Ultrasound surveillance for hepatocellular carcinoma: service evaluation of a radiology-led recall system in a tertiary-referral centre for liver diseases in the UK

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

Single-blind randomised controlled trial.

SETTING AND PARTICIPANTS

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

METHODS

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION

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

TWEETABLE ABSTRACT

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

Alcohol use and hepatocellular carcinoma risk in patients with alcohol-related cirrhosis

OBJECTIVES

Insights into risk factors for hepatocellular carcinoma (HCC) among patients with alcohol-related cirrhosis (ALD cirrhosis) are important for decisions about HCC surveillance. We studied the effects of continued hazardous alcohol use in ALD cirrhosis on HCC risk.

METHODS

Within a nationwide registry-based cohort of patients with ALD cirrhosis, we compared HCC risk between patients with a continued hazardous alcohol use and matched comparators. We used Fine-Gray regression to compare the risk of HCC and Cox regression to compare all-cause mortality. We also included patients with ALD cirrhosis in a clinical case-control study. Cases had HCC, and controls did not. Alcohol use was quantified using the AUDIT-C-questionnaire. Logistic regression was used to analyze the association between hazardous alcohol use and HCC risk.

RESULTS

In the registry-based study, we included 8,616 patients with continued hazardous alcohol use and 8,616 matched comparators. Patients with a continued hazardous alcohol use had a lower HCC risk (subdistribution hazard ratio: 0.64, 95% confidence interval [CI]: 0.57 - 0.72) and higher mortality (hazard ratio: 1.62, 95% CI: 1.56 - 1.67). In the clinical study, we included 146 patients with ALD cirrhosis of whom 53 had newly diagnosed HCC. Hazardous alcohol use was insignificantly associated with a lower HCC risk (odds ratio: 0.61, 95% CI: 0.25 - 1.46).

CONCLUSIONS

Hazardous alcohol use in patients with ALD cirrhosis is associated with higher mortality and, consequently, a lower HCC risk. Even if alcohol is carcinogenic, HCC surveillance will therefore likely be more effective in patients with ALD cirrhosis without a hazardous alcohol use.

Patient-, Provider-, and System-Level Barriers to Surveillance for Hepatocellular Carcinoma in High-Risk Patients in the USA: a Scoping Review

PURPOSE

Hepatocellular carcinoma has a dismal prognosis, except in patients diagnosed early who are candidates for potentially curative therapies. Most HCC cases develop in patients with chronic liver disease. Therefore, expert society guidelines recommend surveillance every 6 months with ultrasound with or without serum alpha-fetoprotein for high-risk patients. However, fewer than 20% of patients in the USA undergo appropriate surveillance.

METHODS

A systematic scoping review was performed with the objective of identifying barriers to screening among high-risk patients in the USA including mapping key concepts in the relevant literature, identifying the main sources and types of evidence available, and identifying gaps in the literature. A total of 43 studies published from 2007 to 2021 were included. Data were extracted and a conceptual framework was created.

RESULTS

Assessment of quantitative studies revealed poor surveillance rates, often below 50%. Three categories of barriers to surveillance were identified: patient-level, provider-level, and system-level barriers. Prevalent patient-level barriers included financial constraints, lack of awareness of surveillance recommendations, and scheduling difficulties. Common provider-level barriers were lack of provider awareness of guidelines for surveillance, difficulty accessing specialty resources, and time constraints in the clinic. System-level barriers included fewer clinic visits and rural/safety-net settings. Proposed interventions include improved patient/provider education, patient navigators, increased community/academic collaboration, and EMR-based reminders.

CONCLUSION

Based on these findings, there is a crucial need to implement and evaluate proposed interventions to improve HCC surveillance.

Utilization of Hepatocellular Carcinoma Surveillance Programs in Patients With Cirrhosis: A Systematic Review and Meta-Analysis

Patients with cirrhosis are advised to undergo hepatocellular carcinoma (HCC) surveillance every 6 months. Routine surveillance is associated with early tumor detection and improved survival. However, surveillance is underutilized. We aimed to characterize the uptake of HCC surveillance in cirrhotic patients following the implementation of interventional programs. We performed a comprehensive literature search of major databases (from inception to October 2020). Surveillance was defined as having an abdominal sonogram every 6 months. Nine studies were included for meta-analysis which involved 4550 patients. The etiology of liver cirrhosis was largely due to hepatitis C or B (n=2023), followed by alcohol (n=857), and nonalcoholic steatohepatitis (n=432). Patients enrolled in surveillance programs were 6 times more likely to undergo abdominal sonography when compared with standard of care (odds ratio=6.00; 95% confidence interval: 3.35-10.77). On subgroup analysis, clinical reminders were associated with a 4 times higher rate of HCC surveillance compared with standard of care (odds ratio=3.80; 95% confidence interval: 2.25-6.39). Interventional programs significantly improve the rate of HCC surveillance. This is clinically impactful and should be considered as a means for improving surveillance rates.

