patients with TP results but resolved over time and was stable in those with FP and indeterminate results. Decisional regret was low and did not differ across groups. In semistructured interviews, patients reported apprehension, anxiety, emotional distress, and coping related to HCC surveillance. CONCLUSIONS Psychological harms of HCC surveillance appear mild but differ by test result. Future research should determine the impact of psychological harms on the value of HCC surveillance programs.
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Affiliation(s)
- Manasa Narasimman
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Ruben Hernaez
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas, USA
| | - Vanessa Cerda
- Peter O'Donnell Jr. School of Public Health, Houston, Texas, USA
| | - MinJae Lee
- Peter O'Donnell Jr. School of Public Health, Houston, Texas, USA
| | - Anubha Sood
- Peter O'Donnell Jr. School of Public Health, Houston, Texas, USA
| | - Sruthi Yekkaluri
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Aisha Khan
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Lisa Quirk
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Yan Liu
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Jennifer R Kramer
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas, USA
| | | | - Caitlin C Murphy
- Peter O'Donnell Jr. School of Public Health, Houston, Texas, USA
| | - Jasmin A Tiro
- Peter O'Donnell Jr. School of Public Health, Houston, Texas, USA
| | - Amit G Singal
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
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16
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Akhlaghipour I, Fanoodi A, Zangouei AS, Taghehchian N, Khalili-Tanha G, Moghbeli M. MicroRNAs as the Critical Regulators of Forkhead Box Protein Family in Pancreatic, Thyroid, and Liver Cancers. Biochem Genet 2023; 61:1645-1674. [PMID: 36781813 DOI: 10.1007/s10528-023-10346-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 02/02/2023] [Indexed: 02/15/2023]
Abstract
The metabolism of human body is mainly regulated by the pancreas, liver, and thyroid using the hormones or exocrine secretions that affect the metabolic processes from food digestion to intracellular metabolism. Therefore, metabolic organ disorders have wide clinical symptoms that severely affect the quality of patient's life. The pancreatic, liver, and thyroid cancers as the main malignancies of the metabolic system have always been considered as one of the serious health challenges worldwide. Despite the novel therapeutic modalities, there are still significant high mortality and recurrence rates, especially in liver and pancreatic cancer patients which are mainly related to the late diagnosis. Therefore, it is required to assess the molecular bases of tumor progressions to introduce novel early detection and therapeutic markers in these malignancies. Forkhead box (FOX) protein family is a group of transcription factors that have pivotal roles in regulation of cell proliferation, migration, and apoptosis. They function as oncogene or tumor suppressor during tumor progression. MicroRNAs (miRNAs) are also involved in regulation of cellular processes. Therefore, in the present review, we discussed the role of miRNAs during pancreatic, thyroid, and liver tumor progressions through FOX regulation. It has been shown that miRNAs were mainly involved in tumor progression via FOXM and FOXO targeting. This review paves the way for the introduction of miR/FOX axis as an efficient early detection marker and therapeutic target in pancreatic, thyroid, and liver tumors.
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Affiliation(s)
- Iman Akhlaghipour
- Student Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Fanoodi
- Student Research Committee, School of Medicine, Birjand University of Medical Sciences, Birjand, Iran
| | - Amir Sadra Zangouei
- Student Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Negin Taghehchian
- Medical Genetics Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ghazaleh Khalili-Tanha
- Department of Medical Genetics and Molecular Medicine, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Meysam Moghbeli
- Medical Genetics Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
- Department of Medical Genetics and Molecular Medicine, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
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17
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Chavda V, Zajac KK, Gunn JL, Balar P, Khadela A, Vaghela D, Soni S, Ashby CR, Tiwari AK. Ethnic differences in hepatocellular carcinoma prevalence and therapeutic outcomes. Cancer Rep (Hoboken) 2023; 6 Suppl 1:e1821. [PMID: 37344125 PMCID: PMC10440848 DOI: 10.1002/cnr2.1821] [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: 12/31/2022] [Revised: 03/17/2023] [Accepted: 04/10/2023] [Indexed: 06/23/2023] Open
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is a leading cause of cancer-related death worldwide. The incidence of HCC is affected by genetic and non-genetic factors. Genetically, mutations in the genes, tumor protein P53 (TP53), catenin beta 1 (CTNNB1), AT-rich interaction domain 1A (ARIC1A), cyclin dependent kinase inhibitor 2A (CDKN2A), mannose 6-phosphate (M6P), smooth muscle action against decapentaplegic (SMAD2), retinoblastoma gene (RB1), cyclin D, antigen presenting cells (APC), AXIN1, and E-cadherin, have been shown to contribute to the occurrence of HCC. Non-genetic factors, including alcohol consumption, exposure to aflatoxin, age, gender, presence of hepatitis B (HBV), hepatitis C (HCV), and non-alcoholic fatty liver disease (NAFLD), increase the risk of HCC. RECENT FINDINGS The severity of the disease and its occurrence vary based on geographical location. Furthermore, men and minorities have been shown to be disproportionately affected by HCC, compared with women and non-minorities. Ethnicity has been reported to significantly affect tumorigenesis and clinical outcomes in patients diagnosed with HCC. Generally, differences in gene expression and/or the presence of comorbid medical diseases affect or influence the progression of HCC. Non-Caucasian HCC patients are significantly more likely to have poorer survival outcomes, compared to their Caucasian counterparts. Finally, there are a number of factors that contribute to the success rate of treatments for HCC. CONCLUSION Assessment and treatment of HCC must be consistent using evidence-based guidelines and standardized outcomes, as well as international clinical practice guidelines for global consensus. Standardizing the assessment approach and method will enable comparison and improvement of liver cancer research through collaboration between researchers, healthcare providers, and advocacy groups. In this review, we will focus on discussing epidemiological factors that result in deviations and changes in treatment approaches for HCC.
