Underuse of hepatocellular carcinoma surveillance in patients with cirrhosis: a nested cohort study

Abstract Objectives Hepatocellular carcinoma (HCC) is the fourth leading cause of cancer-related death worldwide. Most cases occur in patients with an underlying cirrhosis. The French national guidelines recommend semiannual abdominal ultrasound surveillance for early HCC detection in patients with cirrhosis. The primary goal of our retrospective cohort study was to evaluate compliance with this recommendation. Methods We used 2007–2016 general public health insurance program (Régime Général) data from the French National Health Data System (Système National des Données de Santé, or SNDS). Included patients were 18 to 75 years old, diagnosed with liver cirrhosis between 2009 and 2013, and underwent their first ultrasound >4 months after their index date. The number of annual ultrasounds was recorded over a 3-year follow-up period. Compliance was defined as having had at least 2 ultrasounds per year over the follow-up time. Results Among the 66,464 patients included in the analysis, surveillance was optimal (no year with <2 ultrasounds) in 5,082 patients (7.6%), suboptimal (one year with <2 ultrasounds) in 3,928 (5.9%), and failed (remaining cases) in 57,454 (86.4%). Older age, male sex, a high Charlson index, frequent gastroenterologist/hepatologist visits, and viral etiology were associated with better surveillance, whereas low socioeconomic status, despite France’s universal health coverage, was linked to failed surveillance. Conclusions In French patients with cirrhosis, most of cancer surveillance is failing when considering recommendation in vigor. In order to improve surveillance, a better understanding of the social determinants of health equity is needed.