Data from a new study presented by Singal et al at The Liver Meeting found that patients with cirrhosis in the United States have substantial financial burden and this is associated with underuse of surveillance for hepatocellular carcinoma (HCC) (Abstract 201). Improved intervention strategies are needed to address these barriers for at-risk patients, according to the study’s co-authors.
Few studies have explored the impact of patient-related factors on HCC surveillance in the United States. This study examined the association between patient attitudes and perceived barriers to care and HCC surveillance receipt in a large group of patients with cirrhosis.
"A better understanding of barriers to HCC surveillance and identifying patients most likely to underuse surveillance can inform future interventions to increase HCC surveillance and reduce HCC-related mortality."— Amit Singal, MD, MS
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"Although several studies highlight the association between HCC surveillance and improved survival, underuse of surveillance in clinical practice is one of the most common reasons for late-stage HCC presentation—when curative therapies are no longer possible. A better understanding of barriers to HCC surveillance and identifying patients most likely to underuse surveillance can inform future interventions to increase HCC surveillance and reduce HCC-related mortality," explained first author Amit Singal, MD, MS, the David Bruton Jr. Professor in Clinical Cancer Research and Clinical Chief of Hepatology at UT Southwestern Medical Center.
Methods
The researchers conducted a telephone survey among patients with cirrhosis at three U.S. health systems, including a tertiary care referral center, a safety-net health system, and a Veterans Administration hospital between April 2018 and December 2018. They assessed attitudes and barriers to surveillance, including financial barriers, using validated survey measures. They defined HCC surveillance as having an abdominal ultrasound in the year before the survey was conducted. Finally, they identified factors associated with HCC surveillance receipt using multinomial logistic regression, adjusted for clustering by health-care site.
Out of 2,871 cirrhosis patients approached to participate, 35.6% completed the survey. More than half (53.2%) were over the age of 60, 64% were male, and the cohort was racially diverse. Most participants (74%) had a Child-Pugh A score (least severe) for cirrhosis, and 53% were followed in a hepatology clinic.
Results
Approximately 61% of patients had received HCC surveillance in the prior year.
Patients expressed concern about developing HCC: 74.1% said that they were at least somewhat likely to develop HCC in their lifetime, and 36.9% expressed a fear of dying from HCC.
Most patients (89%) said that HCC surveillance was very important, but they also reported barriers receiving it, which included testing costs and difficulties with the scheduling process. Most (91.8%) said they had active insurance coverage, but 9.5% reported that they had delayed care due to financial burden, including the cost of HCC surveillance. In addition, 11.8% reported they needed to borrow money or go into debt to pay for care, 24.4% said they were unable to afford copays or deductibles, and 42.8% expressed worry about being able to pay their medical bills.
"Our findings highlight the need for policy reforms, including expansion of covered benefits and limits on out-of-pocket spending, to reduce the burden in this patient population and improve receipt of surveillance. In health-care systems, interventions such as patient navigation combined with subsidizing out-of-pocket costs may also increase HCC surveillance."— Caitlin Murphy, PhD, MPH
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Receipt of HCC surveillance was associated with the presence of documented cirrhosis, the number of primary-care visits, and receipt of hepatology care. The researchers did not observe differences in surveillance receipt by patients’ fear of developing HCC or the perceived importance of HCC surveillance; however, lack of insurance and financial distress was associated with delayed medical care and lower odds of HCC surveillance receipt.
“By demonstrating that a substantial proportion of patients with cirrhosis experience financial burden, and that this burden is associated with lower receipt of HCC surveillance, our study extends the science of financial burden to HCC surveillance. Our findings highlight the need for policy reforms, including expansion of covered benefits and limits on out-of-pocket spending, to reduce the burden in this patient population and improve receipt of surveillance. In health-care systems, interventions such as patient navigation combined with subsidizing out-of-pocket costs may also increase HCC surveillance,” concluded study coauthor Caitlin Murphy, PhD, MPH, Assistant Professor of Population and Data Sciences at UT Southwestern.
Disclosure: For full disclosures of the study authors, visit aasldpub.onlinelibrary.wiley.com.
