Clinicians need education to understand hepatocellular carcinoma (HCC) tracking and surveillance resources, according to research published May 14 in JAMA Network Open.
A team led by Robert Wong, MD, from Stanford University in California found gaps in HCC surveillance knowledge, particularly among primary care clinicians. These included health system factors that exacerbate persisting delays in timely HCC surveillance three years after the onset of the COVID-19 pandemic.
“Effective delivery of HCC education to primary care clinicians and health system-level interventions must be pursued in parallel to address the complex barriers affecting suboptimal HCC surveillance in patients with cirrhosis,” the Wong team wrote.
Previous reports indicate that surveillance is underused in HCC patients with cirrhosis. This includes a perceived lack of diagnostic radiology resources, with ultrasound being the go-to imaging modality for liver surveillance. This trend makes identifying factors tied to this underuse important in addressing barriers in this area, the researchers wrote.
Wong and co-authors evaluated clinician-level factors that contribute to such underuse in HCC patients. Their survey study included responses from 347 primary care clinicians, as well as gastroenterology and hepatology clinicians at five safety-net health systems in the U.S. The researchers issued and collected responses in 2023 with the goal of assessing knowledge, attitudes, beliefs, perceived barriers, and COVID-19-related disruptions among the clinicians.
The researchers tested HCC knowledge among clinicians with a six-question exam. They found that 53.3% scored five or more of the total questions correctly. Diving further, 77.1% of the gastroenterology and hepatology clinicians who took the exam correctly answered five more questions compared with 45.8% of the primary care clinicians. Clinicians with higher HCC scores were less likely to report barriers to HCC surveillance, the researchers added.
Also, compared with the gastroenterology and hepatology clinicians, the primary care clinicians were more likely to report the following barriers:
- Inadequate time to discuss HCC surveillance (26.6% vs. 4.2%, p = 0.001)
- Difficulty identifying patients with cirrhosis (58.2% vs. 10.4%, p < 0.001)
- Not being up to date with HCC surveillance guidelines (62.6% vs. 10.4%, p < 0.001)
The team also noted that the following factors were reported in less than 10% of all the clinicians and did not differ significantly between primary care clinicians and gastroenterology and hepatology clinicians: shortage of radiology facilities, language barriers, concerns that patients often do not complete surveillance tests that are ordered, difficulty arranging follow-up diagnostic testing for those with a positive HCC screening test, and difficulty arranging treatment for patients diagnosed.
Finally, while most respondents acknowledged delays during the COVID-19 pandemic, 62 of 136 primary care clinicians (45.6%) and 27 of 45 gastroenterology and hepatology clinicians (60%) reported that patients with cirrhosis could complete HCC surveillance without delays.
The study authors wrote that these barriers stress the importance of considering interventions to improve HCC surveillance. These include radiology recall systems, electronic medical record dashboards and reminder systems, or organized health-system-level outreach strategies.
“These findings highlighted that in addition to targeted education, parallel health system-level interventions must be pursued to address the barriers to the availability of resources and infrastructure needed to ensure close monitoring of patients with cirrhosis,” the authors added.
The full study can be found here.
![Examples of ultrasound findings and techniques. (A) Images in a 39-year-old male patient with a mass in the left thigh. The mass is heterogeneous on the B-mode US image (compared with the patient in D) and showed increased microvascularity (superb microvascular imaging [SMI]) and shear-wave elastography (SWE) values. Undifferentiated pleomorphic sarcoma was diagnosed at biopsy (with pleomorphic rhabdomyosarcoma in surgical specimen). (B) Images in an 18-year-old male patient with a mass in the left leg. The mass is hypoechoic on the B-mode image, with no other findings suggestive of malignancy. The lesion is in contact with the cortex of the tibia, which is slightly irregular. CT revealed a doubtful anteromedial tibial erosion. The microvascular study demonstrated high vascularization, suggestive of malignancy. Periosteal Ewing sarcoma was diagnosed with both histologic and immunohistochemical confirmation. (C) Images in a 69-year-old female patient with a lump growing on the outside of the left leg. Multiple SWE examinations were performed (please note the high values obtained in the measurements, whereas the color map highlights the stiffness relative to adjacent tissues). SMI showed areas of increased vascularization to target for sampling. Undifferentiated spindle cell sarcoma was diagnosed at biopsy, with residual leiomyosarcoma in the surgical specimen after neoadjuvant therapy. (D) Images in a 56-year-old female patient with a mass in the right thigh. The mass is heterogeneous at both B-mode ultrasound (similar to patient A) and MRI (coronal T2-weighted spectral attenuated inversion recovery [SPAIR]; T1-weighted pre-contrast and postcontrast imaging), which even shows uptake after the administration of paramagnetic contrast material, which is traditionally suggestive of malignancy. Low values at SMI and elastography are suggestive of benignity. Spindle cell lipoma was diagnosed at biopsy, with atypical spindle cell lipomatous tumor in the surgical specimen.](https://img.auntminnie.com/mindful/smg/workspaces/default/uploads/2026/08/images-radiol250278fig2.APCFLSvX6p.jpg?auto=format%2Ccompress&dpr=2&fit=crop&h=167&q=70&w=250)
