Nearly 20% of patients with hepatocellular carcinoma “wait more than 3 months from presentation to diagnosis, which can contribute to interval tumor growth,” Nishant Patel, MD, and colleagues concluded in the Journal of the National Comprehensive Cancer Network. They based their conclusions on a review of records of consecutive patients with cirrhosis and hepatocellular carcinoma at Parkland Memorial Health and Hospital System, a large urban safety net hospital in Dallas, between January 2005 and July 2012.
“Diagnostic delays are particularly common among outpatients, occurring in more than one-third,” the researchers found. “These delays may be related to several potential issues, including providers failing to recognize positive surveillance tests, patients missing radiology appointments, and insensitive diagnostic tests. Although we did not find any difference in receipt of hepatocellular carcinoma–directed treatment, diagnostic delays were associated with potential interval tumor growth in nearly one-fifth of patients.”
Among 457 patients with cirrhosis and hepatocellular carcinoma, 231 were inpatients, and 226 (49.5%) were diagnosed as outpatients. Although the time from presentation to diagnosis was less than 1 week for more than 90% of inpatients, the median time to diagnosis was 2.2 months for outpatients, with 87 patients (38.5%) experiencing a diagnostic delay, defined as a time to diagnosis exceeding 3 months.
Higher rates of diagnostic delays were observed among those diagnosed as outpatients who had hepatic encephalopathy (56% vs 35%). “Among 49 patients with mass-forming hepatocellular carcinoma and diagnostic delay, 18% had interval tumor growth of 2 cm or greater,” the investigators stated.
The median age of the patients was 56 years, and more than 75% were men. “Our population was racially diverse, with 36% African Americans, 30% Hispanic Caucasians, and 26% non-Hispanic Caucasians,” the researchers noted.
Impact of Electronic Medical Record System
Lower rates of diagnostic delays were observed in patients diagnosed as outpatients who presented after implementation of a comprehensive electronic medical record system, 26% vs 60% for those presenting before electronic medical records. The authors noted, “diagnostic delays may be more common in hospital systems without an electronic medical record, because of higher rates of unrecognized positive surveillance tests.” Patients presenting with an abnormal ultrasound, with or without an elevated alpha-fetoprotein level, also had lower rates of diagnostic delay, 27% vs 50%.
Contributing to Outcome Disparities
The investigators noted that the incidence of hepatocellular carcinoma is increasing because of a growing number of cases of nonalcoholic fatty liver disease and hepatitis C virus. Curative options are “only available for those diagnosed at an early stage. Patients with early hepatocellular carcinoma achieve 5-year survival rates near 70% with resection or liver transplantation, whereas those with advanced hepatocellular carcinoma have a median survival of less than 1 year,” the authors added.
“Despite the availability of efficacious surveillance tests, only 40% of hepatocellular carcinoma cases are diagnosed at an early stage nationally,” the researchers wrote. “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. These issues may be particularly prevalent among racial minorities and socioeconomically disadvantaged patients, potentially contributing to racial and socioeconomic disparities in cancer outcomes.” ■
Patel N, Yopp AC, Singal AG: J Natl Compr Canc Netw 13:543-549, 2015.