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Diagnostic imaging is effective for evaluating patients suspected of having hepatocellular carcinoma (HCC). Although the diagnosis can be established with imaging alone, diagnostic biopsy may be useful for patients with tumors measuring 1 to 2 cm. To date, biopsy and imaging use among patients with HCC has not been evaluated in the general communit...
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Context 1
... had larger tumors (P .01). Table 2 shows biopsy use stratified by tumor size. Among patients with known tumor size, those with tumors 5 cm were most likely (35.3%) to undergo a biopsy (60.6% of all biopsies), with a significant trend toward use of biopsy for larger tumors (P .001). ...
Context 2
... tumor size was associated with decreasing guideline nonconformity among patients who did not receive biopsy (P .001). By comparison, among patients who re- ceived biopsy, there was a consistently high rate ( 50%) of nonconformity unassociated with tumor size (Table 2). ...
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Background:
The use of alpha-fetoprotein (AFP) testing for the surveillance, diagnosis, and prognosis of hepatocellular carcinoma (HCC) remains controversial. Here, we compared AFP testing rates, elevated AFP rates, factors associated with elevated AFP levels, and prognostic factors associated with overall survival (OS) in HCC patients from differ...
Introduction:
For prognostication of hepatocellular carcinoma (HCC), the optimal size cutoff value and the significance of microvascular invasion (mvi) remain inconclusive.
Objective:
This study sought to revisit the inconclusive components of current American Joint Committee on Cancer (AJCC) staging system and to develop a new practical prognos...
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Citations
... Patients with comorbidities may receive health services more often than patients without comorbidities, thus are more likely to come in contact with the health care system (14). However, older patients with comorbidities may be unable to complete the diagnostic workup necessary to make a definitive diagnosis (15). Characteristics associated with delay of definitive diagnosis in CUP to a specified primary site including older age, epithelial/unspecified histology, and higher comorbid burden of disease correspond with current scientific literature on CUP patterns of care, namely population-based studies focusing on patient characteristics and healthcare utilization (4,16,17), adherence and diagnostic guidelines (10), and risk factors and clinical management (18,19). ...
... Patients with comorbidities may receive health services more often than patients without comorbidities, thus are more likely to come in contact with the health care system [13]. However, older patients with comorbidities may be unable to complete the diagnostic workup necessary to make a de nitive diagnosis [14]. Unfavorable characteristics for de nitive diagnosis of CUP to a speci ed primary site including older age, epithelial/unspeci ed histology, and higher comorbid burden of disease correspond with current scienti c literature on CUP patterns of care, namely population-based studies focusing on patient characteristics and healthcare utilization [3,[15][16], adherence and diagnostic guidelines [10], and risk factors and clinical management [17][18]. ...
Purpose. Cancer of unknown primary (CUP) is the fourth most common cause of cancer mortality in the U.S. Median survival after CUP diagnosis is 3-4 months. As CUP and metastatic pancreatic cancer (PC) are comparable in prevalence and survival, PC diagnosis is a useful endpoint to assess patient characteristics associated with definitive diagnosis in older patients who initially present with CUP.
Methods. This study used 2010-2015 SEER-Medicare data. Logistic regression models compared patient characteristics who received definitive diagnosis in two subsets: CUP-PC and PC only.
Results. Approximately 26% of patients who received a definitive diagnosis of metastatic pancreatic cancer started with an initial diagnosis of CUP (n=17,565). The odds of definitive diagnosis in CUP-PC were lower for those with a comorbidity score of 0 (OR 0.85 [0.79, 0.91]) and epithelial/unspecified histology (OR 0.76 [0.71, 0.82]). The odds of definitive diagnosis in CUP-PC were higher for patients of Other race (OR 1.27 [1.13, 1.43]) compared to White patients.
Conclusion. Definitive diagnosis of CUP-PC was favorable in patients in the Other race category with fewer or no comorbidities. Unfavorable characteristics included older patients and those with epithelial/unspecified histology. Future studies will focus on patterns of care and survival in patients with CUP-PC.
