title: Diagnostic delays are common among patients with hepatocellular carcinoma.
abstract: BACKGROUND
  Most patients with hepatocellular carcinoma (HCC) present at advanced stages. The prevalence and clinical impact of delays during diagnostic evaluation among patients with HCC is unclear.
  
  
  OBJECTIVE
  To identify and characterize factors associated with diagnostic delays among patients with HCC.
  
  
  METHODS
  Records were reviewed for consecutive patients with cirrhosis and HCC at a large urban hospital between January 2005 and July 2012. Time from presentation to diagnosis was determined using Kaplan-Meier analysis. Diagnostic delay was defined as time to diagnosis exceeding 3 months, and multivariate logistic regression was used to identify correlates of diagnostic delays.
  
  
  RESULTS
  Among 457 patients with HCC, 226 (49.5%) were diagnosed as outpatients. Among these, median time-to-diagnosis was 2.2 months, with 87 patients (38.5%) experiencing a diagnostic delay. Diagnostic delays were positively associated with the presence of hepatic encephalopathy (odds ratio [OR], 2.29; 95% CI, 1.03-5.07) and negatively associated with presentation after implementation of the electronic medical records (EMR) (OR, 0.28; 95% CI, 0.15-0.52) and presentation with an abnormal ultrasound (OR, 0.36; 95% CI, 0.19-0.67) on multivariate analysis. Higher rates of diagnostic delays were observed among those with hepatic encephalopathy (56% vs 35%), whereas lower rates were seen in those who presented after EMR implementation (26% vs 60%) and those who presented with an abnormal ultrasound with or without an elevated alpha fetoprotein level (27% vs 50%). Among 49 patients with mass-forming HCC and diagnostic delay, 18% had interval tumor growth of 2 cm or greater.
  
  
  CONCLUSIONS
  Nearly 20% of patients with HCC wait more than 3 months from presentation to diagnosis, which can contribute to interval tumor growth.
authors.affiliation: From the Department of Internal Medicine, UT Southwestern Medical Center and Parkland Health Hospital System; and Harold C. Simmons Cancer Center, and the Departments of Surgery and Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas.
authors.forename: Nishant
authors.initials: N
authors.lastname: Patel
authors.affiliation: From the Department of Internal Medicine, UT Southwestern Medical Center and Parkland Health Hospital System; and Harold C. Simmons Cancer Center, and the Departments of Surgery and Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas. From the Department of Internal Medicine, UT Southwestern Medical Center and Parkland Health Hospital System; and Harold C. Simmons Cancer Center, and the Departments of Surgery and Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas.
authors.forename: Adam C
authors.initials: AC
authors.lastname: Yopp
authors.affiliation: From the Department of Internal Medicine, UT Southwestern Medical Center and Parkland Health Hospital System; and Harold C. Simmons Cancer Center, and the Departments of Surgery and Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas. From the Department of Internal Medicine, UT Southwestern Medical Center and Parkland Health Hospital System; and Harold C. Simmons Cancer Center, and the Departments of Surgery and Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas. From the Department of Internal Medicine, UT Southwestern Medical Center and Parkland Health Hospital System; and Harold C. Simmons Cancer Center, and the Departments of Surgery and Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas.
authors.forename: Amit G
authors.initials: AG
authors.lastname: Singal
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D006528:Carcinoma, Hepatocellular / Q000175:diagnosis* / Q000209:etiology / Q000401:mortality / Q000628:therapy; D057210:Delayed Diagnosis; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008103:Liver Cirrhosis / Q000473:pathology; D008113:Liver Neoplasms / Q000175:diagnosis* / Q000209:etiology / Q000401:mortality / Q000628:therapy; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D016017:Odds Ratio; D012189:Retrospective Studies; D012307:Risk Factors; D014057:Tomography, X-Ray Computed