Abstract A22: Programmatic implementation of hepatocellular carcinoma prevention through hepatitis C testing, secondary prevention, and treatment for a medically and minority underserved population
Authors: Dobra Sarah E. , Baker Nidsa , Miller Lesley , Stokes Lauren 
Published: May 2016

This study assessed the programmatic implementation of a multi-disciplinary program to prevent hepatocellular carcinoma through hepatitis C (HCV) testing, secondary prevention among diagnosed individuals (defined as interventions that prevent further progression of liver disease), and treatment within a medically and minority underserved clinic.

The Lewis Cancer & Research Pavilion (LCRP) at St. Joseph's/Candler Health System is a Community Cancer Center and regional destination for cancer care in coastal Georgia. LCRP disparities efforts focus on cancer prevention, screening, and facilitating access to cancer care at two clinics for underserved and uninsured, low-income, predominately African American and Hispanic populations. Because the primary cause of hepatocellular carcinoma is cirrhosis from chronic hepatitis infection, in 2014 the LCRP began implementing Centers for Disease Control and Prevention (CDC) recommendations for HCV testing as a cancer prevention activity at the clinics.

As HCV patients were identified, it became clear that disease specific protocols needed to be developed in order to improve nurse practitioners' clinical practice. Barriers identified and addressed during program implementation included: 1) perception that expensive HCV treatment is inaccessible for uninsured patients, 2) lack of knowledge of CDC clinical testing guidelines resulting in inaccurate HCV diagnosis 3) lack of knowledge of secondary prevention and treatment leading to inappropriate clinical care for HCV+ patients, and 4) under-utilization of Electronic Medical Record (EMR) and other data tracking tools to enhance clinical care.

The LCRP and clinical team identified available community and statewide resources, physician champions, and education resources. A multi-disciplinary team developed protocols for secondary prevention activities while a clinical team implemented clinical testing and treatment algorithms using CDC, American Association for the Study of Liver Diseases (AASLD), and Infectious Diseases Society of American (IDSA) guidelines. These initiatives are consistent with CDC efforts to move HCV management to community-based health-care providers within primary care with supportive training and supervision by HCV care specialists.

The clinic conducted a baseline chart audit of patients with HCV documented in their medical record. At baseline, CDC testing algorithms to confirm diagnosis were followed in 14% of patients who received the initial HCV+ antibody test. Six months after implementation of testing algorithms and other clinical and programmatic improvements, 44% of birth cohort patients (patients born between 1945 and 1964) were screened in compliance with CDC guidelines. Average age of HCV+ patients was 51, 58% were African American, 41% Caucasian, 62% female, and 38% male. Secondary prevention activities including hepatitis A & B vaccines, referral for alcohol and/or substance abuse counseling, depression and mental health screening, and identification of prevention and/or treatment barriers were initiated during the first six months of 2014 with 34% of HCV+ patients. Prevention activities conducted concurrently with treatment planning. Nurse practitioners at the clinic obtained co-management HCV treatment support from an internal medicine and primary care physician.

This cancer prevention program demonstrated improvement in HCV testing, prevention, and treatment within a primary-care nurse-managed community clinic. The inter-disciplinary approach outlined in this model utilized evidence based guidelines and diagnostic algorithms. Application of secondary prevention activities and effective data tracking increased overall programmatic success, and ultimately contributes to the prevention of hepatocellular carcinoma among disparate populations.

Citation Format: Sarah E. Dobra, Nidsa Baker, Lesley Miller, Lauren Stokes. Programmatic implementation of hepatocellular carcinoma prevention through hepatitis C testing, secondary prevention, and treatment for a medically and minority underserved population. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr A22.