... MRI has reported greater sensitivity than CT in HCC detection (80% vs 68%, respectively, (p = 0.002) with HCC lesions lower than 2 centimeters (cm) [14]. Thanks to arterial enhancement or delayed washout with MRI and CT techniques, radiological imaging is normally sufficient for HCC diagnosis, with no additional investigation required [15]. Although liver biopsy is normally reserved for those with inconclusive radiological lesions, it has been observed that approximately 30% of patients with HCC are required to undergo 1 or more liver biopsies [10]. ...
Hepatocellular carcinoma (HCC) is one of the most common and fatal malignancies with an alarming trend all around the world. Common therapeutic approaches in the early stage of disease are surgical resection, ablation, and liver transplantation. Due to the insidious identity of HCC, the majority of the patients are diagnosed at advanced stages, where tumor spreading, or distant metastasis unfortunately have already occurred. Immunotherapeutic options have elicited a promising approach in some malignancies with Food and Drug Administration (FDA) approving the first checkpoint inhibitor anti-cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) ipilimumab for the treatment of melanoma ten years ago. In the past decade, many clinical trials have been investigating anti-CTLA-4 as well as anti-programmed cell death protein 1 (PD-1) therapies in various solid tumors, including HCC. In this mini-review we will discuss the latest clinical data from clinical trials for immune-checkpoint inhibitors for the treatment of HCC.
... The adjusted probability of a complete diagnostic evaluation among patients with one comorbidity was higher than patients without comorbidities or with many comorbidities. These results are unsurprising given other research has documented comorbidities result in a higher quality of care [20]. Patients with comorbidities may contact the health care system more often than patients without comorbidities, thus are more likely to receive diagnostic evaluation [21]. ...
Purpose:
Current cancer registry data cannot distinguish a justified cancer of unknown primary (CUP) diagnosis, where the patient received a complete diagnostic evaluation that was unable to identify the primary tumor, from potentially misclassified patients, documented as CUP but not based on a complete diagnostic evaluation. This misclassification may skew population-based cancer registry surveillance research used to frame and guide translational CUP research. We identified characteristics of patients who received justified vs. potentially misclassified CUP diagnoses in cancer registry data.
Methods:
We developed a conceptual definition of a complete diagnostic evaluation from professional society-recommended guidelines. We translated this definition into procedure codes in the Medicare encounter data. We assessed age, gender, comorbidities, urban or rural residence, income, race, and tumor pathology by receipt of a complete diagnostic evaluation and palliative therapy among 10,575 elderly CUP patients in the Surveillance, Epidemiology, and End Results (SEER)-Medicare dataset. We calculated odds ratios and adjusted probabilities using marginal standardization.
Results:
Only 35% of elderly CUP patients identified in the cancer registry received a complete diagnostic evaluation. After adjustment for age and comorbidities, socioeconomic barriers to a complete diagnostic evaluation persisted: adjusted odds ratio and 95% confidence interval (AOR) for rural vs. urban 0.8(0.8,0.9) and for highest income vs. lowest income 1.2(1.1,1.4). Patients with vague or undocumented tumor pathology in SEER had 80% lower odds of receiving a complete diagnostic evaluation AOR(95%CI)=0.2(0.2,0.2). Although patients with a complete diagnostic evaluation were twice as likely to receive palliative therapy than those without a complete evaluation, AOR(95%CI)=2.0(1.7,2.3), they only had a 46.7% probability of receiving therapy, 95%CI=(44.4,49.1).
Conclusion:
Patients without a complete diagnostic evaluation are not limited to the frail and underserved. For accurate assessment of the CUP burden and disparities in utilization of diagnostic care, we recommend that the SEER definition of CUP include the extent of diagnostic inquiry.
