Implementation of a hepatocellular carcinoma surveillance program in a community-based integrated health system in patients with hepatitis C cirrhosis

Background: Underutilization of hepatocellular cancer (HCC) surveillance has been reported, although data evaluating interventions to improve surveillance are sparse. We assessed the effect of a population-based HCC surveillance program on HCC surveillance utilization and outcomes. Methods: In this retrospective cohort study, we assessed pre- and post-inclusion HCC surveillance patterns among 597 patients with HCV cirrhosis enrolled in a program at an integrated health system between 2013-20. Adequate surveillance was defined as at least 5 surveillance studies within 36 months pre and post enrollment; a secondary outcome was proportion of time covered by surveillance over 36 months. Tumor size, stage, and receipt of curative therapy were compared between HCC detected on the first imaging exam (prevalent HCC) and surveillance-detected HCC (incident HCC). We performed Kaplan Meier analysis and multivariable competing risk analysis to characterize the association between surveillance and mortality. Results: The surveillance program significantly improved surveillance completion (77.6% vs. 5.0%, p<0.001) and proportion time covered (80.9% vs. 15.8%, p<0.001). Compared to prevalent HCC, surveillance-detected cases were more likely unifocal (77.8% vs. 44.8%, p<0.001), early-stage (85.2% vs. 44.8%, p<0.001), with smaller maximum diameter (median 2.3 cm vs. 3.2 cm) and more likely to undergo curative therapy (92.5% vs. 72.4% p=0.010). Survival was improved compared to prevalent cases HR 0.23 (0.11-0.51) after adjusting for age and MELD score. Conclusions: Implementation of a population-based program resulted in significant improvement in HCC surveillance use and clinical outcomes among patients with HCV cirrhosis. These findings may inform similar interventions by other healthcare systems.