Hepatocellular carcinoma (HCC) is the third leading cause of cancer-related death worldwide and one of the leading causes of death among patients with cirrhosis. It has an increasing incidence in the United States because of the current epidemics of nonalcoholic fatty liver disease (NAFLD) and hepatitis C virus (HCV) cases.1 Prognosis for patients with HCC depends on tumor stage at diagnosis, with curative options only available for patients diagnosed at an early stage.2,3 Patients with early-stage HCC achieve 5-year survival rates near 70% with resection and transplantation, whereas those with advanced HCC have a median survival of less than 1 year.4,5
Surveillance using ultrasound at 6-month intervals is recommended in patients with cirrhosis.2,6,7 The goals of surveillance are to detect HCC at an early stage when it is amenable to curative therapy and to reduce all-cause mortality.8 Effective implementation of the screening process requires surveillance (obtaining an ultrasound in patients with cirrhosis), effective detection (finding HCC when it is present at an early stage), and appropriate follow-up (obtaining a 4-phase CT or MRI in patients with an abnormal ultrasound).9 Prior studies have suggested that HCC surveillance may be efficacious for detecting early HCC and improving survival; however, its effectiveness in clinical practice may be impacted by several factors, including low use rates and/or operator-dependency, leading to poor detection rates.10-15 Similarly, treatment underuse and delayed treatment may mitigate any survival benefit in patients who undergo surveillance and are found at an early stage.16,17
Despite improvements in technology and awareness, most HCC cases in the United States continue to be diagnosed at a late stage.18 This failure suggests potential breakdowns in the HCC screening process, including an absence of surveillance, failure of detection, or delayed follow-up. The purpose of this study was to characterize the impact of screening process failures on tumor stage at presentation and overall survival in clinical practice among a racially diverse cohort of patients.
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