US Cirrhosis Patients Often Skip Or Delay Liver Cancer Surveillance Due To Cost And Lack Of Insurance

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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.