Liver cancer diagnosis delayed in almost half of veterans with cirrhosis

Failure to follow guidelines, diagnostic imaging without alpha-fetoprotein measurement, and diagnosis from an incidental finding were all associated with a delay of more than 60 days between a red flag for hepatocellular carcinoma and a diagnosis, a retrospective study found.

Diagnosis of hepatocellular carcinoma (HCC) was commonly delayed in veterans with cirrhosis, according to a new study.

The retrospective study used Veterans Health Administration data on 655 patients with cirrhosis and a diagnosis of HCC from 2006 through 2011 to identify factors associated with HCC diagnosis occurring more than 60 days after a red flag (defined as a liver lesion >1 cm in diameter, which would need to be followed up every three to months; a lesion 1 to 2 cm in diameter, which would need to be followed up or treated as HCC; or a lesion >2 cm in diameter with characteristic arterial vascularization or alpha-fetoprotein >200 ng/mL, which would be treated as HCC). Results were published by Clinical Gastroenterology and Hepatology on July 17.

The results showed that 46.9% of the patients had a delay in diagnosis of more than 60 days. In patients who had diagnostic delays, the median time from first red flag presentation to HCC diagnosis was 6.8 months (95% CI, 5.9 to 7.9 months). Delays were significantly associated with lack of clinician adherence to American Association for the Study of Liver Diseases (AASLD) guidelines (adjusted odds ratio [OR], 4.82; 95% CI, 3.12 to 7.45), a diagnostic imaging evaluation instead of measurement of alpha-fetoprotein (adjusted OR, 2.63; 95% CI, 1.09 to 6.24), and diagnosis as an incidental finding during examination for an unrelated medical problem (adjusted OR, 2.26; 95% CI, 1.09 to 4.67).

The study authors believe this to be the first study assessing diagnostic delays for HCC in an integrated national health system. Some of the delays could be attributed to patient factors, such as missed appointments, but in a third of cases, treating clinicians did not adhere to AASLD guidelines, they noted. “This may be in part due to confusion among providers about which practice guideline to follow, as well as the complexity of HCC diagnostic imaging criteria and radiology reporting,” the authors said. They recommended potential interventions for improvement, including standardized educational training for physicians, multidisciplinary clinics for patients at high risk for HCC, and utilization of HCC tumor boards in the diagnostic process.

Another finding of the study was that patients with diagnostic delays actually had significantly lower mortality compared to those without a delay in diagnosis (unadjusted hazard ratio, 0.57 [95% CI, 0.47 to 0.68]; adjusted hazard ratio, 0.63 [95% CI, 0.50 to 0.78]). The authors recommended caution in the interpretation of this finding. “One possible explanation is that patients who presented with more advanced or worse cirrhosis severity may have received more urgent follow-up than patients with small, slow growing tumors and compensated cirrhosis,” they wrote, recommending additional research in this area.