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Affiliation(s)
- Vivek Chavda
- Department of Pharmaceutics and Pharmaceutical TechnologyL M College of PharmacyAhmedabadIndia
| | - Kelsee K. Zajac
- Department of Pharmacology and Experimental Therapeutics, College of Pharmacy and Pharmaceutical SciencesUniversity of ToledoOhioUSA
| | - Jenna Lynn Gunn
- Department of Pharmacology and Experimental Therapeutics, College of Pharmacy and Pharmaceutical SciencesUniversity of ToledoOhioUSA
| | - Pankti Balar
- Pharmacy SectionL M College of PharmacyAhmedabadIndia
| | - Avinash Khadela
- Department of PharmacologyL M College of PharmacyAhmedabadIndia
| | - Dixa Vaghela
- Pharmacy SectionL M College of PharmacyAhmedabadIndia
| | - Shruti Soni
- PharmD SectionL M College of PharmacyAhmedabadIndia
| | - Charles R. Ashby
- Department of Pharmaceutical Sciences, College of PharmacySt. John's UniversityNew YorkNew YorkUSA
| | - Amit K. Tiwari
- Department of Pharmacology and Experimental Therapeutics, College of Pharmacy and Pharmaceutical SciencesUniversity of ToledoOhioUSA
- Department of Cancer Biology, College of Medicine and Life SciencesUniversity of ToledoToledoOhioUSA
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El-Serag HB, Ward JW, Asrani SK, Singal AG, Rich N, Thrift AP, Deshpande S, Turner BJ, Kaseb AO, Harrison AC, Fortune BE, Kanwal F. Prevention of Hepatocellular Carcinoma (HCC). White Paper of the Texas Collaborative Center for Hepatocellular Cancer (TeCH) Multi-stakeholder Conference. Clin Gastroenterol Hepatol 2023; 21:2183-2192. [PMID: 37086825 PMCID: PMC10524305 DOI: 10.1016/j.cgh.2023.03.029] [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: 02/02/2023] [Revised: 03/17/2023] [Accepted: 03/17/2023] [Indexed: 04/24/2023]
Abstract
BACKGROUND & AIMS Texas has the highest age-adjusted incidence rate of hepatocellular carcinoma (HCC) in the United States. The Cancer Prevention and Research Institute of Texas has funded the Texas Collaborative Center for Hepatocellular Cancer (TeCH) to facilitate HCC research, education, and advocacy activities with the overall goal of reducing HCC mortality in Texas through coordination, collaboration, and advocacy. METHODS On September 17, 2022, TeCH co-sponsored a multi-stakeholder conference on HCC with the Baker Institute Center for Health and Biosciences. This conference was attended by HCC researchers, policy makers, payers, members from pharmaceutical industry and patient advocacy groups in and outside of Texas. This report summarizes the results of the conference. RESULTS The goal of this meeting was to identify different strategies for preventing HCC and evaluate their readiness for implementation. CONCLUSIONS We call for a statewide (1) viral hepatitis elimination program; (2) program to increase nonalcoholic steatohepatitis and obesity awareness; (3) research program to develop health care models that integrate alcohol associated liver disease treatment and treatment for alcohol use disorder; and (4) demonstration projects to evaluate the effectiveness of identifying and linking patient with advanced fibrosis and cirrhosis to clinical care.
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Affiliation(s)
| | - John W Ward
- The Coalition for Global Hepatitis Elimination, The Task Force for Global Health, Decatur, Georgia
| | | | - Amit G Singal
- Department of Medicine, University of Texas Southwestern Medical Center Dallas, Texas
| | - Nicole Rich
- Department of Medicine, University of Texas Southwestern Medical Center Dallas, Texas
| | - Aaron P Thrift
- Section of Epidemiology and Population Sciences, Department of Medicine, Baylor College of Medicine, Houston, Texas; Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas
| | | | - Barbara J Turner
- Department of Medicine, Keck School of Medicine of USC, Los Angeles, California
| | - Ahmed O Kaseb
- Department of Gastrointestinal Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ariel C Harrison
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Brett E Fortune
- Department of Medicine, Montefiore Medical Center, Bronx, New York
| | - Fasiha Kanwal
- Department of Medicine, Baylor College of Medicine, Houston, Texas
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19
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Rich NE, Chernyak V. Standardizing liver imaging reporting and interpretation: LI-RADS and beyond. Hepatol Commun 2023; 7:e00186. [PMID: 37314738 PMCID: PMC10270536 DOI: 10.1097/hc9.0000000000000186] [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: 01/03/2023] [Accepted: 05/02/2023] [Indexed: 06/15/2023] Open
Abstract
Imaging plays a crucial role in diagnosis and post-treatment monitoring of primary liver cancers. Clear, consistent, and actionable communication of imaging results is crucial to avoid miscommunication and potential detrimental impact on patient care. In this review, we discuss the importance, advantages, and potential impact of universal adoption of standardized terminology and interpretive criteria for liver imaging, from the point of view of radiologists and clinicians.
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Affiliation(s)
- Nicole E. Rich
- Department of Internal Medicine, Division of Digestive and Liver Diseases, UT Southwestern, Dallas, Texas, USA
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern, Dallas, Texas, USA
| | - Victoria Chernyak
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
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20
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Rasic G, Beaulieu-Jones BR, Chung SH, Romatoski KS, Kenzik K, Ng SC, Tseng JF, Sachs TE. The Impact of the COVID-19 Pandemic on Hepatocellular Carcinoma Time to Treatment Initiation: A National Cancer Database Study. Ann Surg Oncol 2023; 30:4249-4259. [PMID: 37099088 PMCID: PMC10132402 DOI: 10.1245/s10434-023-13468-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 03/20/2023] [Indexed: 04/27/2023]
Abstract
BACKGROUND The COVID-19 pandemic strained oncologic care access and delivery, yet little is known about how it impacted hepatocellular carcinoma (HCC) management. Our study sought to evaluate the annual effect of the COVID-19 pandemic on time to treatment initiation (TTI) for HCC. METHODS The National Cancer Database was queried for patients diagnosed with clinical stages I-IV HCC (2017-2020). Patients were categorized based on their year of diagnosis as "Pre-COVID" (2017-2019) and "COVID" (2020). TTI based on stage and type of treatment first received was compared by the Mann-Whitney U test. A logistic regression model was used to evaluate factors of increased TTI and treatment delay (> 90 days). RESULTS In total, 18,673 patients were diagnosed during Pre-COVID, whereas 5249 were diagnosed during COVID. Median TTI for any first-line treatment modality was slightly shorter during the COVID year compared with Pre-COVID (49 vs. 51 days; p < 0.0001), notably in time to ablation (52 vs. 55 days; p = 0.0238), systemic therapy (42 vs. 47 days; p < 0.0001), and radiation (60 vs. 62 days; p = 0.0177), but not surgery (41 vs. 41 days; p = 0.6887). In a multivariate analysis, patients of Black race, Hispanic ethnicity, and uninsured/Medicaid/Other Government insurance status were associated with increased TTI by factors of 1.057 (95% CI: 1.022-1.093; p = 0.0013), 1.045 (95% CI: 1.010-1.081; p = 0.0104), and 1.088 (95% CI: 1.053-1.123; p < 0.0001), respectively. Similarly, these patient populations were associated with delayed treatment times. CONCLUSIONS For patients diagnosed during COVID, TTI for HCC, while statistically significant, had no clinically significant differences. However, vulnerable patients were more likely to have increased TTI.
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Affiliation(s)
- Gordana Rasic
- Department of Surgery, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
- Department of Surgery, Boston Medical Center, Boston, MA, USA
| | - Brendin R Beaulieu-Jones
- Department of Surgery, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
- Department of Surgery, Boston Medical Center, Boston, MA, USA
| | - Sophie H Chung
- Department of Surgery, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Kelsey S Romatoski
- Department of Surgery, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Kelly Kenzik
- Department of Surgery, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Sing Chau Ng
- Department of Surgery, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Jennifer F Tseng
- Department of Surgery, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
- Department of Surgery, Boston Medical Center, Boston, MA, USA
| | - Teviah E Sachs
- Department of Surgery, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA.
- Department of Surgery, Boston Medical Center, Boston, MA, USA.
