Strategies to Improve Hepatocellular Carcinoma Surveillance in Veterans With Hepatitis B Infection

The authors identified 3 categories of major barriers contributing to nonadherence to HCC screening guidelines: (1) knowledge barriers, including
underrecognition of chronic HBV infection and lack of awareness about HCC screening guidelines; (2) motivational barriers to recommending HCC screening; and (3) technical/logistic challenges. Additional time was spent in the focus groups devising strategies to address identified barriers. An overlap in barriers to screening adherence was identified by the different HCPs (Figure 2).

Underrecognition of Chronic HBV Infection

For patients to receive appropriate HCC screening, HCPs first must be aware of their patients’ HBV infection status. However, in all the focus groups, providers indicated that chronic HBV infection likely is underdiagnosed in the veteran population because veterans at risk for HBV acquisition might not be tested, HBV serologic tests may be misinterpreted, and there may be failure to communicate positive test results during provider transitions, such as from the inpatient to outpatient setting. Typically, new HBV diagnoses are identified by CMCVAMC primary care and ID physicians, the latter serving as primary care providers (PCPs) for patients with HIV infection. All primary care and ID providers routinely obtained viral hepatitis screening in patients new to their practice, but they stated that they may be less likely to pursue HCC screening for at-risk patients.

Providers suggested implementing HBV-specific educational campaigns throughout the year to highlight the need for ongoing screening and to provide refreshers on interpretation of HBV screening serologies. They advised that, to increase appeal across providers, education should be made available in different formats, including seminars, clinic handouts, or online training modules.

An important gap in test result communication was identified during the focus group discussions. Veterans hospitalized in the psychiatric ward undergo HBV and HCV screenings (ie, testing for HBsAg, hepatitis B surface antibody, and HCV antibody) on admission, but no clear protocol ensured that positive screening tests were followed up in the outpatient setting. The majority of providers indicated that all newly identified diagnoses of HBV infection should receive at least an initial evaluation by a GI provider. Therefore, during discussion with the GI providers, it was proposed that the laboratory automatically notify the viral hepatitis clinic about all positive test results and the clinic designate a triage nurse to coordinate appropriate follow-up and GI referral as needed.

Unaware of HCC Screening Guidelines

Both primary care and ID providers reported that a lack of familiarity with HCC screening guidelines likely contributed to low screening rates at the CMCVAMC. Most discussants were aware that patients with HBV infection should be screened for HCC, but they did not know which test to perform, which patients to screen, and how often. Further, providers reported that chronic HBV infection was seen less frequently than was chronic HCV infection, contributing to reduced familiarity and comfort level with managing patients with HBV infection. Several participants from both primary care and ID provider groups stated they extrapolated guidelines from chronic HCV management in which HCC screening is recommended only for patients with cirrhosis and applied them to patients with HBV infection.²³ In contrast, GI providers reported that they were knowledgeable about HCC screening recommendations and routinely incorporated AASLD guidelines into their practice.

To address this varying lack of awareness, all providers reiterated their support for the development of educational campaigns to be made available in different formats about HBV-related topics, including ongoing screening and interpretation of HBV screening serologies. In addition, primary care and GI providers agreed that all newly identified cases of HBV infection should receive an initial assessment by a GI provider who could outline an appropriate management strategy and determine whether GI or primary care follow-up was appropriate. In contrast, the ID providers did not endorse automatic referral to the GI clinic of new HBV diagnoses in their patients with HIV infection. Instead, ID providers stated that they were confident they could manage chronic HBV infection in their patients with HIV infection independently and refer patients as needed.

Motivational Barriers

Lack of confidence in the value of HCC screening for patients with chronic HBV infection was prevalent among primary care and ID physicians and led to reduced motivation to pursue screening tests. One provider noted that HCC is a “rare enough event that the utility of screening for this in our patient population is unclear.” Both sets of providers contrasted their different approaches to colon cancer and HCC screening: Colon cancer screening “has become more normalized and [we] have good data that early detection improves survival.” Another provider said, “There is lack of awareness about the potential benefit of HCC screening.”

Acknowledging that most patients have multiple comorbidities and often require several tests or interventions, providers in both primary care and the ID focus groups reported that it was difficult to prioritize HCC screening. Among ID physicians who primarily see patients who are co-infected with HIV/HBV, adherence to antiretroviral therapy (along with social issues, including homelessness and active substance use) often predominates clinical visits. Consequently, one participant stated, “Cancer screening goes down on the list of priorities.”

Technical Challenges

All providers identified health system and patientspecific factors that prevent successful adherence to HCC screening guidelines. At the study site, to obtain an ultrasound, the provider completes a requisition that goes directly to the radiology department, which is then responsible for contacting the patient and scheduling the ultrasound test. Ultrasound requisitions can go uncompleted for various reasons, including (1) inability to contact patients because of inaccurate contact information in the medical records; (2) long delays in test scheduling, leading to forgotten or missed appointments; and (3) lack of protocol for rescheduling missed appointments.

All providers agreed that difficulty in getting their patients to follow through on ordered tests is a major impediment to successful HCC surveillance. All providers described patient-specific factors that contribute to low HCC surveillance rates, poor medication adherence, and challenges to the overall care of these patients. These factors included active substance use, economic difficulties, and comorbidities. In addition, providers reported that alternative screening tests that could be administered at the time of the clinic visit, such as blood draws or fecal occult blood test cards, were more likely to be completed successfully in their individual practices.

Furthermore, there was variation in the way providers described the test rationale to patients, which they agreed may influence a patient’s likelihood of obtaining the test. Some providers informed their patients that the ultrasound test was intended to screen specifically for liver cancer, and they believed that concern about possible malignancy motivated patients to follow through with this testing. One of the GI providers noted that his
patients obtained recommended HCC screening because they had faced other serious consequences of HBV infection and were motivated to avoid further complications. However, other providers expressed concern that mentioning cancer might generate undue patient anxiety and instead described the test to patients as a way of evaluating general liver health. They acknowledged that placing less importance on the ultrasound test may lead to lower patient adherence.

Primary care and ID providers suggested that educational campaigns developed especially for patients may help address some of these patient specific factors. Referring to the success of public service announcements about colon cancer screening or direct-to-consumer advertising of medications, providers felt that similar approaches would be valuable for educating high-risk patients about the potential benefits of HCC surveillance and early detection.