HJBR Nov/Dec 2022

HEALTHCARE JOURNAL OF BATON ROUGE I  NOV / DEC 2022 49 John M. Lyons, III, MD, FACS, FSSO Surgical Oncologist Our Lady of the Lake Regional Medical Center and Cancer Institute side, there is lack of awareness, lack of time, high costs, poor access, language/cultural differences, fear of what the tests might reveal. On the provider side, cirrhosis is a silent disease, and it is not always easy to identify in an asymptomatic patient. Addi- tionally, cancer screening is influenced by the treating provider’s “decision fatigue” — cancer screening decreases as the complex- ity of the case increases. Henry DavidThoreau, in 1854, wrote that “men have become tools of their own tools,” and many in healthcare feel that this ac- curately describes the provider interaction with the electronic medical record (EMR). The EMR has been charged with under- mining the personalized face-to-face doc- tor — patient interaction — and it is thought to be a major driver for physician burnout. However, there are some positive attributes to the EMR including meticulous patient documentation, common templates, and ac- curate disease coding and billing. Addition- ally, the EMR houses thousands of important clinical and demographic datapoints, and these datapoints can be queried and used to facilitate cancer screening. Risk profiling and opportunistic screening of patients can often be done without high-tech AI-plat- forms. For example, breast screeners can search for all women over 40 with a rich family oncologic history. Lung screeners can search for those over 50 with a greater than 20 pack-year history of smoking. Similarly, liver screeners can identify all patients with cirrhosis. Many EMRs also have the ability for au- tomation. Once appropriate patients are identified, the screening tests can be ordered and then reordered automatically on an on- going basis. This obviates the need for the busy provider to stop his or her workflow to remember to order a screening test on an otherwise asymptomatic patient with other medical problems. Automating the screening orders standardizes the process and eliminates the potential for human er- ror, making it both more efficient and more effective. This concept is not new. In fact, many ex- amples exist in the medical literature. One large study from China hypothesized that the EMR could be used to improve their cancer screening programs. 10 In this study, test for alpha-fetoprotein (AFP) every six months. However, only 20% of eligible pa- tients are actually screened for liver cancer, and fewer than 10% are screened every six months as is recommended. 1 Admittedly, there has not been a high- quality randomized, controlled trial to eval- uate the effect of liver cancer screening on patients with cirrhosis, and this is likely why the USPSTF has no official statement on it. Nonetheless, mathematical models, 2 a smaller clinical trial, 3 and a meta-analy- sis of 47 cohort studies all demonstrate the survival benefits of liver cancer screening. 4 This evidence is substantiated by the rec- ommendations for liver cancer screening that have been issued by all of the major American hepatology societies, 5 and it has been advocated by European, 6 Canadian, 7 andAsian 8 societies as well. Additionally, the annual incidence of liver cancer among cir- rhotic patients surpasses the threshold of 1.5% that renders screening and surveillance cost-effective. 9 So why is liver cancer screening so unde- rutilized? There are many barriers that re- duce screening participation. On the patient Patients who should undergo Liver Cancer screening Cirrhosis Hepatitis B, C Alcohol Genetic hemochromatosis Non-alcoholic fatty liver disease (NAFLD) Stage 4 primary biliary cholangitis Alpha-1-antitrypsn Other causes of cirrhosis Without cirrhosis Hepatitis B Source: NCCNGuidelines Version 2.2022