Measurement of Hepatocellular Carcinoma Screening and the Impact of Patient and Provider Factors on Screening Receipt, Early Tumor Detection and Overall Survival

Abstract

Hepatocellular carcinoma (HCC) is the 2nd leading cause of cancer-related death worldwide and the leading cause of death among patients with cirrhosis. HCC screening is highly recommended by professional societies to improve early tumor detection and survival, but is underused in clinical practice. This dissertation addresses gaps in the current literature concentrated on HCC screening and specifically focuses on three areas: (1) two improved approaches to measure HCC screening using administrative data, (2) the impact of patient and provider factors on HCC screening, and (3) the impact of HCC screening on early tumor detection and overall survival. The first study in this dissertation explores two improved approaches to measure HCC screening using a linkage of two large population-based sources of data and subsequently characterizes HCC screening rates over time using these measures. Receipt of HCC screening was characterized using: (a) mutually exclusive categories (consistent vs. inconsistent vs. no screening), and (b) proportion of time up-to-date (PUTD) with screening. Most (51.1%) patients did not receive any screening in the 3 years prior to HCC diagnosis, and 13.4% of patients underwent timely, consistent screening annually (PUTD). The second study in this dissertation identifies patient and provider factors that influence HCC screening receipt using the PUTD measure. Patient and provider predictors for HCC screening were assessed using a multivariate two-part regression. Receipt of any HCC screening was associated with younger patient age, female gender, Asian race, longer length of time with known cirrhosis, presence of more than one liver correlated condition, presence of hepatic encephalopathy, higher comorbidity score and having visited a gastroenterologist (p<0.001). The third and final study in this dissertation evaluates the association between HCC screening receipt and clinical outcomes, including: (a) early tumor detection and (b) overall survival using multivariate logistic regression and Cox proportional hazards model, respectively. Receipt of consistent screening was associated with early tumor detection (OR 2.10; 95% CI 1.79-2.47) and improved survival (HR 0.72, 95%CI 0.66 – 0.78). The findings of this dissertation highlight potential areas for intervention including improved awareness and education regarding HCC screening for patients and providers.