People with liver cirrhosis may delay or forgo recommended monitoring for liver cancer because of financial concerns and lack of insurance, according to a study to be presented at The Liver Meeting, the annual meeting of the American Association for the Study of Liver Diseases (AASLD). These findings underline the need for better strategies to address these barriers for at-risk individuals.

Over years or decades, chronic hepatitis B or C, heavy alcohol use, fatty liver disease and other factors can lead to serious liver complications, including cirrhosis (scarring), hepatocellular carcinoma (HCC, the most common type of primary liver cancer) and liver failure that requires a transplant.

People who have progressed to cirrhosis are much more likely to develop liver cancer. AASLD guidelines recommend that such individuals undergo regular surveillance every six months using ultrasound scans, with or without alpha-fetoprotein (AFP) blood tests, in order to catch liver disease at an early, more treatable stage.

“Although several studies highlight the association between HCC surveillance and improved survival, underuse of surveillance in clinical practice is one of the most common reasons for late-stage HCC presentation, when curative therapies are no longer possible,” study coauthor Amit Singal, MD, of the University of Texas Southwestern Medical Center in Dallas, said in a conference press release. “A better understanding of barriers to HCC surveillance, and identifying patients most likely to underuse surveillance, can inform future interventions to increase HCC surveillance and reduce HCC-related mortality.”

Singal and colleagues conducted a telephone survey of people with cirrhosis at a liver disease specialty referral center, a safety-net health system and a Veterans Administration hospital between April and December 2018. The survey asked about attitudes toward and barriers to liver cancer surveillance, including financial challenges.

Of the 2,871 patients asked to participate, 36% completed the survey. Nearly two thirds were men, 53% were age 60 or older and the cohort was racially diverse (35% white, 34% Latino and 29% Black). Most participants (74%) were classified as Child-Pugh A, meaning they had well-preserved liver function, or compensated liver disease. Just over half were followed in a specialist hepatology clinic. A majority (61%) reported that they had received an abdominal ultrasound for HCC surveillance during the past year.

Survey participants expressed worry about developing HCC, the researchers reported, with 74% saying they thought were at least somewhat likely to develop liver cancer in their lifetime and 37% expressing a fear of dying from the malignancy.

Most participants (89%) said HCC surveillance was very important, but they also reported barriers to regular monitoring, including testing costs (cited by 29%), difficulty scheduling the procedure (24%), uncertainty about where to get an ultrasound scan (17%) and transportation difficulties (17%).

Although 92% said they had health insurance coverage, nearly 10% percent reported that they had delayed care because of financial burden, including the cost of HCC surveillance. Almost a quarter (24%) said they could not afford insurance co-pays or deductibles, and 12% said they needed to borrow money or go into debt to pay for their care. Furthermore, 43% expressed worry about whether they could pay their medical bills.

The researchers did not see any differences in the likelihood of HCC surveillance based on participants’ fear of developing liver cancer or the importance they ascribed to ongoing monitoring. People with documented cirrhosis, those who attended more primary care visits and those who received specialty hepatology care were more likely to have recently undergone surveillance. Lack of insurance was associated with a 47% lower likelihood of HCC surveillance, while financial distress resulting in delayed medical care reduced the likelihood of liver cancer monitoring by 27%.

“Nearly half of racial/ethnic minority and low-income patients report medical-related financial problems, including devastating out-of-pocket costs, medical debt and even bankruptcy,” said study coauthor Caitlin Murphy, PhD, MPH, also of the University of Texas Southwestern Medical Center. “Financial burden may negatively impact patient quality of life, lead to poor adherence to treatment recommendations and contribute to persistent disparities in cancer outcomes.”

“Our findings highlight the need for policy reforms, including expansion of covered benefits and limits on out-of-pocket spending, to reduce the burden in this patient population and improve receipt of surveillance,” she added. “In health care systems, interventions such as patient navigation, combined with subsidizing out-of-pocket costs, may also increase HCC surveillance.”

Click here to access the Liver Meeting abstracts.

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