title: Effectiveness of surveillance for hepatocellular carcinoma in clinical practice: A United States cohort.
abstract: The effectiveness of surveillance for hepatocellular carcinoma (HCC) in reducing cancer related mortality among patients with cirrhosis is largely unknown. The objective of this study was to study the effectiveness of HCC surveillance in the national Veterans Administration (VA) clinical practice.
  
  
  
  We conducted a retrospective cohort study of patients with HCC during 2005-2010 by reviewing patients' medical records to determine receipt of HCC surveillance in the 2years prior to HCC diagnosis. We determined association of HCC surveillance with overall mortality adjusting for age, risk factors, model for end-stage liver disease (MELD) score, comorbidity index, alpha-fetoprotein levels, healthcare utilization, Barcelona Clinic Liver Cancer (BCLC) stage, and treatment. We accounted for lead and length time biases.
  
  
  
  Of 887 patients with HCC, only 412 (46.5%) received any surveillance prior to HCC diagnosis. Patients who received surveillance were significantly more likely to have early stage disease HCC (BCLC stage 0/A 27.2% vs. 11.6%) and receive potentially curative (20.9% vs. 11.6%) or palliative (59.2% vs. 45.5%) treatments compared to those without HCC surveillance. Receipt of HCC surveillance was associated with 38% reduction in mortality risk (unadjusted hazard ratios (HR) 0.62, 95% confidence intervals (CI) 0.54-0.71) that declined to 20% (HR 0.80, 95% CI 0.69-0.94) after adjusting for HCC stage and treatment, compared to those without HCC surveillance.
  
  
  
  Among patients with HCC, pre-diagnosis HCC surveillance is associated with a significant 38% reduction in overall mortality. The reduction in mortality risk with surveillance is mediated via stage migration and receipt of HCC specific treatment.
  
  
  
  Surveillance for liver cancer leads to earlier detection of cancer and increases chances of getting curative treatment. This ultimately leads to increased longevity in patients with liver cancer.
authors.affiliation: Section of Gastroenterology and Hepatology, USA; Effectiveness and Quality (iQuEST), Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA. Electronic address: smittal@bcm.edu.
authors.forename: Sahil
authors.initials: S
authors.lastname: Mittal
authors.affiliation: Section of Gastroenterology and Hepatology, USA; Effectiveness and Quality (iQuEST), Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.
authors.forename: Fasiha
authors.initials: F
authors.lastname: Kanwal
authors.affiliation: Effectiveness and Quality (iQuEST), Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.
authors.forename: Jun
authors.initials: J
authors.lastname: Ying
authors.affiliation: Effectiveness and Quality (iQuEST), Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.
authors.forename: Randy
authors.initials: R
authors.lastname: Chung
authors.affiliation: Sections of Health Services Research, Center of Innovation, USA; Effectiveness and Quality (iQuEST), Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.
authors.forename: Yvonne H
authors.initials: YH
authors.lastname: Sada
authors.affiliation: Effectiveness and Quality (iQuEST), Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.
authors.forename: Sarah
authors.initials: S
authors.lastname: Temple
authors.affiliation: Sections of Health Services Research, Center of Innovation, USA; Effectiveness and Quality (iQuEST), Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.
authors.forename: Jessica A
authors.initials: JA
authors.lastname: Davila
authors.affiliation: Section of Gastroenterology and Hepatology, USA; Effectiveness and Quality (iQuEST), Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.
authors.forename: Hashem B
authors.initials: HB
authors.lastname: El-Serag
mesh_terms: D006528:Carcinoma, Hepatocellular; D006801:Humans; D008103:Liver Cirrhosis; D008113:Liver Neoplasms; D012189:Retrospective Studies; D014481:United States; D000509:alpha-Fetoproteins
chemical_list: D000509:alpha-Fetoproteins
keywords: Cirrhosis; Fatty liver; Lead-time; Liver cancer; Screening