Comprehensive Liver Cancer Center Approach to Improve Treatment Lag Time in Patients with Hepatocellular Cancer: A Tertiary Center Experience

Introduction

Hepatocellular carcinoma (HCC), a common complication of cirrhosis, is the fifth most common malignancy in the world and the third leading cause of cancer-related death worldwide [1]. The disease is accountable for 500,000 deaths annually nationwide, resulting in substantial healthcare resource utilization from HCC-related admissions alone [2, 3]. The one-year survival rate for untreated HCC is less than 20%, but this rate improves to over 75% for patients with limited stage disease who undergo curative treatments in a timely fashion [4, 5]. Up to 30% of patients with HCC present with limited-stage disease, yet despite this prevalence, data suggest disconcerting patterns of underutilization of evidence-based therapies for these patients [6, 7]. HCC is a heterogeneous malignancy, most often arising in a diseased organ, with a vast array of possible therapies that rely upon several clinical factors including hepatic function, tumor stage and burden, functional status and institutional proficiency. Unlike other cancers, diagnosis can be made solely by dynamic imaging, and HCC is the only solid organ tumor for which transplant offers a cure, emphasizing the importance in minimizing treatment lag-time (TL-T).

Due to the complexities involved in the treatment of HCC, a multidisciplinary approach is indicated, consisting of a team of providers with complementary expertise and skillsets: hepatology, diagnostic radiology, interventional radiology, surgery, medical and oncology, and pathology. Multidisciplinary conferences facilitate open communication amongst specialists, however their facilitation alone may not necessarily translate to optimal treatment-lag times (TL-T). Patients are still often required to meet with each individual provider for consultation and work-up (diagnostic imaging, biopsy, etc.) on varying clinic days and sometimes even across various institutions, resulting in substantial delays to potentially curative therapies.

For these reasons, a novel approach was adopted at our tertiary care institution: the formation of a multidisciplinary Comprehensive Liver Cancer Center (CLCC). Akin to multidisciplinary oncology clinics, this model facilitates a same-day, single-visit with multiple providers, allowing rapid organization of treatment plans and subsequent interventions with multidisciplinary consensus. The objective of this study was to retrospectively evaluate the impact of a CLCC on the treatment of HCC at a tertiary care center, as measured by TL-T and patient outcomes such as time to liver transplant and overall mortality, before and after implementation of the CLCC.

Statistical Analysis

TL-T was calculated for each patient and compared among groups via t-test analysis. Other data for evaluation included baseline demographic characteristics, distance traveled for healthcare (calculated from residence to tertiary care facility), underlying risk factors or HCC, method of diagnosis, transplantation, and one-year mortality. These variables were analyzed using Fisher’s exact and chi-square tests as appropriate. A p-value less than 0.05 were considered statistically significant for all analyses. The institutional review board at our institution approved this study.

Discussion

HCC is an aggressive malignancy which carries a poor prognosis in the absence of therapy. Without treatment, median survival is less than eight months, with five-year overall survival rates approaching zero [8.9]. The incidence of HCC continues to rise in the United States [10, 11] and for cancer patients who do receive treatment, there is a clear correlation between treatment delay (>90 days) and decreased overall survival [12, 13]. Taken together, these figures highlight the significance of reducing TL-T for the ideal management of this disease. However, achieving optimal care can be complex for patients with HCC, for which the rising incidence, genetic heterogeneity, varying etiology and concurrent chronic liver disease make diagnosis, staging, and selection of treatment challenging. A multidisciplinary approach is necessary for the management of these patients, who benefit from the commitment of multiple caregivers supporting them throughout their disease course.

To improve TL-T, associated outcomes, and the patient healthcare experience, our institution adopted a multidisciplinary CLCC model to facilitate HCC-related care. This paradigm entails a same-day, single visit with multiple healthcare providers leading to rapid formulation of a consensus plan and expedition of subsequent work-up and interventions. The present study now demonstrates measurable patient benefits associated with the implementation of a CLCC model. With the adoption of a CLCC approach, mean TL-T for our patients significantly decreased from roughly 5 months (152.08 days) to just 2 months (68.85 days), translating to an average TL-T reduction of nearly 3 months (83 days). These reductions are attributable to the simultaneous presence of all essential providers at the same clinic visit, thereby eliminating unnecessary delays due to scheduling and appointment coordination alone.

Such a model is particularly important for the underserved patient population of our tertiary care institution. The majority of these patients fall into the lower socioeconomic strata, and many lack the means to miss work and travel back-and-forth to our center for multiple appointments. Although not statistically significant, interestingly, the mean distance traveled to seek care was greater for patients in Group 2 (post-CLCC) than for those in Group 1 (pre-CLCC): 16.06 versus 12.64 miles, respectively (p=0.283), suggesting that patients in Group 2 were willing to endure a longer commute to the hospital. The ease and efficiency of the CLCC model may perhaps facilitate healthcare for a larger population which may otherwise be restricted due to logistical constraints such as distance, work responsibilities, and family obligations.

Complementary results have been published from other studies evaluating the treatment of HCC in the multidisciplinary setting [10, 11]. Chang et al, noted that a greater proportion of patients were evaluated at early (and potentially curable) stages of HCC following implementation of a multidisciplinary model [11], likely associated with reductions in referral times with such an approach. In our study, we also found that a greater proportion of patients in Group 2 (post-CLCC) presented within Milan criteria versus that of Group 1 (pre-CLCC): 61% versus 54% (p=0.227) (Figure 1). This difference may be attributed to streamlined screening and efficient work-up following the induction of the CLCC model, as well as increased referral rates from other providers due to publicity of the CLCC following inception.

Finally, while not statistically significant, a trend towards improved survival outcomes in the post-CLCC setting was also noted, with one-year mortality decreasing from 17% to 11% for Groups 1 and 2, respectively (p=0.16). This reduction may reflect improvements in detection and treatment in the modern era, but may also be a product of the significant decrease in TL-T in the post-CLCC setting, given the strong correlation between treatment delay and decreased survival [12, 13].

Conclusion

The CLCC model fundamentally builds on existing standards of care with aim of improving outcomes among patients diagnosed with HCC and patient compliance. The establishment of a CLCC at our tertiary care center has been associated with shorter time to potentially curative treatments with high potential to translate into an improvement in disease outcomes. These data advocate for the increased adoption of multidisciplinary care occurring nationally. Furthermore, multidisciplinary teams are becoming the standard of care globally for treatment of multiple cancers, driven in part by the publication of national guidelines recommending their use and composition [14, 15]. Future studies of the CLCC model can elucidate the cost benefit associated with the CLCC model, and longer follow-up may translate into expected long-term survival and quality- of-life outcomes for these patients.

Summary

• Hepatocellular carcinoma (HCC) is a leading cause of death among patients with liver disease.
• A multidisciplinary approach is critical in the management of HCC.
• Akin to multidisciplinary oncology clinics, Comprehensive liver cancer center (CLCC) facilitates a same-day, single-visit with multiple providers, allowing rapid organization of treatment plans and subsequent interventions with multidisciplinary consensus.
• CLCC can significantly reduce treatment lag time (TL-T) ensuring potentially better outcomes.
• CLCC is particularly important for the underserved patient population. Many patients from lower socioeconomic strata lack the means to travel back-and- forth for multiple appointments.