Walker M, El-Serag H B, Sada Y, Mittal S, Ying J, Duan Z, Richardson P, Davila J A, Kanwal F
Department of Medicine, Baylor College of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.
Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.
Aliment Pharmacol Ther. 2016 Mar;43(5):621-30. doi: 10.1111/apt.13505. Epub 2016 Jan 19.
Most clinical practice guidelines recommend screening for HCC in patients with cirrhosis. However, patients with compensated cirrhosis are often asymptomatic and may remain unrecognised for years.
To determine the extent to which cirrhosis is unrecognised in a US Veteran population with HCC, and to evaluate the association between lack of cirrhosis recognition and stage of HCC at diagnosis.
We reviewed the electronic medical records of a random sample of HCC cases diagnosed in the national Veterans Affairs system between 2005 and 2011. We conducted multivariable analyses adjusting for patients' demographics, comorbidity, aetiology of underlying disease and healthcare utilisation including HCC surveillance.
Of 1201 patients with HCC and cirrhosis, 24.6% had unrecognised cirrhosis prior to HCC diagnosis. Older patients [>65 years, odds ratio (OR) 2.32], African Americans (OR 1.93), patients with alcoholic or NAFLD liver disease (OR 1.69 and 4.77 respectively), HIV (OR 3.02), and fewer comorbidities (Deyo 0 vs. 3, OR 2.42) had significantly higher odds of having unrecognised cirrhosis than comparison groups. Furthermore, patients with unrecognised cirrhosis were 6.5 times more likely to have advanced stage HCC at diagnosis. The effect of cirrhosis recognition on HCC stage remained significant after adjusting for pre-specified covariates (OR 3.37).
In one quarter of patients, cirrhosis was unrecognised prior to HCC diagnosis, and this group was significantly more likely to have advanced stage HCC. These findings emphasise the importance of timely evaluation for cirrhosis in at-risk populations as a critical step to improving outcomes for patients with HCC.
大多数临床实践指南建议对肝硬化患者进行肝细胞癌（HCC）筛查。然而，代偿期肝硬化患者通常没有症状，可能多年未被发现。
确定在美国退伍军人HCC患者中肝硬化未被识别的程度，并评估肝硬化未被识别与诊断时HCC分期之间的关联。
我们回顾了2005年至2011年在国家退伍军人事务系统中诊断的HCC病例的随机样本的电子病历。我们进行了多变量分析，对患者的人口统计学、合并症、基础疾病病因以及包括HCC监测在内的医疗保健利用情况进行了调整。
在1201例患有HCC和肝硬化的患者中，24.6%在HCC诊断之前肝硬化未被识别。年龄较大的患者[>65岁，比值比（OR）2.32]、非裔美国人（OR 1.93）、患有酒精性或非酒精性脂肪性肝病的患者（分别为OR 1.69和4.77）、HIV感染者（OR 3.02）以及合并症较少的患者（Deyo评分为0分与3分，OR 2.42）相比对照组，肝硬化未被识别的几率显著更高。此外，肝硬化未被识别的患者在诊断时患晚期HCC的可能性高出6.5倍。在对预先指定的协变量进行调整后，肝硬化识别对HCC分期的影响仍然显著（OR 3.37）。
在四分之一的患者中，肝硬化在HCC诊断之前未被识别，并且这一组患者患晚期HCC的可能性显著更高。这些发现强调了对高危人群及时评估肝硬化作为改善HCC患者预后的关键步骤的重要性。
