Christina Wang

Poor adherence and low persistency rates for hepatocellular carcinoma surveillance in patients with chronic hepatitis B.

AbstractOur goal was to examine rates and predictors for hepatocellular carcinoma (HCC) surveillance adherence and persistency, since studies of such adherence and persistency in patients with chronic hepatitis (CHB) are currently limited.Consecutive CHB patients (N = 1329) monitored for ≥1 year at 4 US clinics from January 1996 to July 2013 were retrospectively studied. Surveillance adherence was evaluated based on the American Association for the Study of Liver Diseases guidelines. Kaplan–Meier method was used to analyze surveillance persistency of 510 patients who had initially fair adherence (having at least annual surveillance imaging with further follow-up).Mean age was 48, with the majority being male (58%), Asian (92%), foreign-born (95%), and medically insured (97%). Patients with cirrhosis and those seen at university liver clinics were more likely to have optimal HCC surveillance than those without cirrhosis and those seen at community clinics (38.4% vs 21.6%, P <0.001 and 33.5% vs 14.4%, P < 0.001, respectively). HCC diagnosed in optimally adherent patients trended toward smaller tumor size (P < 0.08). On multivariate analysis also inclusive of age, sex, clinical visits, cirrhosis, clinic setting and antiviral therapy use, strong independent predictors for having at least annual imaging were a history of more frequent clinical visits (odds ratio [OR] = 2.5, P < 0.001) and university-based care (OR = 5.2, P < 0.001). Even for those with initially fair adherence, persistency dropped to 70% at 5 years.Adherence and persistency to HCC surveillance in CHB patients is generally poor. More frequent clinic visits and university-based settings were significant and strong predictors of at least annual HCC surveillance adherence.

Ethnic differences in incidence of hepatitis B surface antigen seroclearance in a real‐life multicenter clinical cohort of 4737 patients with chronic hepatitis B infection

Hepatitis B surface antigen (HBsAg) positivity is associated with increased risk for cirrhosis and hepatocellular carcinoma (HCC). HBsAg seroclearance is thought to be rare in general, but cohort data from US patients are limited.

P585 PATIENTS WITH HCC AND NONVIRAL DISEASES PRESENTED WITH MORE ADVANCED TUMOR, WITHOUT PRIOR HCC SCREENING, AND HAD POORER SURVIVAL, COMPARED WITH VIRAL HCC PATIENTS

lengths were significantly shorter in HCC patients (T/S = 0.71±0.24) compared to controls (T/S = 0.91±0.32) (P < 0.0001). Four heterozygous TERT mutations were identified in four patients. A novel TERT A243V mutation was found in a patient with severe disease (BCLC D). The second (T726M) and third (V1090M) mutations were identified in patients with early stage disease (BCLC A1). The fourth mutation (A1062T), previously described in leukemia and cirrhosis, was found in a patient with cirrhosis, Child–Pugh C, BCLC D. The four mutant patients had short telomeres for their age. Conclusions: These results suggest that telomerase mutations and telomere erosion are risk factors for the development of HCC in patients with cirrhosis.

Tu1010 Poor Adherence to Screening for Hepatocellular Carcinoma (HCC) in Chronic Hepatitis B (CHB) Patients in Community Gastroenterology and University Liver Clinics

