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American Surgical Association

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Rachel M. Lee1, Rapheisha Darby2, Caroline R. Medin1, Grace C. Haser3, Meredith C. Mason1, Lesley S. Miller3, Charles A. Staley1, Shishir K. Maithel1, Maria C. Russell1
1Division of Surgical Oncology, Winship Cancer Institute, Department of Surgery, Emory University, Atlanta, Georgia, United States, 2Grady Liver Clinic, Primary Care Centers, Grady Memorial Hospital, Atlanta, Georgia, United States, 3Division of General Internal Medicine, Department of Medicine, Emory University, Atlanta, Georgia, United States

Introduction: Adherence to hepatocellular carcinoma (HCC) screening guidelines at safety-net hospitals is strikingly poor. Only 23% of patients at our safety-net health system in the southeast had a screening exam within 1-year of a new HCC diagnosis and 46% presented with stage IV disease. Hepatitis C (HCV)-induced cirrhosis remains the most common etiology of HCC (75%) in our safety-net population. We aimed to improve HCC screening and earlier diagnosis of patients with HCV cirrhosis.

Methods: Utilizing an established HCV treatment clinic, we launched an HCC screening quality improvement initiative in April 2018 for HCV patients with stage 3 fibrosis or cirrhosis by transient elastography. The program consisted of every 6 month imaging enhanced by navigators to schedule imaging appointments and track completion.

Results: From April 2018 to December 2020, 318 patients were enrolled with average age 60 years, 80% Black race, and 44% uninsured. Adherence to screening was much higher than reported in the literature; 87%, 67%, and 75% of patients completed their 1st, 2nd, and 3rd imaging tests, respectively. Eighteen patients were diagnosed with HCC with 13 patients diagnosed on first screening exam. Of those with HCC upon entry into the program, 46.2% were stage I, 15.4% stage II, 23.1% stage III and 15.4% were stage IV. The five patients diagnosed on 2nd or 3rd screening exams were all stage I or II. All patients were referred and 12 (67%) received treatment for HCC in the form of liver directed therapy. Median time to receipt of treatment was 69 days (IQR 56, 114). Median OS for treated patients was 21 months versus 6.9 months for those not receiving treatment.

Conclusions: Implementation of an HCC screening program at a safety-net hospital is feasible and facilitates earlier diagnosis. Patient navigation and tracking completion of imaging tests were key components of the programís success. Challenges continue to be more advanced stage at the start of screening and delays in time to treatment. Next steps include expanding the program to non-HCV cirrhotic populations.

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