Stage of referral in HCC Treatment Depends on Geographical location and the Speciality of the Referring Physician
M. Boyle, M. Bourke, M. Iqbal, R. MacNicholas, E. Hoti, D.D. Houlihan
National Liver Transplant Centre, St. Vincent’s University Hospital
Hepatocellular carcinoma (HCC) is the most common primary liver cancer and is a leading cause of cancer mortality.
Early detection of HCC through screening programs is essential for the delivery curative therapy. Adequate surveillance (6 monthly Ultrasound and Alpha Fetaprotein) is costly and time consuming. Geographical disparities in HCC surveillance and access to therapy have been noted in the literature.
Information was retrieved from the HCC database in SVUH. Patient diagnosed with a HCC between January 2014 and August 2015 were included. Referring hospital location and the nature of the referring medical doctor was obtained. We used the Barcelona classification system to characterise stage of HCC at time of referral: stage 0(very early stage); Stage A (Early stage); Stage B(intermediate stage); stage C(advanced stage); stage D(end-stage disease). Stage 0 and A are considered curative.
Patient demographics: We identified 83 patients with a diagnosis of HCC. The median age of the group was 65.5 years (IQR 16.5). 69 (82%) were male. 74 (88%) were Irish. 71(84%) were cirrhotic. Underlying liver disease aetiology included: ALD (30%); HCV (28%); mixed aetiology (19%); HBV (8%); NAFLD (6%); AIH (4%); HFE (4%); PBC (1%) Location of referral: 62 referrals were from Dublin based hospitals; 21 referrals were from regions outside Dublin. From the Dublin region; 60% were BCLC 0/A; 29% BCLC B; 8% BCLC C; 3% BCLC D. Median AFP was 13.6 (IQR 124.2). 16% had PVT. 68% were referred by GI physicians; 6% by non-GI physicians; 26% by surgeons. From regions outside Dublin; 19% were BCLC 0/A; 29% BCLC B; 33% BCLC C; 19 % BCLC D. Median AFP 17.6 (IQR 127.2). 19% had PVT. 38% were referred by GI physicians; 57% by non-GI physicians; 5% by surgeons. Source of Referral: 50 referrals were from gastroenterologists; 16 from non-GI physicians; 17 from surgeons. Of the referrals from gastroenterologists; 62% were BCLC 0/A; 22% BCLC B; 14% BCLC C; 2% BCLC D. Median AFP 12.5 (IQR 109). 16% had PVT. Of the referrals from non-GI physicians; 13% were BCLC 0/A; 31% BCLC B; 25% BCLC C; 31% BCLC D. Median AFP 4.8 (IQR 125.65). 13% had PVT. Of the referrals from surgeons; 47% were BCLC 0/A; 47% BCLC B; 6% BCLC C; 0 BCLC D. Median AFP 105.7 (IQR 156.67). 24% had PVT.
We found significant disparities related to geographic location and specialist interest of the referring physicians. These disparities need to be addressed urgently to ensure all patients receive optimal care.