... However, from 1992 to 2008, the incidence rate of histologically unconfirmed HCC increased 2.5 times more quickly than the incidence rate of HCC that was histologically confirmed [4]. Another analysis of SEER data from the second half of this period, between 2002 and 2005, demonstrated that among 3693 patients with HCC, only 32.4% underwent one or more biopsies [15]. Thus, in order to optimize the yield of our study to evaluate the performance of liver biopsy in HCC diagnosis in a community based setting, we elected to study the time period from 2005 to 2006 when liver biopsy was more frequently used than it is currently. ...
... Those with an AFP greater than 500 ng/mL were less likely to undergo biopsy, whereas the absence of cirrhosis increased the likelihood of undergoing biopsy in our study. The use of diagnostic sequences in accordance with guidelines has been suggested to result in lower rates of liver biopsy [15]. ...
... However, an analysis of the SEER Medicare database found 32.4% of patients with HCC to have undergone 1 or more biopsies analyses; 47.8% of patients underwent a diagnostic sequence inconsistent with guideline recommendations. 99 Delays in diagnostic testing after patients present with a positive result from a screening test are barriers to effective colon and breast-cancer screening. 100;101 However, there are few data on the prevalence of diagnostic delays among HCC patients. ...
Hepatocellular carcinoma (HCC) is the 3(rd) leading cause of cancer-related death worldwide and one of the leading causes of death in patients with cirrhosis.(1) HCC incidence in the United States (US) has more than doubled over the past 2 decades and is anticipated to continue increasing over the next 20 y, due to the growing number of patients with advanced hepatitis C virus (HCV) and/or non-alcoholic steatohepatitis (NASH). At its current pace, HCC is projected to surpass breast and colorectal cancer to become the 3(rd) leading cause of cancer-related death in the US by 2030.(2) Currently only 46% of HCC cases are diagnosed at an early stage and most do not receive curative therapy.(2) Epidemiologic and clinical studies have identified many factors that affect risk for HCC and can be used to identify at-risk patients and implement prevention measures. Although several advances in HCC prevention, early detection, and diagnosis are efficacious and could reduce the incidence and mortality of HCC, widespread dissemination and successful implementation are essential for these strategies to be effective in clinical practice. Challenges include limited recognition of at-risk patients, availability of well-validated risk stratification measures, and surveillance in high-risk groups.
Copyright © 2015 AGA Institute. Published by Elsevier Inc. All rights reserved.
... In fact, MRI was used in less than one-third of cases and showed the lowest accessibility as well as the longest waiting times. Our data are in keeping with those from a recent North American population-based study among elderly Medicare HCC patients showing that MRI was used in only 15% of cases [24]. In the present series CEUS was used more than MRI, either as a single diagnostic tool or in association with CT. ...
Aim:
Adherence to and the applicability of practice guidelines for the management of hepatocellular carcinoma (HCC) in field practice have not been fully addressed. We designed a multicenter field practice prospective study to evaluate the adherence to the 2005 American Association for the Study of Liver Diseases guidelines in Italy.
Materials & methods:
The study began in September 2008 and consecutively enrolled cirrhotic patients with newly diagnosed HCC from 30 local, nonreference centers in Italy. Patients were stratified according to Child-Pugh, the model for end-stage liver disease, tumor-node metastasis, performance status and the Barcelona Clinic Liver Cancer (BCLC) classifications. The diagnostic and therapeutic strategies adopted in each individual patient were recorded. Statistical analysis was carried out on 536 patients using all of the valuable data.
Results:
A total of 286 (54.5%) patients were ≥70 years old. Comorbidities, recorded in 397 (74%) patients, were classified as moderate to severe in 170 patients (43%). Overall, 174 (59%) patients with early-stage BCLC were ≥70 years; 104 (35%) of these had moderate-to-severe comorbidities and 54% were under a regular US surveillance program. Diagnosis was performed by computed tomography in 93% of patients, contrast-enhanced ultrasound in 62% and MRI in 17%. In patients with nodules of ≤2 cm, adherence to noninvasive diagnostic criteria was 56%. Adherence to the BCLC classification was shown to be suboptimal overall, particularly regarding allocation to surgical procedures, and a total of 119 patients (40%) with BCLC stage A did not receive curative therapies.
