ORIGINAL ARTICLE
The Effect of Hepatocellular Carcinoma Surveillance in an Urban Population With Liver Cirrhosis Jeffrey D. Nusbaum, MD,* John Smirniotopoulos, MD,* Henry C. Wright, MD,* Chiranjeev Dash, MD, PhD,w Tarina Parpia, MS,* Joanna Shechtel, BA,* Yaojen Chang, PhD,w Christopher Loffredo, PhD,w and Kirti Shetty, MDz
Background: Hepatocellular carcinoma (HCC) surveillance in patients with cirrhosis is aimed at early detection so that effective therapeutic options may be offered. We undertook this study to assess the patterns of surveillance that had been offered to HCC patients evaluated at our center, and the effect of these strategies on outcome. Methods: Consecutive patients, age 18 years and older, diagnosed with HCC between December 2007 and December 2012 were identified. Surveillance was defined as a-fetoprotein measurement and/or imaging examination in the 12 months before HCC diagnosis. Logistic regression and survival analysis models were utilized to investigate the association of surveillance with patient characteristics and survival. Results: A total of 305 patients with HCC and a background of cirrhosis were analyzed. HCC was detected by surveillance in 131 patients (43%). Of those who underwent surveillance, 92% were diagnosed with early-stage cancer (stages I and II) compared with 62% of those who did not undergo surveillance (P < 0.001). The rate of surgical therapy (hepatic resection and liver transplantation) was almost doubled in the surveillance group (61% vs. 33%, P < 0.05). At median follow-up of 27.3 months, overall survival was high at 55% and surveillance was significantly associated with longer survival (P = 0.006). Conclusions: At our center, surveillance efficacy for HCC detection was notably higher than earlier reported. Impact: Patients who underwent surveillance were more likely to have their tumors detected at an early stage, to qualify for surgical therapy, and to have improved survival.
associated with HCC has also risen and primary liver cancer is the only cancer in the United States for which death rates are increasing. If detected at an early stage, liver transplantation (LT) offers a potential curative option for HCC. However, LT is usually limited to those with early tumors as defined by the Milan criteria,3 that is, single tumors under 5 cm, or 30%). Most of our patients had well-compensated or Child A cirrhosis, with a small percentage suffering from advanced disease. The median MELD score was 11 (ranging from 5 to 22). Median tumor size was 3.2 cm and 50% had solitary tumors. Data to determine stage of HCC were available for 94% (N = 288) of the patients. Of these, 75% were diagnosed as stage I/II.
Surveillance Characteristics HCC was detected by surveillance in 131 patients (43%). Of these patients, 95% had imaging studies. Over half of those undergoing surveillance (53%) underwent a magnetic resonance imaging (MRI) of the abdomen, and only 22% had an ultrasound examination. Fifty-four percent of those undergoing surveillance had imaging only, with 41% undergoing testing with both AFP and imaging, and the remainder had AFP measurements only.
Predictors of Surveillance We examined several demographic and clinical factors including age, race, sex, education, zip code of residence, insurance status, etiology, and severity of liver disease. In univariate models, younger age and low platelet count (< 150,000/mL) were associated with higher likelihood of surveillance, whereas nonprivate insurance and current alcohol intake were associated with lower surveillance rates. After adjusting for age, gender, race, and predictors found to be significantly associated with surveillance status in univariate models, lack of private insurance, current alcohol intake, and platelet count >150,000/mL continued to be significantly associated with surveillance failure (Table 1). The effect of age on surveillance status was modified by the type of insurance (P interaction = 0.04). Among patients with government insurance, younger patients (below 58 y) were more likely to have surveillance than older patients [OR = 3.50; 95% confidence interval (CI), 1.02, 11.99]. However, among patients with private insurance, there was no statistically significant association between age and surveillance status (OR = 0.69; 95% CI, 0.32, 1.49).There was no association noted between educational level/median household income and surveillance status.
