Uncovering Barriers to HCC Surveillance in Patients with Cirrhosis

Dr. Takemoto:

This is Project Oncology on ReachMD. I’m Dr. Jody Takemoto, and joining me to discuss his recent study that focused on clinician-level gaps and barriers to hepatocellular carcinoma surveillance in patients with cirrhosis is Dr. Robert Wong, who’s a Clinical Associate Professor of Medicine in the Division of Gastroenterology and Hepatology at Stanford University School of Medicine and a physician at the Veterans Affairs Palo Alto Healthcare System.

Diving in, Dr. Wong, can you tell us why you conducted this study and what the overall objective was?

Dr. Wong:

Sure. So this recent study that we published in JAMA Network Open really aims to try and understand what are the drivers of low rates of HCC screening and surveillance in patients with cirrhosis. There has been robust data across different populations and even globally, but just focusing on the U.S., there’s robust data that show in patients with cirrhosis, rates of screening for liver cancer are very low. Now that’s important because all the guidelines recommend if you have cirrhosis, because you’re at higher risk of developing liver cancer, you really should be getting screening and surveillance every six months, and typically, this is done with an abdominal ultrasound and a blood test called the alpha fetoprotein. 

Despite the clear recommendations of doing this every six months, there has been some recent data that really show that less than 30 percent of people are actually getting this done on a regular basis, and that’s very concerning because the idea behind implementing screening and surveillance is that we can catch cancers early, and if you catch them small and early, there’s better treatment options. And in fact, for liver cancer in particular, if you catch them early enough, they’re potentially curative, whether it’s with a surgical resection, different types of ablation, or even transplant, so there’s such a high importance to catch these early, but time and time again we see that effective use and completion of liver cancer surveillance has been low.

Dr. Takemoto:

Based on that, how was the study designed, and what do we need to know about the setting and participants involved?

Dr. Wong:

So this study is part of our NIH-funded study. It’s a five-center study. We focused on safety net populations. So for those who are not familiar, safety net health systems are really like county hospitals, those that primarily serve underinsured Medicaid populations. And we wanted to focus on these populations because these are the most vulnerable groups. It’s primarily ethnic minorities and socioeconomically disadvantaged. And we know across all disease states that these people experience existing barriers and access to care, so our goal was really to try to understand what are some of the factors contributing to low liver cancer screening and surveillance in this population. And really, the main takeaway that we hope to get from this five-year study is can we identify a key set of modifiable factors, something we can take away and say, “This is something we can focus on to change,” whether it’s with quality improvement or some kind of intervention that can potentially lead to better outcomes. 

So this study is one aspect that we focused on surveying providers, so we’re trying to understand from the provider view what are some factors that maybe we can help address that might improve it. We focused on both primary care providers as well as GI and hepatology specialty providers. And again, we surveyed these providers across the five safety net sites. 

We found very interesting findings. Some of the key takeaways are, especially among primary care providers, that there is a lot of work to do on our part to help improve knowledge about cirrhosis, what are the recommended cancer screening guidelines, and how to implement that effectively in patients with cirrhosis.

Dr. Takemoto:

Excellent. Can you tell us more about the significance of your findings?

Dr. Wong:

As I mentioned, I think that some of the key takeaways we found is there seems to be a knowledge gap. In many of the questions, especially among primary care providers, one key thing that stood out is some providers didn’t feel comfortable with accurately identifying cirrhosis, and that’s a very fundamental gap because if you’re unable to feel confident in identifying cirrhosis, then of course you’re not going to screen for cancer. So just that one point I think is so important and tells us that we need to have better education or outreach and really work together with our primary care colleagues to see how can we develop ways, algorithms, system, or EHR-based type of interventions that can better identify who has cirrhosis and who doesn’t.  And then among those with cirrhosis, some of the key factors we found were even knowing what the guidelines say. 

There are so many guidelines out there, and sometimes it’s overwhelming. With primary care, where they really have to be jack of all trades and experts in everything, it’s not an easy task to stay up to date with all the specialties, so I think from our end as specialists, we need to do a better job in how to distill these guidelines and really highlight the key take-home points that we want to help our primary care colleagues highlight in their day-to-day practice.

Dr. Takemoto:

For those just tuning in, you’re listening to Project Oncology on ReachMD. I’m Dr. Jody Takemoto, and today I’m speaking with Dr. Robert Wong about his study that focused on clinician-level gaps and barriers to hepatocellular carcinoma surveillance in patients with cirrhosis.

So given these results, Dr. Wong, what recommendations do you have to reduce those gaps and overcome perceived barriers?

Dr. Wong:

U.S. healthcare is challenging, it’s complicated, but how can we think of innovative ways to capitalize on technology, EHR, AI, machine learning, all of these hot topics to really effectively implement liver cancer screening and even potentially—this is pushing it to the fringe—but how can we even automate it and take out the human error so that it doesn’t require us to think about diagnosis, remember to screen, order the tests, and follow up the tests. I mean, in a perfect world, this potentially—if done correctly and safely—can be sort of an automated process that works together with providers.

Dr. Takemoto:

Any additional or final thoughts on future directions for this study?

Dr. Wong:

Yeah. So this is just one spoke, so to speak, of this five-year study is focusing on provider knowledge, attitudes, and perceptions, and this is the first phase of our study. The other parts of our study utilizes the same five centers and is focusing on patient factors.  So this first study we published were provider factors. The second is understanding patient factors, meaning what are the clinical characteristics, demographics, or socioeconomics among these patients that may influence receipt of HCC screening and surveillance. Are there certain groups that are particularly disadvantaged? And is there something we can do about it? Is it because of insurance barriers? Is it because of transportation? Is it because of difficulty with understanding their disease state or comorbidities? So that’s the second area that we’re focusing on. And then third is system factors. That’s going to be a little bit challenging. 

Part of the novelty of this study was trying to target patient, provider, and system-level factors to kind of meld them together and see how can we account for all of these multifactorial barriers in getting timely HCC screening and surveillance.  So we’ve tackled the provider aspect. We’re in the process of tackling the patient. And I think in a future-future direction, we’re going to try to understand the system-level factors, like access to specialty providers, you know, access to radiology. We assume that if a provider orders an ultrasound, it’s going to be done in a timely manner. That’s not always the case. So some of these are difficult to accurately assess and measure, but that’s going to be a challenge we’re going to try to take in the near future.

Dr. Takemoto:

That’s a great way to round out our discussion on clinician barriers to hepatocellular carcinoma surveillance in patients with cirrhosis. I want to thank my guest, Dr. Robert Wong, for joining me.

For ReachMD, I’m Dr. Jody Takemoto. To access this and other episodes in our series, visit Project Oncology on ReachMD dot com, where you can Be Part of the Knowledge. Thanks for listening!