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21
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Otto CC, Wang G, Mantas A, Heise D, Bruners P, Lang SA, Ulmer TF, Neumann UP, Heij LR, Bednarsch J. Time to surgery is not an oncological risk factor in HCC patients undergoing liver resection. Langenbecks Arch Surg 2023; 408:187. [PMID: 37160788 PMCID: PMC10169875 DOI: 10.1007/s00423-023-02922-4] [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: 02/05/2023] [Accepted: 04/29/2023] [Indexed: 05/11/2023]
Abstract
PURPOSE Given limitations of the health care systems in case of unforeseeable events, e.g., the COVID pandemic as well as trends in prehabilitation, time from diagnosis to surgery (time to surgery, (TTS)) has become a research issue in malignancies. Thus, we investigated whether TTS is associated with oncological outcome in HCC patients undergoing surgery. METHODS A monocentric cohort of 217 patients undergoing liver resection for HCC between 2009 and 2021 was analyzed. Individuals were grouped according to TTS and compared regarding clinical characteristics. Overall survival (OS) and recurrence-free survival (RFS) was compared using Kaplan-Meier analysis and investigated by univariate and multivariable Cox regressions. RESULTS TTS was not associated with OS (p=0.126) or RFS (p=0.761) of the study cohort in univariate analysis. In multivariable analysis age (p=0.028), ASA (p=0.027), INR (0.016), number of HCC nodules (p=0.026), microvascular invasion (MVI; p<0.001), and postoperative complications (p<0.001) were associated with OS and INR (p=0.005), and number of HCC nodules (p<0.001) and MVI (p<0.001) were associated with RFS. A comparative analysis of TTS subgroups was conducted (group 1, ≤30 days, n=55; group 2, 31-60 days, n=79; group 3, 61-90 days, n=45; group 4, >90 days, n=38). Here, the median OS were 62, 41, 38, and 40 months (p=0.602 log rank) and median RFS were 21, 26, 26, and 25 months (p=0.994 log rank). No statistical difference regarding oncological risk factors were observed between these groups. CONCLUSION TTS is not associated with earlier tumor recurrence or reduced overall survival in surgically treated HCC patients.
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Affiliation(s)
- Carlos Constantin Otto
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Guanwu Wang
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Anna Mantas
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Daniel Heise
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Philipp Bruners
- Department of Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Sven Arke Lang
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Tom Florian Ulmer
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Ulf Peter Neumann
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
- Department of Surgery, Maastricht University Medical Centre (MUMC), Maastricht, Netherlands
| | - Lara Rosaline Heij
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
- Institute of Pathology, Maastricht University Medical Centre (MUMC), Maastricht, Netherlands
| | - Jan Bednarsch
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany.
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22
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McMahon B, Cohen C, Brown Jr RS, El-Serag H, Ioannou GN, Lok AS, Roberts LR, Singal AG, Block T. Opportunities to address gaps in early detection and improve outcomes of liver cancer. JNCI Cancer Spectr 2023; 7:pkad034. [PMID: 37144952 PMCID: PMC10212536 DOI: 10.1093/jncics/pkad034] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 04/10/2023] [Indexed: 05/06/2023] Open
Abstract
Death rates from primary liver cancer (hepatocellular carcinoma [HCC]) have continued to rise in the United States over the recent decades despite the availability of an increasing range of treatment modalities, including new systemic therapies. Prognosis is strongly associated with tumor stage at diagnosis; however, most cases of HCC are diagnosed beyond an early stage. This lack of early detection has contributed to low survival rates. Professional society guidelines recommend semiannual ultrasound-based HCC screening for at-risk populations, yet HCC surveillance continues to be underused in clinical practice. On April 28, 2022, the Hepatitis B Foundation convened a workshop to discuss the most pressing challenges and barriers to early HCC detection and the need to better leverage existing and emerging tools and technologies that could improve HCC screening and early detection. In this commentary, we summarize technical, patient-level, provider-level, and system-level challenges and opportunities to improve processes and outcomes across the HCC screening continuum. We highlight promising approaches to HCC risk stratification and screening, including new biomarkers, advanced imaging incorporating artificial intelligence, and algorithms for risk stratification. Workshop participants emphasized that action to improve early detection and reduce HCC mortality is urgently needed, noting concern that many of the challenges we face today are the same or similar to those faced a decade ago and that HCC mortality rates have not meaningfully improved. Increasing the uptake of HCC screening was identified as a short-term priority while developing and validating better screening tests and risk-appropriate surveillance strategies.
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Affiliation(s)
- Brian McMahon
- Liver Disease and Hepatitis Program, Alaska Native Tribal Health Consortium, Anchorage, AK, USA
| | | | - Robert S Brown Jr
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY, USA
| | - Hashem El-Serag
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - George N Ioannou
- Department of Medicine, Division of Gastroenterology, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Anna S Lok
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Lewis R Roberts
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Amit G Singal
- Department of Internal Medicine, Division of Digestive and Liver Diseases, UT Southwestern, Dallas, TX, USA
| | - Timothy Block
- Baruch S. Blumberg Institute and Hepatitis B Foundation, Doylestown, PA, USA
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23
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Seif El Dahan K, Reczek A, Daher D, Rich NE, Yang JD, Hsiehchen D, Zhu H, Patel MS, Bayona Molano MDP, Sanford N, Gopal P, Parikh ND, Yopp AC, Singal AG. Multidisciplinary care for patients with HCC: a systematic review and meta-analysis. Hepatol Commun 2023; 7:e0143. [PMID: 37102768 PMCID: PMC10146543 DOI: 10.1097/hc9.0000000000000143] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 01/31/2023] [Indexed: 04/28/2023] Open
Abstract
BACKGROUND Given the complexity of managing HCC, professional society guidelines advocate multidisciplinary care (MDC) for patients with HCC. However, implementation of MDC programs requires a significant investment of time and resources. We conducted a systematic review and meta-analysis to enumerate potential benefits of MDC for patients with HCC. METHODS We conducted a search of the PubMed/MEDLINE and EMBASE databases and national conference abstracts to identify studies published after January 2005 that reported early-stage presentation, treatment receipt, or overall survival among patients with HCC, stratified by MDC status. We calculated pooled risk ratios and HRs for clinical outcomes according to MDC receipt using the DerSimonian and Laird method for random effects models. RESULTS We identified 12 studies (n = 15,365 patients with HCC) with outcomes stratified by MDC status. MDC was associated with improved overall survival (HR = 0.63, 95% CI: 0.45-0.88); however, its association with curative treatment receipt was not statistically significant (risk ratio = 1.60, 95% CI: 0.89-2.89) and pooled estimates were limited by high heterogeneity (I2 > 90% for both). Studies (n = 3) were discordant regarding an association between MDC and time-to-treatment initiation. MDC was associated with early-stage HCC (risk ratio = 1.60, 95% CI: 1.12-2.29), suggesting possible referral bias contributing to improved outcomes. Limitations of studies also included risk of residual confounding, loss to follow-up, and data preceding the availability of immune checkpoint inhibitors. CONCLUSION MDC for patients with HCC is associated with improved overall survival, underscoring the likely benefit of managing patients with HCC in a multidisciplinary care setting.
