High proportion of Canadian patients with HIV-HCV co-infection and liver cirrhosis are not having ultrasounds to check for liver cancer

Over a third of HIV-positive people with hepatitis C virus-related liver cirrhosis are not having regular ultrasound examinations to check for possible liver cancer, Canadian research published in Clinical Infectious Diseases shows.

Two patients diagnosed with hepatocellular carcinoma (HCC, liver cancer) did not have ultrasound screens.

Patients receiving care at centres with standardised systems for screening were significantly more likely to have an abdominal ultrasound.

“Patient care protocols with automated reminders may be a particularly effective means of ensuring compliance with screening,” suggest the investigators.

There is a high prevalence of hepatitis C virus (HCV) co-infection among people with HIV. Liver disease is now an important cause of death in these individuals. An ever-increasing proportion of these deaths is caused by HCC.

Guidelines in Canada, Europe and the United States recommend that people with HCV-related liver cirrhosis should be screened every six to twelve months for HCC using abdominal ultrasounds.

Canadian investigators caring for people co-infected with HIV and HCV wanted to see if this guidance was being followed. They therefore designed a prospective study involving co-infected adult patients with confirmed or possible liver cirrhosis who received care at 16 centres across Canada between 2003 and 2012.

Research personnel collected information on whether an abdominal ultrasound was done for each patient. The investigators examined the participants’ demographic data and clinical records to see if any factors were associated with an increased chance of having ultrasound investigations.

The patient population comprised 144 people with documented cirrhosis and 220 individuals with possible cirrhosis (the presence of biomarkers showing serious hepatic dysfunction).

During a median of 2.5 years of follow-up, participants with documented cirrhosis had a mean of 0.6 abdominal ultrasounds each year. Well over a third of participants (36%) with confirmed cirrhosis never had an ultrasound.  The frequency of examinations for participants with at least one screening was a mean of one ultrasound per year.

The overall mean frequency of abdominal ultrasound screening for participants with possible cirrhosis was 0.4 investigations per year. During 2.4 years of follow-up, 50% of participants with possible cirrhosis never had an abdominal ultrasound. The mean frequency of monitoring for those who did have this test was 0.7 investigations per year.

“More than one third of patients with documented or possible cirrhosis did not undergo appropriate screening for hepatocellular carcinoma with ultrasoundography during the course of their follow-up,” comment the authors. “The infrequent performance of ultrasounds in the group with possible cirrhosis in particular suggests that patients at risk of advanced liver disease may not be recognized and diagnosed as such.”

The authors suggest that a focus on virologic and treatment outcomes in co-infected individuals could explain why large numbers of patients were never screened: “Given the importance of virologic control of HIV and treatment of HCV, medical visits may be focused more on management of these infections, as opposed to the consequences of liver disease.”

These consequences can be severe. A total of nine cases of HCC were diagnosed during follow-up. Two cases involved patients who had never had an abdominal ultrasound, suggesting to the investigators “missed opportunities for detecting HCC”.

For the other participants, there was a long interval between the last ultrasound and HCC diagnosis.

There was a 69% mortality rate among patients with HCC.

In the investigators’ first set of analysis, poverty (p = 0.01) and injecting drug use (p = 0.02) were associated with lower chances of ultrasound screening for people with confirmed cirrhosis. In contrast, patients were significantly more likely to be screened if they had alcohol abuse problems or were taking HIV therapy.

Analysis that controlled for potential confounders showed that the only factor associated with ultrasound screening was the presence of a systematic screening system at the clinic offering care. Participants receiving care at a centre with such a system were twice as likely to have an ultrasound compared to people treated at a hospital without systematic screening (confirmed cirrhosis, OR = 2,20; 95% CI, 1.37-3.53, p = 0.001); possible cirrhosis, OR = 1.96; 95% CI, 1.21-3.16, p = 0.006).

“The strongest predictor of having had screening was the presence of a systematic process in place to schedule and follow screening ultrasounds, usually with the involvement of a hepatologist,” comment the researchers. “Methods to improve compliance with screening, such as patient and health-care worker education, financial support to attend visits and appropriate radiologic infrastructure should be explored to reduce the impact of HCC in the co-infected population.”