asked to complete general demographics information, RAND 36-Item (SF-36) Health Survey Health Survey, and the Zarit Burden Scale. The quality of life of caregivers based on the SF-36 was compared using t-tests, using the scores of the national reference population as controls. Results: Of the 50 caregivers who consented to participate in the study, 48 (96.0%) participants returned their completed survey. Among the respondents, the mean age was 56.9 ±11.4 years, 40 (83.3%) were female, and 34 (70.8%) were spouses/significant other to the patient. Compared to the adjusted national normative data, caregivers scored substantially lower in categories of role limitations due to emotional problems (61.8 vs 81.8, p= 0.001); mental health (65.8 vs. 75.2, p= 0.005); social functioning (69.5 vs 83.5, p= 0.002), and general health (66.3 vs. 70.1, p<0.001). While the adjusted Physical Component Score (PCS) of the caregivers was at the national mean, the Mental Component Score (MCS) was lower than the national average of 43.0 ±13.9 vs the national mean of 50.0 ±10.0 (p= 0.001). Though only 8 of 48 (16.7%) subjects reported a formal clinical diagnosis for depression or anxiety, 23 subjects (47.9%) had a MCS less than 42, a strong predictor based on previous studies of clinical depression. Conclusions: Primary caregivers of patients with advanced liver disease have a significantly lower mental health compared to the general population. In our cohort, less than 20% of caregivers are formally diagnosed with clinical depression or anxiety, suggesting that there may be under recognition of mental health dysfunction in this population. Enhanced recognition of mental health dysfunction among caregivers of liver patients may result in improved quality of life of both caregivers and patients.

Mo1045 Compared to HCC Patients With Chronic Viral Hepatitis (Viral HCC), Hcc Patients With Nonviral Etiologies (Nonviral HCC) Were Less Likely to Undergo HCC Screening, Presented With More Advanced Tumors, and Had Poorer Overall Survival

Purpose: HCC rarely occurs in patients without chronic liver disease, and the clinical outcomes of HCC patients may differ by etiologies of underlying liver disease. Routine HCC screening/surveillance is recommended for those with chronic hepatitis B and cirrhosis of all etiologies, but it is unclear if there are differences in adherence in different populations. Our goal was to compare screening adherence and clinical outcomes of viral vs. nonviral HCC patients. Methods: This is a retrospective cohort study of 200 consecutive nonviral HCC patients (67 with alcoholic liver disease [ALD], 73 with cryptogenic/nonalcoholic fatty liver disease [NAFLD] and 52 with others) and 396 patients with viral HCC (268 with chronic hepatitis C, 119 with chronic hepatitis B and 9 with both) randomly selected from a total cohort of 1,214 patients with viral HCC who presented at a U.S. medical center in 1991-2011. HCC patients were identified via ICD-9 electronic query with data collected in all cases by individual chart review and National Death Index search. HCC screening adherence was optimal if US or CT/MRI were done every 6-12 months. Results: Compared to viral HCC patients, those with nonviral HCC were older (65±13 vs. 57±11, p<0.0001) and more likely to be non-Asian (74% vs. 51%, p<0.001), but had similar CPT scores (6.6 ±1.7 vs. 6.9±1.8, p=0.13). While the majority of viral HCC patients had a history of optimal HCC screening (69%), almost none of the nonviral HCC patients did (1%). Compared to viral HCC patients, nonviral HCC patients were much more likely to present withBLCL Stage C/D (42% vs. 19%), p<0.001) and beyond the Milan criteria for liver transplantation (75% vs. 54%, p<0.001). Nonviral HCC patients had significantly lower 5-year survival compared to their viral HCC counterparts: 48% vs 57% (p=0.036) (Figure). Similarly, patients who received optimal screening had significantly higher 5-year overall survival compared to those with suboptimal or no screening (62% vs. 47%, p=0.012). Onmultivariate analysis also inclusive of age, sex and ethnicity, independent predictors for lower mortality were HCC screening (OR=0.50, p=0.015), in addition to viral liver disease etiology (OR= 0.39, p=0.002). Conclusions: Nonviral HCC patients were much less likely to have a history of HCC screening, presented with higher tumor stages, and had poorer survival. The lack of HCC screening in nonviral HCC patients may be due to poor adherence and access to care as may be seen in those with ALD or underdiagnosis of chronic liver disease/cirrhosis as may be seen in those with cryptogenic or NAFLD. Further studies and efforts should be focused on early diagnosis of underlying liver disease, cirrhosis, and improvingHCC screening compliance in at-risk patients; which is especially important with the rising obesity epidemic and projected increase of HCC incidence due to NAFLD.