Updated : Nov 08, 2019 in Research Articles

U.S. Cirrhosis Patients Often Skip or Delay Liver Cancer Surveillance Due to Cost and Lack of Insurance

BOSTON – Data from a new study presented this week at The Liver Meeting® – held by the American Association for the Study of Liver Diseases – found that cirrhosis patients in the U.S. have substantial financial burden, and this is associated with underuse of surveillance – the ongoing collection of health information– for hepatocellular carcinoma (HCC). Improved intervention strategies are needed to address these barriers for at-risk patients, according to the study’s co-authors.

Few studies have explored the impact of patient-related factors on HCC surveillance in the U.S. This study, led by researchers at the University of Texas Southwestern Medical Center in Dallas, examined the association between patient attitudes and perceived barriers to care and HCC surveillance receipt in a large group of patients with cirrhosis. 

“Although several studies highlight the association between HCC surveillance and improved survival, underuse of surveillance in clinical practice is one of the most common reasons for late-stage HCC presentation, when curative therapies are no longer possible. A better understanding of barriers to HCC surveillance, and identifying patients most likely to underuse surveillance, can inform future interventions to increase HCC surveillance and reduce HCC-related mortality,” says study co-author Amit Singal, MD, MS, the David Bruton Jr. Professor in Clinical Cancer Research and clinical chief of Hepatology at University of Texas (UT) Southwestern Medical Center in Dallas.

The researchers conducted a telephone survey among cirrhosis patients at three U.S. health systems, including a tertiary care referral center, a safety-net health system and a Veterans Administration (VA) hospital between April and December 2018. They assessed attitudes and barriers to surveillance, including financial barriers, using validated survey measures. They defined HCC surveillance as having an abdominal ultrasound in the year before the survey was conducted. Finally, they identified factors associated with HCC surveillance receipt using multinomial logistic regression, adjusted for clustering by healthcare site. 

Out of 2,871 cirrhosis patients approached to participate, 35.6 percent completed the survey. More than half (53.2 percent) were over the age of 60, 64 percent were male, and the cohort was racially diverse. Most participants (74 percent) had a Child-Pugh A score (least severe) for cirrhosis, and 53 percent were followed in a hepatology clinic. Most of the participants (61.4 percent) had received HCC surveillance in the prior year, but more than a third had not. 

Patients expressed concern about developing HCC. 74.1 percent said that they were at least somewhat likely to develop HCC in their lifetime, and more than a third (36.9 percent) expressed a fear of dying from HCC. 

Most patients (89 percent) said that HCC surveillance was very important, but they also reported barriers to this essential care, which included testing costs and difficulties with the scheduling process. Most (91.8 percent) said they had active insurance coverage, but 9.5 percent reported that they had delayed care due to financial burden, including the cost of HCC surveillance. In addition, 11.8 percent reported they needed to borrow money or go into debt to pay for care; 24.4 percent said they were unable to afford copays or deductibles; and 42.8 percent expressed worry about being able to pay their medical bills. 

Receipt of HCC surveillance was associated with the presence of documented cirrhosis, the number of primary-care visits and receipt of hepatology care in the study’s findings. The researchers did not observe differences in surveillance receipt by patients’ fear of developing HCC or the perceived importance of HCC surveillance. However, lack of insurance and financial distress was associated with delayed medical care and lower odds of HCC surveillance receipt, they found.

“Nearly half of racial/ethnic minority and low-income patients report medical-related financial problems, including devastating out-of-pocket costs, medical debt and even bankruptcy. Financial burden may negatively impact patient quality of life, lead to poor adherence to treatment recommendations, and contribute to persistent disparities in cancer outcomes,” says co-author Caitlin Murphy, PhD, MPH, assistant professor, Population and Data Sciences at UT Southwestern. “By demonstrating that a substantial proportion of patients with cirrhosis experience financial burden, and that this burden is associated with lower receipt of HCC surveillance, our study extends the science of financial burden to HCC surveillance. Our findings highlight the need for policy reforms, including expansion of covered benefits and limits on out-of-pocket spending, to reduce the burden in this patient population and improve receipt of surveillance. In healthcare systems, interventions such as patient navigation, combined with subsidizing out-of-pocket costs, may also increase HCC surveillance.”