Conclusions:
This multicenter survey showed that, in the 'real world', adherence to the both the diagnostic and therapeutic American Association for the Study of Liver Diseases 2005 algorithms was low, particularly in patients with early-stage HCC. Difficulties in applying the algorithms in routine clinical practice and the high prevalence of older patients with relevant comorbidities may account for our findings. Strategies to help improve adherence to international guidelines for HCC in field practice are required.
Background:
Overuse, the provision of health services for which harms outweigh the benefits, results in suboptimal patient care and may contribute to the rising costs of cancer care. We performed a systematic review of the evidence on overuse in oncology.
Methods:
We searched Medline, EMBASE, the Cochrane Library, Web of Science, SCOPUS databases, and 2 grey literature sources, for articles published between December 1, 2011 and March 10, 2017. We included publications from December 2011 to evaluate the literature since the inception of the ABIM Foundation's Choosing Wisely initiative in 2012. We included original research articles quantifying overuse of any medical service in patients with a cancer diagnosis when utilizing an acceptable standard to define care appropriateness, excluding studies of cancer screening. One of 4 investigator reviewed titles and abstracts and 2 of 4 reviewed each full-text article and extracted data. Methodology used PRISMA guidelines.
Results:
We identified 59 articles measuring overuse of 154 services related to imaging, procedures, and therapeutics in cancer management. The majority of studies addressed adult or geriatric patients (98%) and focused on US populations (76%); the most studied services were diagnostic imaging in low-risk prostate and breast cancer. Few studies evaluated active cancer therapeutics or interventions aimed at reducing overuse. Rates of overuse varied widely among services and among studies of the same service.
Conclusions:
Despite recent attention to overuse in cancer, evidence identifying areas of overuse remains limited. Broader investigation, including assessment of active cancer treatment, is critical for identifying improvement targets to optimize value in cancer care.
Noninvasive diagnostic criteria for cirrhotic hepatocellular carcinoma (HCC) were first established in 2001 by the European Association for the Study of the Liver.
The aim of this study was to evaluate adherence to the HCC diagnostic algorithm over time and identify factors associated with nonadherence.
Between 2001 and 2013, 224 consecutive cirrhotic HCC cases were retrospectively reviewed. Nonadherent biopsy (NAB) was defined as cases diagnosed either by biopsy despite meeting noninvasive criteria for HCC or by biopsy in place of an optional second imaging modality. Nonadherent nonbiopsy (NANB) was defined as cases diagnosed without performing biopsy when noninvasive criteria were not met. Factors associated with nonadherence were identified using multivariate analysis.
Nonadherence rate decreased from 52 to 30% over the study period (P=0.003). Among all patients, there were 34% NAB and 13% NANB cases. Compared with the adherence group, both NAB and NANB groups were likely to undergo only computed tomography scanning [odds ratio (OR) 3.08, 95% confidence interval (CI) 1.71-5.66 and OR 3.18, 95% CI 1.28-8.27, respectively] and were less likely to undergo MRI (OR 0.29, 95% CI 0.16-0.53 and OR 0.26, 95% CI 0.10-0.66, respectively). In addition, the NAB group was less likely to be presented in a multidisciplinary tumor conference (OR 0.12, 95% CI 0.02-0.61).
This is the first study to report adherence to HCC diagnostic guidelines over time in a veteran hospital. Despite overall improvement, nonadherence at the present time is still high (∼30%). Underutilization of MRI and the multidisciplinary tumor conference is associated with nonadherence, representing a potential area for improvement.
Increased use of clinical practice guidelines, evidence-based medicine, and electronic health records can help oncologists meet the challenges of workforce shortages, rising costs, and an aging population, creating a culture of care that benefits payers, providers, and patients.
