Introduction Hepatocellular carcinoma (HCC) is an increasingly common and devastating consequence of chronic liver disease (CLD). Early diagnosis of CLD provides opportunities to alter disease course and offer surveillance. In our centre, surveillance was historically arranged during general hepatology clinic appointments, which were often overbooked or delayed. We analysed how patients ultimately diagnosed with HCC presented to secondary care, to identify key areas for service improvement.
Method All patients with a diagnosis of HCC attending our Trust between 1/1/12 and 1/1/14 were included in the data collection including demographics and tumour characteristics, alongside details of the mode of presentation to specialist services, management and clinical outcomes. Next, a nurse-led surveillance clinic (NSC) was instituted to run alongside the hepatology clinic, and performance and satisfaction data collected.
Results 2/3 of those who developed HCC did so on a background of pre-existing liver disease. In many, HCC was the first presentation to secondary care, but 33% were already under specialist follow up.
Of the first presentations, the majority had significant liver disease and 71% also had historically abnormal liver function tests (LFT), but had never been referred to hepatology. No-one in this group was eligible for potentially curative therapy.
25% of patients within secondary care were not on surveillance – all had advanced disease and were only eligible for best supportive care (BSC).
Half of patients on surveillance were not monitored in accordance with guidelines, although 1/3 overall were still eligible for curative therapy. However, even where only BSC was appropriate, median survival was significantly improved compared to those presenting for the first time (7 months vs. 1 month).
To improve our service, we instituted an NSC for those with compensated cirrhosis. After 1 year, our audit showed no patients lost to follow up, few delays in surveillance, and improved patient satisfaction across all domains.
Conclusion Most HCC occurred in those with undiagnosed pre-existing liver disease, despite evidence of historically abnormal LFT in over 70% of cases. Failure to investigate abnormal LFT is a missed opportunity to identify potentially reversible disease, or offer surveillance. In these cases, HCC is usually advanced/incurable, with little time to come to terms with the terminal diagnosis. To combat this, we are working with local commissioners and primary care to standardise pathways for abnormal LFT and increase early identification of liver disease.
Within secondary care, our surveillance procedures were suboptimal, although treatment options and outcomes were better in this group. In response, we have instituted an NSC, which has performed well in year 1 and is well liked by patients.
Disclosure of interest None Declared.
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