Hepatocellular carcinoma (HCC) is the third leading cause of cancer-related death worldwide. Although its incidence is lower in the United States and Europe, its incidence is rapidly increasing because of a growing number of cases of nonalcoholic fatty liver disease (NAFLD) and hepatitis C virus (HCV).1 Prognosis for patients with HCC depends on tumor stage at diagnosis, with curative options only available for those diagnosed at an early stage. Patients with early HCC achieve 5-year survival rates near 70% with resection or liver transplantation, whereas those with advanced HCC have a median survival of less than 1 year.2 Surveillance at 6-month intervals is recommended in patients with cirrhosis and is associated with improved early detection and overall survival.3,4
Despite the availability of efficacious surveillance tests, only 40% of HCC cases are diagnosed at an early stage nationally.5 Tumor stage at diagnosis can be impacted by several factors in clinical practice, including low surveillance rates and delays in follow-up of abnormal screening tests.6–9 These issues may be particularly prevalent among racial minorities and socioeconomically disadvantaged patients, potentially contributing to racial and socioeconomic disparities in cancer outcomes.10,11
Delays in diagnostic testing after presentation with a positive screening test have been well described as a barrier for effective colon and breast cancer screening; however, no studies to date have characterized the prevalence and potential clinical impact of diagnostic delays among patients with HCC.12 For HCC, delays as little as 3 months in diagnostic follow-up can allow for significant tumor growth and lead to lower chances of effective treatment options.13 A better understanding of breakdowns in follow-up is necessary to identify appropriate intervention strategies. Integrated health systems are the ideal setting to study potential failures, because patients are typically followed through the entire continuum of HCC care from presentation to diagnosis to treatment. Therefore, the primary goals of this study were to quantify diagnostic delays among patients diagnosed with HCC and identify factors associated with delays in follow-up testing.
The authors have disclosed that they have no financial interests, arrangements, affiliations, or commercial interests with the manufacturers of any products discussed in this article or their competitors.
This work was conducted with support from NIH/NCATS Grant UL1-TR000451. Dr. Singal was supported in parts by a grant from the AHRQ R24 HS022418 and the UT Southwestern Center for Patient-Centered Outcomes Research. The content is solely the responsibility of the authors and does not necessarily represent the official views of UT-STAR, the UT Southwestern Medical Center and its affiliated academic and health care centers, the National Center for Advancing Translational Sciences, or the NIH.
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