Screening for Hepatocellular Carcinoma in Patients with Hepatitis B

Chronic hepatitis B (CHB) infection is a significant risk factor for developing hepatocellular carcinoma (HCC). As HCC is associated with significant morbidity and mortality, screening patients with CHB at a high risk for HCC is recommended in an attempt to improve these outcomes. However, the screening recommendations on who to screen and how often are not uniform. Identifying patients at the highest risk of HCC would allow for the best use of health resources. In this review, we evaluate the literature on screening patients with CHB for HCC, strategies for optimizing adherence to screening, and potential risk stratification tools to identify patients with CHB at a high risk of developing HCC.

Use of Hepatocellular Carcinoma Surveillance in Patients With Cirrhosis: A Systematic Review and Meta-Analysis

BACKGROUND AND AIMS

Hepatocellular carcinoma (HCC) surveillance is associated with early tumor detection and improved survival; however, it is often underused in clinical practice. We aimed to characterize surveillance use among patients with cirrhosis and the efficacy of interventions to increase surveillance.

APPROACH AND RESULTS

We performed a systematic literature review using the MEDLINE database from January 2010 through August 2018 to identify cohort studies evaluating HCC surveillance receipt or interventions to increase surveillance in patients with cirrhosis. A pooled estimate for surveillance receipt with 95% confidence intervals was calculated. Correlates of surveillance use were defined from each study and prespecified subgroup analyses. Twenty-nine studies, with a total of 118,799 patients, met inclusion criteria, with a pooled estimate for surveillance use of 24.0% (95% confidence interval, 18.4-30.1). In subgroup analyses, the highest surveillance receipt was reported in studies with patients enrolled from subspecialty gastroenterology/hepatology clinics and lowest in studies characterizing surveillance in population-based cohorts (73.7% versus 8.8%, P < 0.001). Commonly reported correlates of surveillance included higher receipt among patients followed by subspecialists and lower receipt among those with alcohol-associated or nonalcoholic steatohepatitis (NASH)-related cirrhosis. All eight studies (n = 5,229) evaluating interventions including patient/provider education, inreach (e.g., reminder and recall systems), and population health outreach strategies reported significant increases (range 9.4%-63.6%) in surveillance receipt.

CONCLUSIONS

HCC surveillance remains underused in clinical practice, particularly among patients with alcohol-associated or NASH-related cirrhosis and those not followed in subspecialty gastroenterology clinics. Interventions such as provider education, inreach including reminder systems, and population health outreach efforts can significantly increase HCC surveillance.

Poor adherence to hepatocellular carcinoma surveillance: A systematic review and meta-analysis of a complex issue

BACKGROUND & AIMS

Hepatocellular carcinoma (HCC) surveillance is associated with improved outcomes and long-term survival. Our goal is to evaluate adherence rates to HCC surveillance.

METHODS

We performed a systematic search of the PubMed and Scopus databases and abstract search of relevant studies from recent major liver meetings. All searches and data extraction were performed independently by two authors. Analysis was via random-effects models and multivariate meta-regression.

RESULTS

A total of 22 studies (n = 19 511) met inclusion criteria (original non-interventional studies with defined cirrhosis or chronic hepatitis B or chronic hepatitis C with advanced fibrosis populations, and surveillance tests and intervals). Overall adherence rate was 52% (95% CI 38%-66%). Adherence was significantly higher in cirrhotic patients compared to chronic hepatitis B and other high-risk patients, in European compared to North American studies, in less than 12-month compared to yearly surveillance intervals, and in prospective compared to retrospective studies (71%, 95% CI 64%-78% vs 39%, 95% CI 26%-51%, P < .001). The between-study heterogeneity of all above analyses was significant (P < .001). Only the study design (retrospective vs prospective cohort) had statistical significance in a multivariate meta-regression model (P < .05) and could account for some of the differences above.

CONCLUSIONS

Overall adherence rate to HCC surveillance was suboptimal at 52% with no significant differences by liver disease aetiology or study location in multivariate meta-regression analysis. Further research and educational efforts are needed to improve the current rate of HCC surveillance.

Novel specific markers for hepatocellular carcinoma: Perspective on clinical applications

Hepatocellular carcinoma (HCC) is one of the most common cancers worldwide. Despite continuous global efforts aimed at HCC eradication and improvements in various treatment techniques, the prognosis of HCC remains very poor. How to monitor malignant transformation of hepatocytes or diagnose HCC at early stage is still a medical challenge. A growing understanding of the multiple pathogenic factors including hepatitis B virus or hepatitis C virus infection, lipid accumulation, aflatoxin B1 intake and so on suggests that hepatocarcinogenesis is a multistep process. A large number of oncogenes or tumor suppressor genes have been identified. Early screening of HCC patients has been reported to confer a survival benefit. Although serum alpha-fetoprotein (AFP) and hepatoma-specific AFP have been used as conventional tumor markers, they often show false-positive results and lack sufficient sensitivity and specificity. In order to provide optimal treatment for each patient with HCC, more precise and effective biomarkers are urgently needed in all phases of management from early detection to staging, treatment monitoring, and prognosis evaluation. Recently, numerous studies have shown the clinical utility of novel blood-based biomarkers, such as circulating tumor cells, key signal molecules or specific proteins, long non-coding RNAs, and microRNAs. In this article, we will review some novel HCC-related biomarkers and discuss their future perspective on clinical applications.