Barriers Found in PCP Knowledge of Surveillance of Hepatocellular Carcinoma

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Researchers from US universities conducted a web-based survey to investigate knowledge and potential barriers to HCC surveillance among PCPs.
Researchers from US universities conducted a web-based survey to investigate knowledge and potential barriers to HCC surveillance among PCPs.

In a web-based survey conducted among primary care practitioners (PCPs), barriers to effective surveillance of hepatocellular carcinoma (HCC) were found, indicating the need for clinical interventions, according to a study published in Clinical Gastroenterology and Hepatology.

Researchers from the University of Michigan and University of Texas Southwestern (UT Southwestern) Medical Centers enrolled PCPs at these institutions to take the survey: 65 from 5 primary care clinics at UT Southwestern and 68 from 4 clinics at the University of Michigan. PCPs were defined as any general internal medicine or family practice provider who annually saw at least 1 patient with cirrhosis.

The survey comprised 3 sections: 1) surveillance practices (ie, type of patients seen, patterns of surveillance modality, interactions with patients regarding HCC surveillance); 2) surveillance beliefs (provider attitudes about HCC surveillance and efficacy of surveillance modalities); and 3) practice and provider characteristics. Results were analyzed from June to December 2017.

The primary outcome was provider-reported practice patterns and knowledge regarding HCC surveillance recommendations as reported in the American Association for the Study of Liver Disease (AASLD) recommendation statement, which states that HCC should be monitored using ultrasound with or without alpha fetoprotein (AFP) every 6 months. Providers were first asked to provide self-reported semiannual surveillance rates for patients with cirrhosis. They were then tasked to recommend HCC surveillance for patient vignettes categorized into overuse, underuse, and appropriate guideline-consistent use.

The median age of providers was 41 years; 65% were women and 58% were non-Hispanic white. The majority of providers agreed that HCC surveillance is effective for early tumor detection (91.9%) and reducing overall mortality (81.4%), is cost effective (82.5%), and can present legal liability if not performed in at-risk patients (80.5%). More than 40% of providers incorrectly presumed HCC surveillance is also cost-effective in patients without cirrhosis.

Nearly 60% of providers strongly agreed that the combination of ultrasound with AFP can be effective; more than 70% believed computed tomography (CT) and magnetic resonance imaging (MRI) can detect tumor. The majority (>90%) felt guidelines, such as those from AASLD, provide the tools to perform HCC surveillance; however, more than 75% agreed that more high-qualifying data quantifying screening-related beliefs and harms are needed.

The most commonly reported barriers to screening for HCC include providers not being up-to-date with HCC surveillance recommendations (41.8%), provider belief that HCC is outside the scope of primary care (29.4%), minimal time in clinic (14.3%), having more urgent clinical concerns (12.1%), and strained communication with patients about HCC surveillance (10.2%).

The proportion of providers who deferred surveillance to subspecialists was higher at the University of Michigan (40.9% vs 26.4%). For all providers, the most commonly used tests were ultrasound with or without AFP; 98.4% and 90.3% of PCPs ordered HCC surveillance using ultrasound and AFP, respectively. Of note, providers were more likely to use CT/MRI-based surveillance in patients with obesity or decompensated cirrhosis than in patients with HCV or alcohol-related cirrhosis (16.1% and 19.5% vs 2.3%, respectively).

“Whereas most PCPs performed HCC surveillance, one-third referred patients to Hepatology and deferred surveillance to subspecialists,” the authors stated. “Providers believed HCC surveillance could be efficacious for early tumor detection and improving survival; however, they expressed some important misconceptions about HCC surveillance and reported barriers including limited time in clinic and competing clinical concerns. Our study highlights the need for interventions including provider education to optimize HCC surveillance in clinical practice.”

Reference

Simmons OL, Feng Y, Parikh ND, Singal AG. Primary care provider practice patterns and barriers to hepatocellular carcinoma surveillance [published online July 26, 2018]. Clin Gastroenterol Hepatol. doi: 10.1016/j.cgh.2018.07.029

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