Our data demonstrate that the impact of psychosocial barriers on our capacity to deliver care varies with the nature of the treatment under consideration: curative vs cancer control. For example, active substance use disorder, homelessness, and severe established mental illness were often considered insurmountable when the treatment in question was LT. Nevertheless, despite the high prevalence in our study group of barriers, such as lack of transport while living far from a VA medical center, or alcohol use disorder, a curative treatment with either LT, tumor ablation, or resection could be offered to over half of our cohort. When noncurative therapies are included, most patients (85%) received HCC-specific care, with good relative survival.
Our reported high receipt of HCC-specific care and patient survival is in contrast to previously reported low rates of HCC-specific care in in a national survey of management of 1296 veteran patients infected with HCV who developed HCC from 1998 to 2006. In this population, HCC-specific treatment was provided to 34%.16 However our data are consistent with our previously published data of patients with HCC managed through an institutional MDTB.6 Indeed, as shown by a univariate analysis in our present study, individualizing care to address modifiable patient barriers, such as providing provisions for lodging if needed, was associated with an increased likelihood of receiving HCC-specific care. On the other hand, advanced tumor stage (> T2) at diagnosis and a diagnosis of depression, which was the most common psychiatric diagnosis in our cohort, were both associated with decreased likelihood of receiving HCC-specific care. Clinical factors such as MELD score, total bilirubin, and serum AFP all affected the likelihood of providing HCC-specific care. In a multivariate analysis, factors that predicted ability to receive curative therapy included absence of substance use, T2 stage of tumor, and Child-Turcotte-Pugh class A cirrhosis. This is expected as patients with HCC within T2 stage (or Milan criteria) with compensated cirrhosis are most likely to receive curative therapies, such as resection, ablation, or LT.2
Conclusions
Our study demonstrates a high burden of psychosocial challenges in veterans with HCC. These accounted for a significant barrier to receive HCC-specific care. Despite the presence of these patient barriers, high rates of HCC-specific treatment are attainable through individualization and coordination of patient care in the context of a MDTB model with nurse navigation. Provision of targeted social support to ameliorate these modifiable factors improves patient outcomes.