Use of Surveillance for Hepatocellular Carcinoma Among... : Hepatology (original) (raw)

Hepatobiliary Malignancies

Use of Surveillance for Hepatocellular Carcinoma Among Patients With Cirrhosis in the United States

Davila, Jessica A.1,*; Morgan, Robert O.1; Richardson, Peter A.1; Du, Xianglin L.3; McGlynn, Katherine A.4; El-Serag, Hashem B.1,2

1_Sections of Health Services Research, Houston Center for Quality of Care & Utilization Studies, Houston VA Medical Center and Baylor College of Medicine, Houston, TX_

2_Sections of Gastroenterology, Houston Center for Quality of Care & Utilization Studies, Houston VA Medical Center and Baylor College of Medicine, Houston, TX_

3_Department of Epidemiology, The University of Texas School of Public Health, Houston, TX_

4_Division of Cancer Epidemiology and Genetics, National Cancer Institute, Department of Health and Human Services, Bethesda, MD_

*Address reprint requests to: The Michael E. DeBakey VA Medical Center, 2002 Holcombe Boulevard (152), Houston, TX 77030. E-mail:[email protected]; fax: 713-748-7359

Received 27 July 2009; accepted 1 February 2010

Supported in part by grants from the American Cancer Society (RSGPB-07-010-01-CPHPS to J. A. D.; NCI R01 125487 and DK K24 04107 to H. B. E.-S.) and the Houston VA Health Services Research and Development Center of Excellence (HFP90-020).

Published online in Wiley InterScience (www.interscience.wiley.com).

Potential conflict of interest: Nothing to report.

Additional Supporting Information may be found in the online version of this article.

Abstract

Surveillance for hepatocellular carcinoma (HCC) in patients with cirrhosis is recommended but may not be performed. The extent and determinants of HCC surveillance are unknown. We conducted a population-based United States cohort study of patients over 65 years of age to examine use and determinants of prediagnosis surveillance in patients with HCC who were previously diagnosed with cirrhosis. Patients diagnosed with HCC during 1994-2002 were identified from the linked Surveillance, Epidemiology, and End-Results registry–Medicare databases. We identified alpha-fetoprotein (AFP) and ultrasound tests performed for HCC surveillance, and examined factors associated with surveillance. We identified 1,873 HCC patients with a prior diagnosis of cirrhosis. In the 3 years before HCC, 17% received regular surveillance and 38% received inconsistent surveillance. In a subset of 541 patients in whom cirrhosis was recorded for 3 or more years prior to HCC, only 29% received routine surveillance and 33% received inconsistent surveillance. Among all patients who received regular surveillance, approximately 52% received both AFP and ultrasound, 46% received AFP only, and 2% received ultrasound only. Patients receiving regular surveillance were more likely to have lived in urban areas and had higher incomes than those who did not receive surveillance. Before diagnosis, approximately 48% of patients were seen by a gastroenterologist/hepatologist or by a physician with an academic affiliation; they were approximately 4.5-fold and 2.8-fold, respectively, more likely to receive regular surveillance than those seen by a primary care physician only. Geographic variation in surveillance was observed and explained by patient and physician factors.

Conclusion:

Less than 20% of patients with cirrhosis who developed HCC received regular surveillance. Gastroenterologists/hepatologists or physicians with an academic affiliation are more likely to perform surveillance. Hepatology 2010