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Affiliation(s)
- Karim Seif El Dahan
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Annika Reczek
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Darine Daher
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Nicole E. Rich
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Ju Dong Yang
- Department of Internal Medicine, Cedars Sinai Medical Center, Los Angeles, California,USA
| | - David Hsiehchen
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Hao Zhu
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Madhukar S. Patel
- Department of Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
| | | | - Nina Sanford
- Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Purva Gopal
- Department of Pathology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Neehar D. Parikh
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Adam C. Yopp
- Department of Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Amit G. Singal
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
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24
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Wagle NS, Park S, Washburn D, Ohsfeldt RL, Rich NE, Singal AG, Kum HC. Racial, Ethnic, and Socioeconomic Disparities in Treatment Delay Among Patients With Hepatocellular Carcinoma in the United States. Clin Gastroenterol Hepatol 2023; 21:1281-1292.e10. [PMID: 35933076 PMCID: PMC9898458 DOI: 10.1016/j.cgh.2022.07.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 06/25/2022] [Accepted: 07/23/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Failures have been reported across the cancer care continuum in patients with hepatocellular carcinoma (HCC); however, the impact of treatment delays on outcomes has not been well-characterized. We described the prevalence of treatment delays in a racially and ethnically diverse cohort of patients and its association with overall survival. METHODS Using the Surveillance, Epidemiology, and End Results-Medicare database, we identified patients diagnosed with HCC between 2001 and 2015. We performed multivariable logistic regression analysis to identify factors associated with treatment delay (ie, receipt of HCC-directed therapy >3 months after diagnosis). Cox proportional hazards regression analysis with a 5-month landmark was used to characterize the association between treatment delay and overall survival, accounting for immortal time bias. RESULTS Of 8450 patients with treatment within 12 months of HCC diagnosis, 1205 (14.3%) experienced treatment delays. The proportion with treatment delays ranged from 6.8% of patients undergoing surgical resection to 21.6% of those undergoing liver transplantation. In multivariable analysis, Black patients (odds ratio, 1.96; 95% confidence interval [CI], 1.21-3.15) and those living in high poverty neighborhoods (odds ratio, 1.55; 95% CI, 1.25-1.92) were more likely to experience treatment delays than white patients and those living in low poverty neighborhoods, respectively. Treatment delay was independently associated with worse survival (hazard ratio 1.15, 95% CI, 1.05-1.25). CONCLUSIONS Nearly 1 in 7 patients with HCC experience treatment delays, with higher odds in Black patients and those living in high poverty neighborhoods. Treatment delays are associated with worse survival, highlighting a need for interventions to improve time-to-treatment.
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Affiliation(s)
- Nikita Sandeep Wagle
- Population Informatics Lab, Texas A&M University, College Station, Texas; Department of Health Policy & Management, School of Public Health, Texas A&M Health Science Center, College Station, Texas
| | - Sulki Park
- Population Informatics Lab, Texas A&M University, College Station, Texas; Department of Industrial & Systems Engineering, Texas A&M University, College Station, Texas
| | - David Washburn
- Population Informatics Lab, Texas A&M University, College Station, Texas; Department of Health Policy & Management, School of Public Health, Texas A&M Health Science Center, College Station, Texas
| | - Robert L Ohsfeldt
- Population Informatics Lab, Texas A&M University, College Station, Texas; Department of Health Policy & Management, School of Public Health, Texas A&M Health Science Center, College Station, Texas
| | - Nicole E Rich
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas
| | - Amit G Singal
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas.
| | - Hye-Chung Kum
- Population Informatics Lab, Texas A&M University, College Station, Texas; Department of Health Policy & Management, School of Public Health, Texas A&M Health Science Center, College Station, Texas; Department of Industrial & Systems Engineering, Texas A&M University, College Station, Texas
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25
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Ramouz A, Fakour S, Jafari M, Khajeh E, Golriz M, Majlesara A, Merle U, Springfeld C, Longerich T, Mieth M, Mehrabi A. Surgical management of primary liver cancers during the COVID-19 pandemic: overcoming the dilemma with standardization. HPB (Oxford) 2023:S1365-182X(23)00124-7. [PMID: 37149487 PMCID: PMC10105379 DOI: 10.1016/j.hpb.2023.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 04/06/2023] [Accepted: 04/13/2023] [Indexed: 05/08/2023]
Abstract
BACKGROUND The present study evaluates the impact of the pandemic on outcomes after surgical treatment for primary liver cancer in a high-volume hepatopancreatobiliary surgery center. METHODS Patients, who underwent liver resection for primary liver resection between January 2019 and February 2020, comprised pre-pandemic control group. The pandemic period was divided into two timeframes: early pandemic (March 2020-January 2021) and late pandemic (February 2021-December 2021). Liver resections during 2022 were considered as the post-pandemic period. Peri-, and postoperative patient data were gathered from a prospectively maintained database. RESULTS Two-hundred-eighty-one patients underwent liver resection for primary liver cancer. The number of procedures decreased by 37.1% during early phase of pandemic, but then increased by 66.7% during late phase, which was comparable to post-pandemic phase. Postoperative outcomes were similar between four phases. The duration of hospital stay was longer during the late phase, but not significantly different compared to other groups. CONCLUSION Despite an initial reduction in number of surgeries, COVID-19 pandemic had no negative effect on outcomes of surgical treatment for primary liver cancer. The structured standard operating protocol in a high-volume and highly specialized surgical center can withstand negative effects, a pandemic may have on treatment of patients.
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Affiliation(s)
- Ali Ramouz
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Sanam Fakour
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Marzieh Jafari
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Elias Khajeh
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Mohammad Golriz
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany; Liver Cancer Centre Heidelberg (LCCH), Heidelberg University Hospital, Heidelberg, Germany
| | - Ali Majlesara
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Uta Merle
- Liver Cancer Centre Heidelberg (LCCH), Heidelberg University Hospital, Heidelberg, Germany; Department of Internal Medicine IV, University of Heidelberg, Heidelberg, Germany
| | - Christoph Springfeld
- Liver Cancer Centre Heidelberg (LCCH), Heidelberg University Hospital, Heidelberg, Germany; Department of Medical Oncology, Heidelberg University Hospital, National Center for Tumor Diseases, Heidelberg, Germany
| | - Thomas Longerich
- Liver Cancer Centre Heidelberg (LCCH), Heidelberg University Hospital, Heidelberg, Germany; Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus Mieth
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany; Liver Cancer Centre Heidelberg (LCCH), Heidelberg University Hospital, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany; Liver Cancer Centre Heidelberg (LCCH), Heidelberg University Hospital, Heidelberg, Germany.
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26
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Bannangkoon K, Hongsakul K, Tubtawee T, Janjindamai P. Effect of COVID-19 Pandemic-Related Delays in Chemoembolization on the Survival of Patients with Hepatocellular Carcinoma. Can J Gastroenterol Hepatol 2023; 2023:8114732. [PMID: 37090102 PMCID: PMC10121341 DOI: 10.1155/2023/8114732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 03/12/2023] [Accepted: 03/23/2023] [Indexed: 04/25/2023] Open
Abstract
Background and Aims COVID-19 has led to potential delays in liver cancer treatment, which may have undesirable effects on the prognosis of patients. We aimed to quantify the COVID-19 pandemic impact on the survival of patients with hepatocellular carcinoma (HCC) who underwent transarterial chemoembolization (TACE). Methods A retrospective study was conducted in patients with HCC who underwent TACE at a tertiary care center during the prelockdown (March to July 2019) and lockdown (March to July 2020) periods. Demographic data, tumor characteristics, functional status, and vital status were collected from the hospital medical records. The endpoints were TACE interval, treatment response, and survival after TACE. Cox proportional hazards regression determined the significant preoperative factors influencing survival. Results Compared to prelockdown, a significant delay occurred during the lockdown in repeated TACE treatments (76.7 vs. 63.5 days, P=0.007). The trend suggested a significant decrease in patients with HCC in the repeated TACE group (-33.3%). After screening, 145 patients were included (prelockdown (n = 87), lockdown (n = 58)). There was no significant difference in the 1-month objective response rate between the prelockdown and lockdown groups (65.5% vs. 64.4%, P=1.00). During follow-up, 56 (64.4%) and 34 (58.6%) deaths occurred in the prelockdown and lockdown groups, respectively (P=0.600). Multivariate analysis revealed no association between the lockdown group and decreased survival (HR 0.88, 95% CI 0.57-1.35, P=0.555). Conclusions The impact of the COVID-19 pandemic on liver cancer care resulted in significant decreases and delays in repeated TACE treatments in 2020 compared to 2019. However, treatment delays did not seem to significantly impact survival.
