Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor.
Department of Biostatistics, Dana Farber Cancer Center, Boston, Massachusetts.
JAMA Netw Open. 2022 Jul 1;5(7):e2223504. doi: 10.1001/jamanetworkopen.2022.23504.
Hepatocellular carcinoma (HCC) surveillance is underused in clinical practice, which may be owing to patient and clinician barriers.
To characterize HCC surveillance barriers and associations with clinical outcomes in a multicenter cohort of patients with cirrhosis.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective, multicenter cohort study included 5 medical centers in the United States. Patients with cirrhosis and newly diagnosed HCC treated from 2014 to 2018 were included. Data were analyzed from June 2021 to February 2022.
Surveillance completion in the 36-month period prior to HCC diagnosis.
Surveillance receipt was classified as semiannual, annual, or no surveillance. Multivariable logistic regression analysis was used to identify factors associated with semiannual surveillance. We conducted multivariable logistic and Cox regression analyses to characterize associations between surveillance completion with curative treatment and overall survival.
A total 629 eligible patients (median [IQR] age, 63.6 [56.2-71.0] years; 491 [78.1%] men) were assessed, including 7 American Indian or Alaska Native patients (1.1%), 14 Asian patients (2.2), 176 Black patients (28.0%), 86 Hispanic patients (13.1%), and 340 White patients (54.1%). Nearly two-thirds of the cohort had no surveillance prior to HCC diagnosis (mean [range by site] 63.7% [37.9%-80.4%]), with a mean (range by site) of 14.0% (5.3%-33.3%) of patients having received semiannual surveillance and 22.3% (14.3%-28.8%) of patients having received annual surveillance. The most common reasons for no surveillance were lack of surveillance orders or nonadherence (mean [range by site], 82.4% [66.7%-92.4%], although a mean (range by site) of 17.6% (10.2%-22.1%) of patients had unrecognized cirrhosis at HCC presentation. Semiannual surveillance was associated with hepatitis B infection (odds ratio [OR], 3.06 [95% CI, 1.24-7.23]) and inversely associated with Black race (OR, 0.41 [95% CI, 0.20-0.80]) and lack of cirrhosis recognition (OR, 0.14 [95% CI, 0.02-0.46]). Semiannual HCC surveillance was significantly associated with curative treatment receipt (OR, 2.73 [95% CI, 1.60-4.70]) but not overall survival (HR, 0.81 [95% CI, 0.55-1.18]).
In this cohort study of patients with cirrhosis, HCC surveillance was underused in more than 80% of patients and associated with failures across the screening process. Dedicated programs to improve cirrhosis detection and HCC surveillance attainment are needed.
肝癌（HCC）监测在临床实践中未得到充分利用，这可能是由于患者和临床医生的障碍所致。
描述肝硬化患者多中心队列中 HCC 监测障碍及其与临床结局的关系。
设计、地点和参与者：这是一项回顾性、多中心队列研究，纳入了美国 5 家医疗中心。纳入了 2014 年至 2018 年新诊断为 HCC 且接受治疗的肝硬化患者。数据分析于 2021 年 6 月至 2022 年 2 月进行。
HCC 诊断前 36 个月内完成监测。
将监测完成情况分为半年、每年或无监测。采用多变量逻辑回归分析确定与半年监测相关的因素。我们进行了多变量逻辑和 Cox 回归分析，以描述与接受根治性治疗和总体生存相关的监测完成情况。
共评估了 629 名符合条件的患者（中位[IQR]年龄，63.6 [56.2-71.0] 岁；491 [78.1%] 为男性），包括 7 名美国印第安人或阿拉斯加原住民患者（1.1%），14 名亚裔患者（2.2%），176 名黑人患者（28.0%），86 名西班牙裔患者（13.1%）和 340 名白人患者（54.1%）。近三分之二的患者在 HCC 诊断前未进行监测（平均[按站点范围]63.7%[37.9%-80.4%]），平均（按站点范围）有 14.0%（5.3%-33.3%）的患者接受了半年监测，22.3%（14.3%-28.8%）的患者接受了每年监测。不进行监测的最常见原因是缺乏监测医嘱或不遵守医嘱（平均[按站点范围]，82.4%[66.7%-92.4%]，尽管平均（按站点范围）有 17.6%（10.2%-22.1%）的患者在 HCC 就诊时未被识别出患有肝硬化）。半年监测与乙型肝炎感染相关（比值比[OR]，3.06[95%CI，1.24-7.23]），与黑种人（OR，0.41[95%CI，0.20-0.80]）和未识别出肝硬化（OR，0.14[95%CI，0.02-0.46]）呈负相关。半年 HCC 监测与接受根治性治疗显著相关（OR，2.73[95%CI，1.60-4.70]），但与总体生存无关（HR，0.81[95%CI，0.55-1.18]）。
在这项肝硬化患者的队列研究中，超过 80%的患者未充分利用 HCC 监测，且在整个筛查过程中存在各种失败。需要专门的计划来提高对肝硬化的检测和 HCC 监测的实现。