Effects of Surveillance The majority of HCC patients in our study presented in early stages of disease (stage I: 54%, stage II: 22%). Of the patients who underwent surveillance, 92% were diagnosed with early-stage cancer (stages I and II) compared with 62% of those who did not undergo surveillance (P < 0.001) as shown in Table 2 (all calculations based on 288 patients with staging data available). We examined the rates of surgical intervention (HR and LT), LRT (which included transarterial chemoembolization, transarterial
TABLE 1. Predictors of Prior Surveillance in Patients With HCC Diagnosis (N = 305)
Univariate Analysis
Multivariate Analysis*
Variables
OR
95% CI
OR
95% CI
Age
The Effect of Hepatocellular Carcinoma Surveillance in an Urban Population With Liver Cirrhosis Jeffrey D. Nusbaum, MD,* John Smirniotopoulos, MD,* Henry C. Wright, MD,* Chiranjeev Dash, MD, PhD,w Tarina Parpia, MS,* Joanna Shechtel, BA,* Yaojen Chang, PhD,w Christopher Loffredo, PhD,w and Kirti Shetty, MDz
Background: Hepatocellular carcinoma (HCC) surveillance in patients with cirrhosis is aimed at early detection so that effective therapeutic options may be offered. We undertook this study to assess the patterns of surveillance that had been offered to HCC patients evaluated at our center, and the effect of these strategies on outcome. Methods: Consecutive patients, age 18 years and older, diagnosed with HCC between December 2007 and December 2012 were identified. Surveillance was defined as a-fetoprotein measurement and/or imaging examination in the 12 months before HCC diagnosis. Logistic regression and survival analysis models were utilized to investigate the association of surveillance with patient characteristics and survival. Results: A total of 305 patients with HCC and a background of cirrhosis were analyzed. HCC was detected by surveillance in 131 patients (43%). Of those who underwent surveillance, 92% were diagnosed with early-stage cancer (stages I and II) compared with 62% of those who did not undergo surveillance (P < 0.001). The rate of surgical therapy (hepatic resection and liver transplantation) was almost doubled in the surveillance group (61% vs. 33%, P < 0.05). At median follow-up of 27.3 months, overall survival was high at 55% and surveillance was significantly associated with longer survival (P = 0.006). Conclusions: At our center, surveillance efficacy for HCC detection was notably higher than earlier reported. Impact: Patients who underwent surveillance were more likely to have their tumors detected at an early stage, to qualify for surgical therapy, and to have improved survival.
associated with HCC has also risen and primary liver cancer is the only cancer in the United States for which death rates are increasing. If detected at an early stage, liver transplantation (LT) offers a potential curative option for HCC. However, LT is usually limited to those with early tumors as defined by the Milan criteria,3 that is, single tumors under 5 cm, or 30%). Most of our patients had well-compensated or Child A cirrhosis, with a small percentage suffering from advanced disease. The median MELD score was 11 (ranging from 5 to 22). Median tumor size was 3.2 cm and 50% had solitary tumors. Data to determine stage of HCC were available for 94% (N = 288) of the patients. Of these, 75% were diagnosed as stage I/II.
Surveillance Characteristics HCC was detected by surveillance in 131 patients (43%). Of these patients, 95% had imaging studies. Over half of those undergoing surveillance (53%) underwent a magnetic resonance imaging (MRI) of the abdomen, and only 22% had an ultrasound examination. Fifty-four percent of those undergoing surveillance had imaging only, with 41% undergoing testing with both AFP and imaging, and the remainder had AFP measurements only.
Predictors of Surveillance We examined several demographic and clinical factors including age, race, sex, education, zip code of residence, insurance status, etiology, and severity of liver disease. In univariate models, younger age and low platelet count (< 150,000/mL) were associated with higher likelihood of surveillance, whereas nonprivate insurance and current alcohol intake were associated with lower surveillance rates. After adjusting for age, gender, race, and predictors found to be significantly associated with surveillance status in univariate models, lack of private insurance, current alcohol intake, and platelet count >150,000/mL continued to be significantly associated with surveillance failure (Table 1). The effect of age on surveillance status was modified by the type of insurance (P interaction = 0.04). Among patients with government insurance, younger patients (below 58 y) were more likely to have surveillance than older patients [OR = 3.50; 95% confidence interval (CI), 1.02, 11.99]. However, among patients with private insurance, there was no statistically significant association between age and surveillance status (OR = 0.69; 95% CI, 0.32, 1.49).There was no association noted between educational level/median household income and surveillance status.
Effects of Surveillance The majority of HCC patients in our study presented in early stages of disease (stage I: 54%, stage II: 22%). Of the patients who underwent surveillance, 92% were diagnosed with early-stage cancer (stages I and II) compared with 62% of those who did not undergo surveillance (P < 0.001) as shown in Table 2 (all calculations based on 288 patients with staging data available). We examined the rates of surgical intervention (HR and LT), LRT (which included transarterial chemoembolization, transarterial
TABLE 1. Predictors of Prior Surveillance in Patients With HCC Diagnosis (N = 305)
Univariate Analysis
Multivariate Analysis*
Variables
OR
95% CI
OR
95% CI
Age