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Affiliation(s)
- Kittipitch Bannangkoon
- Department of Radiology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
| | - Keerati Hongsakul
- Department of Radiology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
| | - Teeravut Tubtawee
- Department of Radiology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
| | - Phurich Janjindamai
- Department of Radiology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
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27
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Parikh ND, Tayob N, Singal AG. Blood-based biomarkers for hepatocellular carcinoma screening: Approaching the end of the ultrasound era? J Hepatol 2023; 78:207-216. [PMID: 36089157 PMCID: PMC10229257 DOI: 10.1016/j.jhep.2022.08.036] [Citation(s) in RCA: 51] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 08/23/2022] [Accepted: 08/29/2022] [Indexed: 02/01/2023]
Abstract
Hepatocellular carcinoma (HCC) is a leading cause of cancer-related death worldwide, in part because of inadequate early detection strategies. Current recommendations for screening consist of semi-annual abdominal ultrasound with or without serum alpha-fetoprotein in patients with cirrhosis and in demographic subgroups with chronic hepatitis B infection. However, this screening strategy has several deficiencies, including suboptimal early-stage sensitivity, false positives with subsequent harms, inter-operator variability in ultrasound performance, and poor adherence. A blood-based biomarker with sufficient performance characteristics for early-stage disease could overcome several of these barriers to improving early-stage detection. However, prior to use of a biomarker for screening in clinical practice, a multistep validation is required in order to understand test performance characteristics. These steps include case-control validation, followed by validation in prospective cohorts of at-risk patients. Until recently, we lacked adequate longitudinal validation cohorts for early HCC detection; however, several validation cohorts are maturing, including the Hepatocellular Carcinoma Early Detection Study and the Texas Hepatocellular Carcinoma Consortium, which will allow for rigorous validation of candidate biomarkers. While there are several promising biomarkers awaiting validation, in order to supplant abdominal ultrasound, a candidate biomarker must show adequate test performance and overcome practical hurdles to ensure adoption in clinical practice. The promise of blood-based biomarkers is significant, especially given the limitations of ultrasound-based screening; however, they require adequate validation and several logistical obstacles must be overcome prior to clinical implementation.
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Affiliation(s)
- Neehar D Parikh
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA; Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA.
| | - Nabihah Tayob
- Department of Biostatistics, Dana Farber Cancer Center, Boston, MA, USA
| | - Amit G Singal
- Harold C. Simmons Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Wong RJ, Jayasekera C, Jones P, Kanwal F, Singal AG, Ahmed A, Taglienti R, Younossi Z, Kulik L, Mehta N. An Open-Access, Interactive Decision-Support Tool to Facilitate Guideline-Driven Care for Hepatocellular Carcinoma. Gastroenterology Res 2022; 15:297-307. [PMID: 36660470 PMCID: PMC9822660 DOI: 10.14740/gr1573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/07/2022] [Indexed: 12/23/2022] Open
Abstract
Hepatocellular carcinoma (HCC) is increasing in incidence and is a leading cause of cancer-related mortality worldwide. Adherence to HCC surveillance guidelines and appropriate treatment triage of liver lesions may improve receipt of curative-intent treatment and improved survival. Late-stage HCC diagnosis reflects sub-optimal implementation of effective HCC surveillance, whereas inappropriate treatment triage or linkage to care accounts for the non-receipt of curative-intent in close to half of early-stage HCC in the USA. A free, open-access decision-support tool for liver lesions that incorporates current guideline recommendations in a user-friendly interface could improve appropriate and timely triage of patients to appropriate care. This review provides a summary of gaps and disparities in linkage to HCC care and introduces a free, internet-based, interactive decision-support tool for managing liver lesions. This tool has been developed by the HCC Steering Committee of the Chronic Liver Disease Foundation and is targeted toward clinicians across specialties who may encounter liver lesions during routine care or as part of dedicated HCC surveillance.
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Affiliation(s)
- Robert J. Wong
- Veterans Affairs Palo Alto Healthcare System, Stanford University School of Medicine, Palo Alto, CA, USA,Corresponding Author: Robert J. Wong, Veterans Affairs Palo Alto Healthcare System, Stanford University School of Medicine, Palo Alto, CA 94304, USA.
| | | | | | - Fasiha Kanwal
- Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA
| | - Amit G. Singal
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Aijaz Ahmed
- Stanford University School of Medicine, Stanford, CA, USA
| | | | | | | | - Neil Mehta
- University of California, San Francisco, CA, USA
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Impact of the COVID-19 Pandemic on the Outcomes of Transarterial Chemoembolization in Patients with Hepatocellular Carcinoma: A Single Center Experience from a Developing Country. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58121701. [PMID: 36556903 PMCID: PMC9786879 DOI: 10.3390/medicina58121701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/05/2022] [Accepted: 11/15/2022] [Indexed: 11/24/2022]
Abstract
Background and Objectives: Treatment of cancer patients during the COVID-19 pandemic has been a challenge worldwide. In accordance with the current recommendations for hepatocellular carcinoma (HCC) management during the COVID-19 pandemic, loco-regional therapy such as transarterial chemoembolization (TACE) was proposed with the purpose of achieving local tumor control and improving overall survival. The aim of this prospective cohort study was to evaluate the outcomes of TACE treatment in patients with HCC during the COVID-19 pandemic in comparison with the outcomes of patients treated in the pre-pandemic period. Materials and Methods: Between September 2018 and December 2021, 154 patients were managed by serial TACE procedures for different liver tumors. Ninety-seven patients met the study criteria and were divided into two groups: the study group n = 49 (patients treated from May 2020 to December 2021); the control group n = 48 (patients treated from September 2018 to May 2020). Results: The mean waiting time for TACE was significantly longer in the study group compared to the control group (p < 0.001). No significant difference in survival between the groups is noted (log-rank test p = 0.823). In multivariate analysis, the MELD score (HR 1.329, 95% CI 1.140−1.548, p < 0.001) remained a significant predictor of mortality. Conclusions: COVID-19 pandemic did not affect the final outcome of TACE treatment.
