title: A training program for primary care physicians improves the effectiveness of ultrasound surveillance of hepatocellular carcinoma.
abstract: OBJECTIVE
  Cirrhosis is the main risk factor of hepatocellular carcinoma (HCC), but only a minority of cirrhotic patients are referred to the hepatologist by primary care physicians (PCP) and receive regular ultrasound surveillance. The aim of this study was to determine whether a training program targeted to PCP could enhance the effectiveness of surveillance in a real-life setting.
  
  
  METHODS
  A total of 120 PCP in an Italian area with a high incidence of HCC were trained to identify cirrhotic patients, to refer them to the Hepatology Centers of the area, and to start regular ultrasound surveillance. Clinical characteristics, outcome of treatments, and survival of 190 consecutive HCC patients in the same centers after training were compared with 244 HCC referred from the same area before training, and to 232 HCC referred by untrained PCP from other areas.
  
  
  RESULTS
  Trained PCP referred significantly more HCC patients detected under surveillance and at an early stage (Barcelona Clinic Liver Cancer-A), suitable for radical treatments. In the intervention area, the 3 and 5-year survival of HCC patients increased after training from 35 to 48% and from 20 to 40%, respectively (P<0.05). In contrast, survival was unchanged in the other areas. At multivariate analysis, independent predictors adversely affecting survival were Child-Pugh B-C, α-fetoprotein more than 10 ng/dl, nonviral etiology, intermediate/advanced Barcelona Clinic Liver Cancer stage, and referral by an untrained PCP.
  
  
  CONCLUSIONS
  Specific training of PCP aimed at the identification and referral of cirrhotic patients efficiently improves HCC survival.
authors.affiliation: aHepatology Unit, Policlinico S. Marco, Zingonia bHepatology Unit, Azienda Ospedaliera di Treviglio cRadiology Department, Azienda Ospedaliera di Treviglio dPrimary Care Physician, 'Bassa Bergamasca Area' Health District, Bergamo eDepartment of Infectious and Tropical Diseases, Policlinico Umberto Primo, University of Rome, Rome, Italy.
authors.forename: Paolo
authors.initials: P
authors.lastname: Del Poggio
authors.forename: Stefano
authors.initials: S
authors.lastname: Olmi
authors.forename: Francesca
authors.initials: F
authors.lastname: Ciccarese
authors.forename: Marzio
authors.initials: M
authors.lastname: Mazzoleni
authors.forename: Michele
authors.initials: M
authors.lastname: Jazzetti
authors.forename: Carlo
authors.initials: C
authors.lastname: Jamoletti
authors.forename: Mario
authors.initials: M
authors.lastname: Mattiello
authors.forename: Anna
authors.initials: A
authors.lastname: Del Poggio
authors.forename: Vanessa
authors.initials: V
authors.lastname: Portugali
authors.forename: Tommaso
authors.initials: T
authors.lastname: Stroffolini
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D006528:Carcinoma, Hepatocellular / Q000000981:diagnostic imaging* / Q000209:etiology / Q000401:mortality; D018450:Disease Progression; D055088:Early Detection of Cancer / Q000379:methods*; D004502:Education, Medical, Continuing / Q000379:methods*; D005260:Female; D006801:Humans; D007318:Inservice Training / Q000379:methods*; D007558:Italy; D053208:Kaplan-Meier Estimate; D008103:Liver Cirrhosis / Q000150:complications / Q000000981:diagnostic imaging* / Q000401:mortality; D008113:Liver Neoplasms / Q000000981:diagnostic imaging* / Q000209:etiology / Q000401:mortality; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009367:Neoplasm Staging; D058007:Physicians, Primary Care / Q000193:education*; D011159:Population Surveillance; D011237:Predictive Value of Tests; D015397:Program Evaluation; D012017:Referral and Consultation; D012307:Risk Factors; D013997:Time Factors; D014463:Ultrasonography