M. M. Dua1, T. B. Tran1, K. Hwa2, C. Cho-Phan3, G. A. Poultsides1, B. C. Visser1 1Stanford University,Surgery,Palo Alto, CA, USA 2VA Palo Alto Health Care System,Surgery,Palo Alto, CA, USA 3Stanford University,Medicine,Palo Alto, CA, USA
Introduction: Hepatobiliary malignancies are complex cases that require treatment through surgical, locoregional, and systemic therapies. Improved outcomes are observed when these cases are discussed among tumor boards and treated by multidisciplinary referral centers. We hypothesize there is significant delay in referral of many patients with primary hepatobiliary malignancies to tertiary multidisciplinary teams. The purpose of this study was to identify areas of mismanagement leading to delayed referral and treatment of hepatobiliary malignancies.
Methods: A retrospective review was performed of the patients referred to Liver Tumor Board from 2012-2014. Treatment recommendations were made by representatives from surgical oncology, hepato-pancreato-biliary (HPB) surgery, transplant surgery, interventional radiology, radiation oncology and medical oncology. Gross areas of mismanagement were defined as: 1) serial imaging of growing hepatobiliary tumors; 2) dismissal of imaging with overt tumors and negative biopsy; 3) failure to establish follow-up after identification of index tumor; and 4) failure to refer patients with resectable tumors. Referring institution characteristics were analyzed to determine risk factors for delayed referral.
Results: Of 208 patients, 80 (38%) were grossly mismanaged, most frequently because of definition 1 (49%) and definition 3 (26%). Risk factors for delayed referral included hospitals with less than 200 beds (OR-14.4, p<0.001), hospitals without any tumor board (OR-53, p<0.001), and hospitals without a surgeon specializing in oncology or HPB (OR-21.9, p<0.001). Cholangiocarcinoma was more frequently mismanaged than Hepatocellular carcinoma (OR-3 v 1.7).
Conclusion: The profound delay in referral of many patients with hepatobiliary malignancies compromises outcomes. Efforts to improve physician awareness and understanding of these tumors can facilitate expedited access to multidisciplinary care.