title: Hepatocellular carcinoma screening rates vary by etiology of cirrhosis and involvement of gastrointestinal sub-specialists.
abstract: BACKGROUND
  Regular screening of cirrhotic patients for hepatocellular carcinoma (HCC) has been suboptimal, but there is little data regarding specific risk factors for reduced screening.
  
  
  METHODS
  From 1996 to 2010, patients with cirrhosis were retrospectively identified from outpatient gastroenterology and primary care practices. Data was obtained from the diagnosis of cirrhosis until the time of elevated alpha-fetoprotein (AFP) or lesion suspicious for HCC, death, liver transplantation, or end of the data collection period. Recommended screening was defined as abdominal imaging (ultrasound, contrast-enhanced CT, or MRI) with or without serum alpha-fetoprotein (AFP) at least once every 12 months based on professional guidelines.
  
  
  RESULTS
  One hundred fifty-six patients with cirrhosis were identified. The etiologies of cirrhosis were viral hepatitis (n = 65), alcohol (n = 40), non-alcoholic steatohepatitis (NASH) (n = 27), and non-viral, non-alcoholic, non-NASH cirrhosis (n = 24). Of the 156 patients, 51% received recommended screening for HCC. Patients with NASH cirrhosis received recommended screening significantly less (p = 0.016) than cirrhotics with viral hepatitis, alcoholic cirrhosis, or non-viral, non-alcoholic, non-NASH cirrhosis and were less likely to receive gastroenterology referral (p < 0.001). Additionally, 20 patients were diagnosed with cirrhosis incidentally during a surgical procedure. These patients were significantly less likely to receive recommended HCC screening than those diagnosed non-surgically (10.0 vs. 56.6%; p < 0.001). Screening was significantly more likely to occur in patients seen regularly by a gastrointestinal subspecialist (66.7 vs. 22.8%; p < 0.001).
  
  
  CONCLUSIONS
  Patients with NASH cirrhosis and incidentally discovered cirrhosis have low rates of HCC screening and are referred less often to gastroenterologists. These data suggest a need for increased education about NASH cirrhosis and better systems of communication among general practitioners, surgeons, and gastroenterologists.
authors.affiliation: Department of Medicine, Massachusetts General Hospital, Warren 1007, 55 Fruit Street, Boston, MA 02114, USA. vpatwardhan@partners.org
authors.forename: Vilas
authors.initials: V
authors.lastname: Patwardhan
authors.forename: Sonali
authors.initials: S
authors.lastname: Paul
authors.forename: Kathleen E
authors.initials: KE
authors.lastname: Corey
authors.forename: Sameer M
authors.initials: SM
authors.lastname: Mazhar
authors.forename: James M
authors.initials: JM
authors.lastname: Richter
authors.forename: Michael
authors.initials: M
authors.lastname: Thiim
authors.forename: Raymond T
authors.initials: RT
authors.lastname: Chung
mesh_terms: D000328:Adult; D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000175:diagnosis* / Q000209:etiology; D005260:Female; D005762:Gastroenterology / Q000706:statistics & numerical data; D006801:Humans; D008103:Liver Cirrhosis / Q000209:etiology*; D008113:Liver Neoplasms / Q000175:diagnosis* / Q000209:etiology; D008297:Male; D008403:Mass Screening / Q000706:statistics & numerical data*; D008875:Middle Aged; D012189:Retrospective Studies