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Lee YT, Singal AG, Lauzon M, Agopian VG, Luu M, Noureddin M, Todo T, Kim IK, Friedman ML, Kosari K, Nissen NN, Roberts LR, Heimbach JK, Gores GJ, Yang JD. Disparities in curative treatments and outcomes for early stage intrahepatic cholangiocarcinoma in the United States. Cancer 2022; 128:3610-3619. [PMID: 35997126 PMCID: PMC9530023 DOI: 10.1002/cncr.34436] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/24/2022] [Accepted: 06/02/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Curative surgical treatments afford the best prognosis for patients with intrahepatic cholangiocarcinoma (iCCA); however, the comparative effectiveness of treatment options and factors associated with curative treatment receipt for early stage iCCA remain unknown. METHODS The authors identified patients who were diagnosed with early stage iCCA, defined as a unifocal tumor <3 cm, during 2004-2018 from the National Cancer Database. Multivariable logistic and Cox regression analyses were used to identify the factors associated with curative treatment and overall survival (OS), respectively. RESULTS The proportion of patients with early stage iCCA increased from 4.5% in 2004 to 7.3% in 2018, with the odds of early stage detection increasing by 3.1% per year (odds ratio [OR], 1.031; 95% CI, 1.015-1.049). Of 1093 patients who had early stage iCCA, 464 (42.5%) underwent resection, 113 (10.3%) underwent ablation, 62 (5.7%) underwent liver transplantation, and 454 (41.5%) received noncurative treatments. Hispanic patients (adjusted OR [aOR], 0.57; 95% CI, 0.33-0.97) and Black patients (aOR, 0.47; 95% CI, 0.28-0.77) were less likely to receive curative treatments than White patients. Compared with patients who underwent surgical resection, those who underwent liver transplantation had a trend toward improved OS (adjusted hazard ratio [aHR], 0.63; 95% CI, 0.37-1.08), whereas those who underwent local ablation (aHR, 1.39; 95% CI, 1.01-1.92) and noncurative treatments (aHR, 3.97; 95% CI, 3.24-4.88) experienced worse OS. CONCLUSIONS More than one third of patients with early stage iCCA did not receive curative treatment, with Hispanic and Black patients being less likely to receive curative treatments than White patients. Surgical resection and liver transplantation were associated with improved survival compared with local ablation. Future studies should investigate disparities in curative treatment receipt and outcomes for early stage iCCA.
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Affiliation(s)
- Yi-Te Lee
- California NanoSystems Institute, Crump Institute for Molecular Imaging, University of California, Los Angeles, Los Angeles, CA, USA
- Department of Molecular and Medical Pharmacology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Amit G. Singal
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Marie Lauzon
- Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Vatche G. Agopian
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA, USA
- Jonsson Comprehensive Cancer Center, University of California, Los Angeles, Los Angeles, CA, USA
| | - Michael Luu
- Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Mazen Noureddin
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Tsuyoshi Todo
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Irene K. Kim
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Marc L. Friedman
- Department of Radiology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Kambiz Kosari
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Nicholas N. Nissen
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Lewis R. Roberts
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | | | - Gregory J. Gores
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Ju Dong Yang
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Parikh ND, Tayob N, Al-Jarrah T, Kramer J, Melcher J, Smith D, Marquardt P, Liu PH, Tang R, Kanwal F, Singal AG. Barriers to Surveillance for Hepatocellular Carcinoma in a Multicenter Cohort. JAMA Netw Open 2022; 5:e2223504. [PMID: 35867057 PMCID: PMC9308050 DOI: 10.1001/jamanetworkopen.2022.23504] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 06/02/2022] [Indexed: 01/07/2023] Open
Abstract
Importance Hepatocellular carcinoma (HCC) surveillance is underused in clinical practice, which may be owing to patient and clinician barriers. Objective To characterize HCC surveillance barriers and associations with clinical outcomes in a multicenter cohort of patients with cirrhosis. Design, Setting, and Participants This retrospective, multicenter cohort study included 5 medical centers in the United States. Patients with cirrhosis and newly diagnosed HCC treated from 2014 to 2018 were included. Data were analyzed from June 2021 to February 2022. Exposure Surveillance completion in the 36-month period prior to HCC diagnosis. Main Outcomes and Measures Surveillance receipt was classified as semiannual, annual, or no surveillance. Multivariable logistic regression analysis was used to identify factors associated with semiannual surveillance. We conducted multivariable logistic and Cox regression analyses to characterize associations between surveillance completion with curative treatment and overall survival. Results A total 629 eligible patients (median [IQR] age, 63.6 [56.2-71.0] years; 491 [78.1%] men) were assessed, including 7 American Indian or Alaska Native patients (1.1%), 14 Asian patients (2.2), 176 Black patients (28.0%), 86 Hispanic patients (13.1%), and 340 White patients (54.1%). Nearly two-thirds of the cohort had no surveillance prior to HCC diagnosis (mean [range by site] 63.7% [37.9%-80.4%]), with a mean (range by site) of 14.0% (5.3%-33.3%) of patients having received semiannual surveillance and 22.3% (14.3%-28.8%) of patients having received annual surveillance. The most common reasons for no surveillance were lack of surveillance orders or nonadherence (mean [range by site], 82.4% [66.7%-92.4%], although a mean (range by site) of 17.6% (10.2%-22.1%) of patients had unrecognized cirrhosis at HCC presentation. Semiannual surveillance was associated with hepatitis B infection (odds ratio [OR], 3.06 [95% CI, 1.24-7.23]) and inversely associated with Black race (OR, 0.41 [95% CI, 0.20-0.80]) and lack of cirrhosis recognition (OR, 0.14 [95% CI, 0.02-0.46]). Semiannual HCC surveillance was significantly associated with curative treatment receipt (OR, 2.73 [95% CI, 1.60-4.70]) but not overall survival (HR, 0.81 [95% CI, 0.55-1.18]). Conclusions and Relevance In this cohort study of patients with cirrhosis, HCC surveillance was underused in more than 80% of patients and associated with failures across the screening process. Dedicated programs to improve cirrhosis detection and HCC surveillance attainment are needed.
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Affiliation(s)
- Neehar D. Parikh
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor
| | - Nabihah Tayob
- Department of Biostatistics, Dana Farber Cancer Center, Boston, Massachusetts
| | - Taim Al-Jarrah
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor
| | - Jennifer Kramer
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas
| | - Jennifer Melcher
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas
| | - Donna Smith
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas
| | - Patrick Marquardt
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Po-Hong Liu
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Runlong Tang
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Fasiha Kanwal
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
- Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas
- Division of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Amit G. Singal
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
- Harold C. Simmons Cancer Center, University of Texas Southwestern Medical Center, Dallas
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Carissimi F, Scotti MA, Ciulli C, Fogliati A, Uggeri F, Chiarelli M, Braga M, Romano F, Garancini M. COVID-19 and Liver Surgery: How the Pandemic Affected an Italian Medium-Volume HBP Center. Front Surg 2022; 9:918348. [PMID: 35836608 PMCID: PMC9275712 DOI: 10.3389/fsurg.2022.918348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 06/02/2022] [Indexed: 01/19/2023] Open
Abstract
Introduction While the COVID-19 pandemic is still ongoing, it is even more evident that victims of the pandemic are not only those who contract the virus, but also the countless patients suffering from other serious diseases (i.e., tumor) who have undergone delayed potentially life-saving surgery due to a lack of beds. Like many hospitals, ours also initially blocked all elective oncologic surgery, but these operations were “recovered” and reintegrated in a relatively short time, thanks to the establishment of COVID-free wards and operating rooms with staff dedicated to oncological surgery. In tis context, our aim is to assess whether and how the severe acute respiratory syndrome Coronavirus-2 (SARS-CoV-2) pandemic has impacted our hepatobiliary surgery unit. Methods From our prospective database, we retrospectively took data from patients undergoing liver surgery in 2018–2019 (pre-COVID) and 2020–2021 (COVID period). Patients admitted to COVID-free wards must necessarily have a negative nasal swab from the previous 24 h. Results Between January 1, 2018, and December 31, 2019 (Group 1), 101 patients were treated; during the pandemic [January 1, 2020, and December 31, 2021 (Group 2)], 126 patients were treated. There was no statistical difference between the groups. The median postoperative hospital stay was 7 days for both groups; 7 patients had major complications (Clavien-Dindo > 3) in Group 1 and 11 in Group 2 (p = 0.795). A total of 4 patients died in Group 1 and 6 during the pandemic (p = 0.754). Tumor burden was significantly greater in Group 2 where nodule size, lymphadenectomy, and extrahepatic disease were significantly greater (p = 0.011, p = 0.004, and p = 0.026, respectively). Conclusion During the COVID pandemic, our HPB unit managed to offer a volume of tertiary-center hepatobiliary surgery without a significant impact in terms of length of stay, morbidity, or mortality despite the increase in tumor burden during the pandemic years.
