RCT of Screening Strategies Among Patients at High Risk for Developing HCC in a Safety-net Health System

Summary

Hepatocellular carcinoma (HCC) is the 9th leading cause of cancer-related death in the US and one of the leading causes of death in patients with cirrhosis. Fewer than 1 in 5 high-risk patients undergo HCC screening, with lower rates in non-Caucasian and low socioeconomic status patients receiving care through safety-net health systems. Screening and follow-up failures lead to more advanced cancers, when curative therapies are not available and survival is significantly worse. Over 60% of HCC are diagnosed at advanced stages, due to poor recognition of high-risk patients, underuse of screening among these patients, and poor follow-up of abnormal screening tests. To address these barriers, the investigators propose to conduct a comparative effectiveness research randomized controlled trial of three screening strategies among a socioeconomically disadvantaged and racially diverse cohort of cirrhotic patients at high risk for developing HCC.

Overall, 1800 patients attending Parkland, the Dallas safety-net health system, will be randomized to:

* Group 1: Usual care, with visit-based HCC screening per discretion of individual providers
* Group 2: Mailed HCC screening invitation outreach to eligible patients (low resource intensity)
* Group 3: Mailed HCC screening invitation outreach to eligible patients combined with centralized patient navigation to promote screening completion and follow-up (high resource intensity)

Through three specific aims, this effectiveness research randomized controlled trial will:

* Aim 1: Engage stakeholders in design and implementation of HCC screening outreach interventions.
* Aim 2: Compare the clinical effectiveness and patient acceptability of the intervention strategies to increase completion of one-time and repeat HCC screening.
* Aim 3: Evaluate whether intervention effects are moderated by patient sex, race, ethnicity, English proficiency, and connectedness to primary care.

The screening intervention strategies combine EMR-enabled case identification, system-level screening outreach, and patient navigation to improve identification of previously unrecognized cirrhotic patients, promote HCC screening completion, and facilitate follow-up of abnormal screening tests. This study will engage stakeholders throughout the research process, evaluate the effectiveness and acceptability of HCC screening strategies, and determine which patient subgroups benefit the most.

Conditions

• Carcinoma, Hepatocellular
• Liver Neoplasms

Interventions

OTHER

Mailed Outreach Invitation

Individuals randomized to Group 2 will receive: 1. Mailed outreach invitation to complete HCC screening ultrasound and alpha-fetoprotein (AFP) blood test. 2. "Live" phone calls 2 to 4 weeks after the mailed invitation to facilitate HCC screening completion. Up to three attempts will be made. All communications will use standard English or Spanish scripts. 3. Centralized process to promote guideline-appropriate follow up testing with CT or MRI or referral to GI Clinic.

OTHER

Mailed Outreach Invitation and Patient Navigation

Individuals randomized to Group 3 will receive: 1. Mailed outreach invitation to complete HCC screening ultrasound and alpha-fetoprotein (AFP) blood test. 2. "Live" phone calls 2 to 4 weeks after the mailed invitation to facilitate HCC screening completion "and address patients' self-reported barriers to HCC screening (e.g., it does not apply to me). Up to three attempts will be made. All communications will use standard English or Spanish scripts. 3. Centralized navigation to promote screening completion (i.e., appointment reminder phone calls from patient navigator) and guideline-appropriate follow up testing with CT or MRI or referral to GI Clinic.

Sponsors & Collaborators

• Agency for Healthcare Research and Quality (AHRQ)

  collaborator FED

• Parkland Health and Hospital System

  collaborator OTHER

• The University of Texas Health Science Center, Houston

  collaborator OTHER

• Johns Hopkins Bloomberg School of Public Health

  collaborator OTHER

• University of Texas Southwestern Medical Center

  lead OTHER

Principal Investigators

• Amit Singal, MD · University of Texas Southwestern Medical Center

Study Design

Allocation

RANDOMIZED

Purpose

HEALTH_SERVICES_RESEARCH

Masking

DOUBLE

Model

PARALLEL

Eligibility

Min Age

21 Years

Sex

ALL

Healthy Volunteers

No

Timeline & Regulatory

Start

2014-12-31

Primary Completion

2017-08-31

Completion

2017-08-31

Countries

• United States

Study Locations