HCC surveillance program in a nurse-led clinic: assessing adherence to guidelines and possibility of reducing pressure on services by applying AMAP score

ABSTRACT

BackgroundNICE recommends offering 6 monthly surveillance with USS for all cirrhotic patients with an exception for patients identified for end-of-life care. But surveillance intervals are often missed when care is delivered through Consultant-led clinics. Having introduced a nurse-led stable cirrhosis clinic in 2016, we assessed whether the recommended interval was being achieved and what impact the ‘aMAP’ score stratifying annual HCC risk as low (<0.2%), medium (1%) and high (4%) might have on service utilisation.MethodsA retrospective review of all patients attending our nurse-led stable cirrhosis clinic. The review included demographic data, aetiology of liver disease, and calculation of aMAP (age, gender, albumin-bilirubin) scores using parameters from initial clinic visits. We assessed adherence to the twice-yearly US scan since our adaptation of NICE guidelines in 2018.ResultsBetween 2016–2018, 117 (49 female) cirrhotic patients were enrolled in the clinic. The majority of the patients had ALD (55) and NASH (24). Other aetiologies HCV, HFE and PBC. All patients had Child A disease except 7 with Child B7–8. 13/117 patients were excluded from the surveillance because of other co-morbidities and age. Of the remaining, 90(87%) patients had their USS at 6 months interval, 2(2%) missed only one scan (not requested by clinician), 7(7%) failed to attend their appointments, 5(4%) either declined surveillance or were lost to follow up. aMAP score identified 70/104(67%) high risk, 29(28%) medium risk and only 5(5%) low risk for HCC. HCC was diagnosed in 4/104 patients after 3 years of follow-up (2 medium risks;2 high risks). Death was reported in 10 (1HCC;4 liver failure;3 other cancers;1 post-operative complication;1 sepsis). Despite interruptions caused by the COVID-19 pandemic, no HCC was diagnosed in 1st US scan after restarting the services.ConclusionsHCC surveillance organised through a dedicated nurse-led stable cirrhosis clinic can achieve excellent adherence to planned USS intervals. Only a small number were identified as low risk within our cohort using the aMAP score offering limited opportunity to reduce the volume of USS for this indication in Derby.