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Affiliation(s)
- Francesca Carissimi
- Department of Surgery, HPB and Gastroenterological Surgery Unit, San Gerardo Hospital, Monza, Italy
- Department of Surgery, School of Medicine, University of Milano-Bicocca, Milan, Italy
| | - Mauro Alessandro Scotti
- Department of Surgery, HPB and Gastroenterological Surgery Unit, San Gerardo Hospital, Monza, Italy
| | - Cristina Ciulli
- Department of Surgery, HPB and Gastroenterological Surgery Unit, San Gerardo Hospital, Monza, Italy
- Department of Surgery, School of Medicine, University of Milano-Bicocca, Milan, Italy
| | - Alessandro Fogliati
- Department of Surgery, HPB and Gastroenterological Surgery Unit, San Gerardo Hospital, Monza, Italy
- Department of Surgery, School of Medicine, University of Milano-Bicocca, Milan, Italy
| | - Fabio Uggeri
- Department of Surgery, HPB and Gastroenterological Surgery Unit, San Gerardo Hospital, Monza, Italy
- Department of Surgery, School of Medicine, University of Milano-Bicocca, Milan, Italy
| | | | - Marco Braga
- Department of Surgery, HPB and Gastroenterological Surgery Unit, San Gerardo Hospital, Monza, Italy
- Department of Surgery, School of Medicine, University of Milano-Bicocca, Milan, Italy
| | - Fabrizio Romano
- Department of Surgery, HPB and Gastroenterological Surgery Unit, San Gerardo Hospital, Monza, Italy
- Department of Surgery, School of Medicine, University of Milano-Bicocca, Milan, Italy
| | - Mattia Garancini
- Department of Surgery, HPB and Gastroenterological Surgery Unit, San Gerardo Hospital, Monza, Italy
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Hernandez N, Bessone F. Hepatotoxicity Induced by Biological Agents: Clinical Features and Current Controversies. J Clin Transl Hepatol 2022; 10:486-495. [PMID: 35836762 PMCID: PMC9240255 DOI: 10.14218/jcth.2021.00243] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 10/24/2021] [Accepted: 12/15/2021] [Indexed: 12/13/2022] Open
Abstract
Novel biological agents including cytokines and recombinant fusion proteins are increasingly prescribed for cancer, rheumatologic, autoimmune, and inflammatory diseases, and are currently being evaluated in hepatocellular carcinoma (HCC). They are classified by their mechanism of action and include tumor necrosis factor-alpha (TNF-α) antagonists, T cell mediated antitumor inhibitors, interleukin receptor antagonists, and immune checkpoint inhibitors (ICIs). Some ICIs cause frequent hepatotoxicity with a variable clinical, biochemical, and serological presentation, especially in patients receiving another immunomodulatory agent. Half of the cases of liver damage induced by biological agents spontaneously regress after drug withdrawal, but the others require steroid therapy. Unfortunately, there are no widely accepted recommendation for the use of corticosteroids in these patients, even though international cancer societies have their own guidelines. Differentiating drug-induced autoimmune hepatitis (DIAIH) from classic AIH is challenging for pathologists, but liver biopsy is valuable, particularly in cases with unclear clinical presentation. Interesting, novel histological patterns have been described in liver damage induced by these agents (i.e., endothelitis, ring granuloma and secundary sclerosing cholangitis associated with lymphocytic infiltration of cytotoxic CD8+T cells). Here, we describe the clinical and biochemical characteristics of patients with hepatotoxicity induced by TNF-α antagonists and ICIs. Controversial issues involved in the administration of corticosteroid therapy, and hepatitis B virus (HBV) reactivation induced by immunosuppressive therapy are also discussed.
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Affiliation(s)
- Nelia Hernandez
- Hospital de Clinicas, Universidad de la Republica, Montevideo, Uruguay
| | - Fernando Bessone
- Hospital Provincial del Centenario, University of Rosario School of Medicine, Rosario, Argentina
- Correspondence to: Fernando Bessone, Facultad de Ciencias Médicas, Hospital Provincial del Centenario, University of Rosario School of Medicine, Rosario, Argentina. ORCID: https://orcid.org/0000-0002-8569-8123. Tel: +54-341-5026969, Fax: +54-341-4387014, E-mail:
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Li J, Zhang X, Yao L, Hu K. The bioinformatics and experimental analysis of the novel roles of virus infection-associated gene CDC20 for prognosis and immune infiltration in hepatocellular carcinoma. Aging (Albany NY) 2022; 14:4513-4529. [PMID: 35622386 PMCID: PMC9186757 DOI: 10.18632/aging.204093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 05/10/2022] [Indexed: 11/25/2022]
Abstract
Infection virus including HBV and HCV has been well recognized as a major cause inducing hepatocellular carcinoma (HCC). However, molecular investigations into the HTLV-1 (Human T-lymphotropic virus type-1) and HCC have been rare. In this study, we integrated several public datasets of HCC patients and filtered seven genes including CDC20 as the HTLV-1 infection-related genes which were differentially expressed in HCC. CDC20 was chosen for further investigation based on its promising prognostic power. The expression profiles, prognostic assessment, association with clinicopathologic characteristics, prediction of correlated signal pathways, and the immune-modulating function of CDC20 were assessed. We found that CDC20 expression was significantly increased in hepatocellular carcinoma tissues and cell lines, and was correlated with histologic grade, pathologic stage, tumor status, and patient age. CDC20 exhibited prognostic value on overall survival and disease specific survival and was an independent prognostic factor. It was primarily involved in several signal pathways, especially the omega-hydroxylase P450 and epoxygenase P450 signal pathways. Moreover, CDC20 expression showed significant positive associations with the levels of several immune cells such as T helper 2 cells and follicular helper T cells, immunostimulators including TNFRSF18 and MICB, immunoinhibitors including KDR and PDCD1LG2, chemokines including XCL1 and CCL26, and chemokine receptors including CCR10 and CXCR3. This study for the first time delineated the correlation of CDC20 with HTLV-1 infection-associated HCC. The disorder of expression and function of CDC20 makes it a probable biomarker for better etiological classification, prognostic prediction, and precision medicine.