Dr. Singal will present these findings at AASLD’s press conference in Room 210 at the Hynes Convention Center in Boston on Saturday, Nov. 9 from 4 – 5:30 PM. The study entitled “Financial Burden Is Common in U.S. Patients with Cirrhosis and Associated with Lower HCC Surveillance Receipt” will be presented on Monday, Nov. 11 at 10:30 AM in Ballroom BC. The corresponding abstract (number 0201) can be found in the journal, HEPATOLOGY.

About the AASLD 

AASLD is the leading organization of clinicians and researchers committed to preventing and curing liver disease. The work of our members has laid the foundation for the development of drugs used to treat patients with viral hepatitis. Access to care and support of liver disease research are at the center of AASLD’s advocacy efforts.

Press releases and additional information about AASLD are available online at www.aasld.org.

Abstract 0201: FINANCIAL BURDEN IS COMMON IN U.S. PATIENTS WITH CIRRHOSIS AND ASSOCIATED WITH LOWER HCC SURVEILLANCE RECEIPT

Authors: Dr. Amit G. Singal, MD, MS, Katharine McCallister2, Cynthia Ortiz2, Jennifer Kramer3, Song Zhang2, Aisha Khan4, Yan Liu5, Dr. Nicole E. Rich6, Dr. Neehar D Parikh7, Jasmin Tiro2, Purva Gopal2, Simon Lee2, Caitlin Murphy2 and Dr. Ruben Hernaez8, (1)UT Southwestern Medical Center, (2)Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E Debakey VA Medical Center, (3)Baylor College of Medicine, (4)Section of Gastroenterology and Hepatology, Baylor College of Medicine, (5)Internal Medicine, University of Texas Southwestern Medical Center, (6)Department of Internal Medicine, University of Michigan, (7)Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine

Abstract Text

Background: Hepatocellular carcinoma (HCC) surveillance is underused in clinical practice; however, few studies have evaluated the impact of patient-level factors on surveillance receipt. We characterized the association between patient attitudes and perceived barriers and HCC surveillance receipt in a rlarge cohort of patients with cirrhosis.

Methods: We conducted a telephone-based survey study among cirrhosis patients at 3 U.S. health systems (a tertiary care referral center, safety-net health system, and VA hospital) between April and December 2018. Surveillance attitudes and barriers, including financial barriers, were assessed using validated survey measures.HCC surveillance receipt was defined by an abdominal ultrasound in the year prior to the survey. Multinomial logistic regression, adjusting for clustering by site, was performed to identify factors associated with surveillance receipt.

Results: Of 2871 patients approached, 1021 (35.6%) completed the survey. Most (53.2%) were older than 60 years, 64% were male, and the cohort was racially diverse (35% non-Hispanic white, 34% Hispanic white, 29% Black). Most had Child A cirrhosis (74%), and 53% were followed in Hepatology clinic. Most (61.4%) patients received surveillance in the prior year; however, this had not been completed in over one-third of patients. Patients expressed worry about developing HCC, with 74.1% reporting they were at least somewhat likely to develop HCC during their lifetime and 36.9% expressing fear of dying from HCC. Overall, 89% of patients reported HCC surveillance to be “very important”. However, patients reported barriers to receiving HCC surveillance including cost of testing (28.9%), difficulty with the scheduling process (24.1%), uncertainty where to complete an ultrasound (17.1%), and transportation difficulties (17.8%). Most patients (91.8%) reported having active insurance; however, financial burden of medical care (including cost of HCC surveillance) resulted in 9.5% delaying care, 11.8% needing to borrow money or go into debt, 24.4% being unable to cover co-pays or deductibles, and 42.8% expressing worry about the ability to pay medical bills. Receipt of surveillance was associated with presence of documented cirrhosis (p=0.04), number of primary care visits (p<0.001), and receipt of hepatology care (p<0.001). We did not observe differences in surveillance receipt by patient fear of developing HCC or perceived importance of HCC surveillance; however, lack of insurance (OR 0.53, 95%CI 0.33 – 0.86) and financial distress resulting in delayed medical care (OR 0.73, 95%CI 0.54 – 0.98) were both associated with lower odds of HCC surveillance receipt.

Conclusion: Financial burden of medical care is common in patients with cirrhosis and may be associated with lower surveillance receipt in clinical practice, thereby representing a potential intervention target to improve HCC surveillance effectiveness in the U.S.

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