Strategies to Improve Hepatocellular Carcinoma Surveillance in Veterans With Hepatitis B Infection
Discussion
In this study, an extremely low HCC surveillance rate was observed among veterans with chronic HBV infection, despite HCC incidence rates that were comparable with those observed among patients in Europe and North America.24 Importantly, the incidence rate among those who met HCC surveillance criteria in this study was 0.88 cases per 100 person-years, which exceeded the 0.2 theoretical threshold incidence for efficacy of surveillance.4 This study adds to the growing body of literature demonstrating poor adherence to HCC surveillance among high-risk groups, including those with cirrhosis and chronic HCV and HBV infections.5,14,25 Because of the missed opportunities for HCC surveillance in veterans with HBV infection, the authors explored important barriers and potential strategies to improve adherence to HCC screening. Through focus groups with an open-ended discussion format, the authors were able to more comprehensively assess barriers to screening and discuss possible interventions, which had not been possible in prior studies that relied primarily on surveys.
Barriers to Screening
Underrecognition of HBV infection was recognized as a major barrier to HCC screening and likely contributed to the low HCC surveillance rates seen in this study, particularly among PCPs, who generally represent a patient’s initial encounter with the health care system. Among veterans with positive HBsAg testing during the study period, 7% had no chart documentation of being chronically infected with HBV. Through focus group discussions, it became clear that these missed cases were most frequently due to misinterpretation of HBV serologies or incomplete handoff of test results.
To prevent these errors, an automated notification process was proposed and is being developed at the CMCVAMC, whereby GI providers evaluate all positive HBsAg tests received by the laboratory to determine the appropriate follow-up. Another approach previously shown to be successful in increasing disease recognition and follow-up is the integration of hepatitis care services into other clinics (eg, substance use disorder) that serve veterans who have a high prevalence of viral hepatitis and/or risk factors.26 Proper identification of all chronic HBV patients who may need screening for HCC is the first step toward improving HCC surveillance rates.
Lack of information about HCC screening guidelines and evidence supporting screening recommendations was a recurring theme in all the focus groups and may help explain varying rates of screening adherence among the providers. Despite acknowledging the lack of awareness about screening guidelines, ID specialists were less likely than were PCPs to endorse a need for GI referral for all patients with HBV infection.
Infectious disease providers emphasized motivational barriers to HCC surveillance, which were driven by their lack of confidence in the sensitivity of the screening test and lack of awareness of improved survival with earlier HCC diagnosis. Within the past few years, studies have challenged the quality of existing evidence to support routine HCC surveillance, which possibly fueled these providers’ uncertainty about its relevance for their patients with HBV infection.27,28 Nonetheless, there seems to be limited feasibility for obtaining additional high-quality data to clarify this issue, possibly through randomized controlled trials, because of sufficient existing patient and provider preference for conducting HCC surveillance.29
The GI providers who routinely treat HCC are likely to have a different perspective from PCPs about the frequency of HCC occurrence in chronic HBV infection and the demonstrable survival benefit with early detection and thus may have greater motivation to pursue screening. Similarly, providers observed that patients who understood that the abdominal ultrasound was for the early detection of liver cancer seemed to be more likely to be adherent with providers’ ultrasound recommendations. In the absence of a clear understanding of the potential benefits of HCC screening tests, providers may be more reluctant to recommend the tests and patients may be less likely to complete them.
Education
To address these knowledge and motivational barriers, providers emphasized the need for educational opportunities designed to close these knowledge gaps and provide resources for additional information. Given the differing levels of training and experience among providers, educational programs should be multifaceted and encompass different modalities, such as in-person seminars, online training modules, and clinic-based reminders, to reach all HCPs.
Additionally, providers advocated implementing educational efforts aimed at high-risk patients to raise awareness about liver cancer. Because such programs can provide more information than can be conveyed during a brief clinic visit, they may help quell patient anxiety that is induced by the idea of liver cancer screening—an important concern expressed by various providers.
Adherence to any recommended test or medication regimen has been shown to be inversely linked to the technical or logistic complexity of the recommendation.30 At CMCVAMC an unwieldy process for obtaining abdominal or liver ultrasounds—the recommended HCC screening test—contributed to low rates of HCC surveillance. Providers noted anecdotally that screening tests that could be given during the clinic visit, such as blood draws or even fecal occult blood test cards, were more likely to be successfully completed than tests that required additional outside visits. There is no standard approach for scheduling screening sonography across the VA system, but studying screening adherence at various facilities could help identify best practices that warrant national implementation. Proposing changes to the process for ordering and obtaining an ultrasound were outside the scope of this study, given that it did not involve additional relevant staff such as radiologists and ultrasound technicians. However, this area represents future investigation that is needed to achieve substantial improvements to HCC surveillance rates within the VA health system.
Limitations
This study should be interpreted in the context of several potential limitations. The retrospective study design limited the authors to the existing CPRS data. However, chart review primarily focused on abstracting objective data, such as the number of abdominal imaging studies performed, to arrive at a quantitative measure of HCC surveillance that likely was subject to less bias. The findings of the study, conducted at a single VA facility in Philadelphia, may not be generalizable beyond a veteran population in an urban setting. In addition, providers in the focus groups were self-motivated to participate and might not represent the experiences of other providers. Last, the relatively small number of patients seen by the different HCPs in this study may have precluded having sufficient power to detect differences in adherence rates at the provider level.
Conclusion
An extremely low HCC surveillance rate was observed among veterans with chronic HBV infection in this study. Health care providers at the CMCVAMC identified multiple challenges to ensuring routine HCC surveillance in high-risk HBV-infected patients that likely have contributed to the extremely low rates of HCC observed over the past decade.
In this qualitative study, although broad themes and areas of agreement emerged across the different HCP groups involved in caring for patients with HBV infection, there were notable differences between groups in their approaches to HCC surveillance. Engaging with HCPs about proposed interventions based on the challenges identified in the study focus groups resulted in a better understanding of their relative importance and the development of interventions more likely to be successful.