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Affiliation(s)
- Juanni Li
- Department of Pathology, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China
| | - Xiaofang Zhang
- Departments of Burn and Plastic, Ningxiang People's Hospital, Hunan University of Chinese Medicine, Changsha 410600, Hunan, China
| | - Lei Yao
- Department of Hepatobiliary Surgery, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China
| | - Kuan Hu
- Department of Hepatobiliary Surgery, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China
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Liu X, Liu F, Yu H, Zhang Q, Liu F. Development and Validation of a Prediction Model for Predicting the Prognosis of Postoperative Patients with Hepatocellular Carcinoma. Int J Gen Med 2022; 15:3625-3637. [PMID: 35411181 PMCID: PMC8994662 DOI: 10.2147/ijgm.s351265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 03/10/2022] [Indexed: 12/24/2022] Open
Affiliation(s)
- Xiaoliang Liu
- Department of General Surgery, The Affiliated Hospital of West Anhui Health Vocational College, Lu'an City, Anhui Province, People’s Republic of China
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei City, Anhui Province, People’s Republic of China
| | - Feng Liu
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei City, Anhui Province, People’s Republic of China
| | - Haifeng Yu
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei City, Anhui Province, People’s Republic of China
| | - Qiaoqian Zhang
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei City, Anhui Province, People’s Republic of China
| | - Fubao Liu
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei City, Anhui Province, People’s Republic of China
- Correspondence: Fubao Liu, Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Anhui Medical University, No. 218, Jixi Road, Hefei City, Anhui Province, People’s Republic of China, Tel +86 135 1566 2646, Email
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Ribaldone DG, Caviglia GP, Gaia S, Rolle E, Risso A, Campion D, Brunocilla PR, Saracco GM, Carucci P. Effect of COVID-19 Pandemic on Hepatocellular Carcinoma Diagnosis: Results from a Tertiary Care Center in North-West Italy. Curr Oncol 2022; 29:1422-1429. [PMID: 35323319 PMCID: PMC8946861 DOI: 10.3390/curroncol29030119] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 02/17/2022] [Accepted: 02/23/2022] [Indexed: 12/23/2022] Open
Abstract
The COVID-19 pandemic has forced us to direct most of the available resources towards its management. This has led to the neglect of all other pathologies, including cancer. The aim of this study was to verify whether the difficulty in accessing the health system has led to a reduction in new diagnoses of hepatocellular carcinoma (HCC) and whether this has already been reflected in a more advanced stage of the cancer. A single-center, retrospective study including adult patients with a new diagnosis of HCC was performed. Patients were divided into three groups: the prelockdown phase (May 2019–February 2020), the lockdown phase (March 2020–December 2020), and the postlockdown phase (January 2021–October 2021); 247 patients were included. The number of patients diagnosed with HCC distinctly diminished in the periods March 2020–December 2020 (n = 69; −35%) and January 2021–October 2021 (n = 72; −32%) as compared to the period May 2019–February 2020 (n = 106). Noteworthy was the reduced surveillance in the period January 2021–October 2021 as compared to May 2019–February 2020 (22.9% vs. 36.6%, p = 0.056). No significant changes have yet been observed in tumor characteristics (BCLC staging distribution remained unvaried, p = 0.665). In conclusion, the number of new HCC diagnoses decreased sharply in the first 2 years of the pandemic, with no worsening of the stage. A more advanced stage of the disease could be expected in the next few years in patients who have escaped diagnosis.
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Affiliation(s)
- Davide Giuseppe Ribaldone
- Department of Medical Sciences, University of Turin, 10100 Turin, Italy; (G.P.C.); (A.R.); (G.M.S.)
- Correspondence: (D.G.R.); (P.C.); Tel.: +39-11-633-3615 (D.G.R.); Fax: +39-11-633-3970 (D.G.R.)
| | - Gian Paolo Caviglia
- Department of Medical Sciences, University of Turin, 10100 Turin, Italy; (G.P.C.); (A.R.); (G.M.S.)
| | - Silvia Gaia
- Division of Gastroenterology, Città della Salute e della Scienza University-Hospital, 10100 Turin, Italy; (S.G.); (E.R.); (D.C.); (P.R.B.)
| | - Emanuela Rolle
- Division of Gastroenterology, Città della Salute e della Scienza University-Hospital, 10100 Turin, Italy; (S.G.); (E.R.); (D.C.); (P.R.B.)
| | - Alessandra Risso
- Department of Medical Sciences, University of Turin, 10100 Turin, Italy; (G.P.C.); (A.R.); (G.M.S.)
| | - Daniela Campion
- Division of Gastroenterology, Città della Salute e della Scienza University-Hospital, 10100 Turin, Italy; (S.G.); (E.R.); (D.C.); (P.R.B.)
| | - Paola Rita Brunocilla
- Division of Gastroenterology, Città della Salute e della Scienza University-Hospital, 10100 Turin, Italy; (S.G.); (E.R.); (D.C.); (P.R.B.)
| | - Giorgio Maria Saracco
- Department of Medical Sciences, University of Turin, 10100 Turin, Italy; (G.P.C.); (A.R.); (G.M.S.)
- Division of Gastroenterology, Città della Salute e della Scienza University-Hospital, 10100 Turin, Italy; (S.G.); (E.R.); (D.C.); (P.R.B.)
| | - Patrizia Carucci
- Division of Gastroenterology, Città della Salute e della Scienza University-Hospital, 10100 Turin, Italy; (S.G.); (E.R.); (D.C.); (P.R.B.)
- Correspondence: (D.G.R.); (P.C.); Tel.: +39-11-633-3615 (D.G.R.); Fax: +39-11-633-3970 (D.G.R.)
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Rich NE, Carr C, Yopp AC, Marrero JA, Singal AG. Racial and Ethnic Disparities in Survival Among Patients With Hepatocellular Carcinoma in the United States: A Systematic Review and Meta-Analysis. Clin Gastroenterol Hepatol 2022; 20:e267-e288. [PMID: 33387668 PMCID: PMC8243558 DOI: 10.1016/j.cgh.2020.12.029] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 12/22/2020] [Accepted: 12/24/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Hepatocellular carcinoma (HCC) is the fastest rising cause of cancer-related death in the United States; however, HCC incidence and mortality are not equally distributed among racial and ethnic groups. Our aim was to characterize the direction and magnitude of racial and ethnic disparities in overall survival and early tumor detection among patients with HCC. METHODS We searched MEDLINE, EMBASE and Cochrane databases from inception through August 2020 for studies reporting HCC outcomes (early stage presentation and overall survival) by race and ethnicity. We calculated pooled hazard ratios (HRs) and odds ratios (ORs) for each racial and ethnic group (White, Black, Hispanic, Asian) using the DerSimonian and Laird method for a random-effects model. RESULTS We identified 35 articles comprising 563,097 patients (53.0% White, 17.3% Black, 18.4% Hispanic, 5.0% Asian). Compared with White patients, Black patients had worse survival (pooled HR 1.08; 95% CI, 1.05 - 1.12), whereas Hispanic (pooled HR 0.92; 95% CI, 0.87 - 0.97) and Asian (pooled HR 0.81; 95% CI, 0.73 - 0.88) patients had better survival. Among articles reporting tumor stage (n = 20), Black patients had lower odds of early stage HCC compared with White patients (OR, 0.66; 95% CI, 0.54 - 0.78). Conversely, there was no difference in odds of early HCC detection for Asian (OR, 1.01; 95% CI, 0.97 - 1.05) or Hispanic patients (OR, 0.87; 95% CI, 0.74 - 1.01) compared with White patients. The most common limitation of studies was risk of residual confounding from socioeconomic status and liver dysfunction. CONCLUSIONS There are significant racial and ethnic disparities in HCC prognosis in the United States, with Black patients having worse overall survival and Hispanic and Asian patients having better overall survival compared with White patients. Interventions are needed to reduce disparities in early HCC detection to improve HCC prognosis.
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Affiliation(s)
- Nicole E Rich
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas; Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, Texas.
| | - Christian Carr
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Adam C Yopp
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas; Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, Texas
| | - Jorge A Marrero
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas; Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, Texas
| | - Amit G Singal
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas; Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, Texas
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