SCREEN, TREAT, OR PREVENT HCC:

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1 SCREEN, TREAT, OR PREVENT HCC: Liver Cancer Prevention in Texas Baby Boomers Barbara J Turner MD, MSEd Founding Director, Center for Research to Advance Community Health University of Texas Health San Antonio Addressing Health Disparities

2 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

3 The growing threat of liver cancer 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 NCHS Data Brief no. 314, July 2018 Islami et al. CA Cancer J Clin 2017

4 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, JAMA. 2017;317(4): doi: /jama

5 Liver-bile duct cancer in Texas Mean U.S. = 8.1 Mean TX = 11.4 (per 100,000) NCI CDC State Cancer Profiles

6 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): Hepatology 2015 Nov;62(5):

7 Complex implementation: HCV screening, evaluation, and management USPSTF guidelines (2013) to implement universal HCV screening of baby boomers (born ) 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

8 HCV Implementation Projects University Hospital screening all eligible hospitalized baby boomers ( ) 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

9 All ReACH HCV screening programs 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 7 primary care systems use specialist teleconsultation manage patients on site (primarily Federally Qualified Health Centers)

10 CPRIT program screening results In CPRIT-funded programs: HCV screening Dallas- Parkland 19,291 4,057 South Texas 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%)

11 Increased risk of HCV (antibody positive) Younger age among persons born 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)

12 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:

13 Core components: HCV screening in primary care Adoption: Buy-in and cooperation of administrators and practice leadership Adoption: Identify lead clinician and practice coordinator Adoption: Education & training staff & clinicians (CME) Adoption and Reach: EMR support for HCV screening and monitoring Reach: Patient and community education flyers, community meetings, presentations, website Implementation: Integrate screening into workflow

14 Community outreach Presentations in community settings English/Spanish delivery by CHW, oncologist, and peer educators

15 Core components: HCV management in primary care 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

HCV education, removes the stigma of the

16 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

17 Core components: HCV management in primary care 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

18 Teleconsultation model care cascade (68.5%) (39.1%) 84 (35.7%) 74 (31.5%) 72 (30.6%) 50 0 RNA+ Specialist review Initiated treatment Completed treatment 12wk PT RNA Cured

19 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

20 STOP HCV-HCC website Stophepatitisc.com CPRIT funding Informed by statewide leadership panel Intended for the public and healthcare professionals

21 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

STOP Hepatocellular Carcinoma

STOP Hepatocellular Carcinoma Laura Tenner MD MPH, Amit G. Singal MD MS, Mamta Jain MD, Barbara Turner MD, Barbara Riske MS ReACH Center and Dept of Medicine UT Health San Antonio Dept of Medicine UT Southwestern