SCREEN, TREAT, OR PREVENT HCC:

Liver Cancer Prevention in Texas Baby

Boomers

Addressing Health Disparities

Barbara J Turner MD, MSEdFounding Director, Center for Research to Advance Community Health

University of Texas Health San Antonio

Overview

¨ Introduction

¨ Brief overview of hepatitis C virus (HCV) and liver

cancer (hepatocellular carcinoma or HCC)

¨ Findings from our HCV research

¨ Insights from the front lines and practical tips

¤ Brenda Westbrooks-Patient cured of HCV

¤ Raudel Bobadilla- Care navigator/CHW

¤ Dr. Debra Irwin-Primary care clinician

¨ What’s next: Opportunities to cure HCV and reduce

HCC

The growing threat of liver cancer

NCHS Data Brief no. 314, July 2018

Islami et al. CA Cancer J Clin 2017

“However, most liver cancers are potentially

preventable, and interventions to curb the rising

burden of liver cancer and reduce racial/ethnic

disparities should include the targeted

application of existing knowledge in prevention, early detection, and treatment…”

Mortality from liver cancer (2014)

Mokdad AH, Dwyer-Lindgren L, Fitzmaurice C, et al. Trends and Patterns of Disparities in Cancer Mortality Among US Counties,

1980-2014. JAMA. 2017;317(4):388–406. doi:10.1001/jama.2016.20324

Liver-bile duct cancer in Texas 2011-15

¨ Mean U.S. = 8.1

¨ Mean TX = 11.4

(per 100,000)

NCI – CDC State Cancer Profiles

HCV: leading cause of HCC in U.S.

¨ HCV accounts for approximately half HCC in the U.S.

¨ 2.7 to 4 million Americans have chronic HCV

¨ Persons with HCV-related cirrhosis have a 2 to 6% annual risk of HCC

¨ HCV also most common cause of liver failure and liver

transplant

Gastroenterology 1997 Feb;112(2):463-72

Hepatology 2015 Nov;62(5):1353-63

Complex implementation: HCV screening,

evaluation, and management

¨ USPSTF guidelines (2013) to implement universal HCV

screening of baby boomers (born 1945-65)

¨ No model for primary care implementation

¨ Unique challenges for practices serving the highest

risk population – low income minorities in the U.S

¤ Lack of coverage of tests for uninsured

¤ Poor access to specialty care

¤ Unable to afford highly effective direct-acting antivirals

HCV Implementation Projects

¨ University Hospital screening all eligible hospitalized baby boomers (2012-2014) ¤ CDC

¨ 2 Rio Grande Valley FQHCs (2014 – current)¤ 1115 Medicaid Waiver

¨ 2 residency and 3 faculty primary care clinics in San Antonio (2014 – current)¤ 1115 Medicaid Waiver

¨ 5 primary care systems in South Texas and Parkland in Dallas since 2015 (2015 – current)¤ CPRIT

All ReACH HCV screening programs

7 primary care systems use

specialist teleconsultationmanage patients on site (primarily Federally Qualified Health Centers)

¨ In 10 health care systems:

¤Screening and navigation in 39 clinics

¤51,489 patients screened

¤2,968 (5.7%) HCV Ab+

¤2,891 received RNA testing

¤1,807 (3.5% of all screened) diagnosed with chronic HCV

CPRIT program screening results

¨ In CPRIT-funded programs:

Dallas-

Parkland

South Texas

HCV

screening

19,291 4,057

HCV Ab+ 1,630 (8.5%) 447 (11.0%)

HCV RNA+ 1,127 (5.8%) 200 (4.9%)

HCC 149 (0.7%) 3 (0.07%)

Increased risk of HCV (antibody positive)

¨ Younger age among persons born 1945-65

¨ Men over two times more likely to have HCV infection

than women

¨ Hispanics less likely to test HCV+ non-Hispanic whites

¨ Uninsured more likely to test HCV+

¨ Among persons testing HCV+, only younger age was

significantly associated with a greater likelihood of

chronic HCV (HCV RNA positive)

Greater risk of advanced liver damage

¨ Hispanics are over three times more likely to have liver

fibrosis than non-Hispanics

¨ Uninsured patients are over two times more likely to

have liver fibrosis than insured

¨ Alcohol use and the combination of diabetes and obesity are also associated with significantly more advanced

liver damage

¨ THESE GROUPS NEED TO BE DIAGNOSED AND

TREATED SOON

Turner BJ et al. Hepatology. 2015;62:1388-95.

Adoption: Buy-in and cooperation of administrators and practice leadership

Adoption: Identify lead clinician and practice coordinator

Reach: Patient and community education – flyers, community meetings, presentations, website

Implementation: Integrate screening into workflow

Adoption: Education & training staff & clinicians (CME)

Adoption and Reach: EMR support for HCV screening and monitoring

Core components: HCV screening in primary care

Community outreach

¨ Presentations in community settings

¨ English/Spanish delivery by CHW, oncologist, and peer educators

Reach & Implementation: HCV screening tests (reflex), cover for uninsured

Reach & Implementation: Case manager to coordinate care for patients with chronic HCV+ (one year or more)

Reach & Implementation: Patient education personalize supplemented by mobile app-based low literacy education

Implementation: Educational webinar for primary care clinicians on HCV evaluation, staging, and management

Implementation: Patient evaluation and staging, cover for uninsured, and complete case review form

Implementation: HCV specialist office hours

Core components: HCV management in primary care

HCV Mobile App

¨ Available in English and Spanish

¨ Include teach-back statements

¨ Collects data on substance use to guide care

The English/Spanish app provides HCV

education, removes the stigma of the disease, and emphasizes the opportunity for cure

Implementation: Management (e.g. comorbidities substance use) and treatment plan operationalized – case manager + practice

Implementation: Uninsured apply for Medicaid (rejected) and apply for drug from Prescription Assistance Program

Implementation: Patient and family supported to address barriers to treatment then complete treatment to cure

Effectiveness: Registry of all patients screened, diagnosed, and all stages of follow-up to cure

Effectiveness: Anonymous comparative feedback to practices about performance

Effectiveness: Report to DSHS, funding agencies, larger clinical-research community and patient community

Core components: HCV management in primary care

Teleconsultation model care cascade

235

161 (68.5%)

92 (39.1%)84 (35.7%)

74 (31.5%) 72 (30.6%)

0

50

100

150

200

250

RNA+Specialist

review

Initiated

treatmentCompleted

treatment

12wk PT

RNA Cured

Challenge of maintenance

¨ EMR fails to support identification of patients without

time-consuming staff/clinician effort

¨ Practice competing priorities – not a HEDIS measure

¨ No ongoing coverage for lab/imaging of uninsured

¨ No payment mechanism for case management –patients often lost to follow-up

¨ No coverage for specialist consultation (despite being less intensive than ECHO program)

¨ Follow-up of patients with cirrhosis even after cure

STOP HCV-HCC website

¨ Stophepatitisc.com

¨ CPRIT funding

¨ Informed by statewide

leadership panel

¨ Intended for the public and

healthcare professionals

Acknowledgments

Raudel Bobadilla BS, CHW

Aro Choi MS

Ludivina Hernandez CHW

Ariel Gomez BS, CHES

Sarah Lill MAM

Charles Mathias PhD

Trisha Melhado MPH

Julie Parish Johnson, MS, LCDC, CRC

Laura Tenner MD

Andrea Rochat MFA

Paula Winkler MEd

Mamta Jain, MD

Amit Singal MD

Lisa Quirk MS, MPH