Hepatocellular carcinoma surveillance ultrasound
Radiographers at the Worcestershire Acute Hospitals NHS Trust have successfully implemented an ultrasound service for detecting one of the most common types of liver cancer, hepatocellular carcinoma. Joanna Neale and Emily Shell share their experience of setting up the service
By Joanna Neale and Emily Shell, sonographers at Worcestershire Acute NHS Trust
Hepatocellular carcinoma surveillance ultrasound
Radiographers at the Worcestershire Acute Hospitals NHS Trust have successfully implemented an ultrasound service for detecting one of the most common types of liver cancer, hepatocellular carcinoma. Joanna Neale and Emily Shell share their experience of setting up the service
By Joanna Neale and Emily Shell, sonographers at Worcestershire Acute NHS Trust
Hepatocellular carcinoma (HCC) is the most common type of primary liver cancer and is the fastest-rising cause of cancer-related deaths in the UK. Currently, only 20 per cent of liver cancers are detected in stages 1-2 and are generally asymptomatic.
Therefore, early detection significantly improves prognosis and survival rates. This is achieved by utilising ultrasound scanning. Here, we will detail how a successful, robust HCC surveillance programme was implemented within Worcestershire Acute NHS Trust.
Ultrasound screening is used as it is non-invasive, cost-efficient, time-effective, widely available, portable and does not have the associated risks of cross-sectional imaging. Ultrasound can detect liver tumours as small as 1-2cm. However, it has its limitations, and the diagnostic quality can depreciate in patients with a high BMI or a liver with a fibrous echotexture. In these situations, alternative imaging can be suggested for screening and lesion characterisation.
The HCC surveillance programme is recommended for patients with a high risk of developing HCC, particularly those with chronic liver disease, cirrhosis and hepatitis. NICE guidelines published in 2017 state that adults with a high risk of developing HCC are offered six-monthly surveillance ultrasounds.
What we do and how we do it
At the trust, the service was set up with no extra funding but by streamlining in-house resources.
Guidelines recommend that the surveillance scans are performed by a small specialist team, who scan under a dedicated focused surveillance protocol, using a report proforma, to increase consistency across the service.
Historically, screening scans were organised by the medical team, and were often arranged at incorrect intervals. They could be performed by any sonographer or radiologist under the ultrasound abdominal protocol – resulting in irregular screening and a loss of consistency, as techniques and reporting styles differed greatly.
The CRIS (booking) code was changed to USRVL. It’s a great way to separate the lists and ensure patients are being scanned by the surveillance team. It’s perfect for audits too.
We rewrote our patient letters highlighting that this was a focused surveillance scan and not a general abdomen scan.
We educated not just clinical staff but also our small administration team to not be judgemental. Our patients were less likely to attend because of a fear of judgement. Our administration team is sensitive to our patients’ needs.
We have a good working relationship with our referrers, including the clinical nurse specialists. This allows open communication when patients have been removed from the programme or transferred to another hospital. This collaboration also enables us to coordinate any additional support the patient may need.
We contact patients via multiple methods of communication: mail, email, text and telephone calls – whichever the patient prefers.
The surveillance team was also given access to the booking system to create follow-up requests. This reduces the risk of patients being lost in the system, and results in an increase in correct scan intervals and patient preference inclusions.
Focused ultrasound scan
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Focused ultrasound scan
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Issues and how to fix them
HCC surveillance programmes have notoriously high DNA rates. Some DNA’s are unavoidable; however, we put several simple measures in place to improve attendance.
We ask [geographical] patient site and/or time preference and add it to the booking notes. These are easy questions at the end of the examination, but they have had the biggest impact out of all our measures. We offer appointments between 8am and 8pm, at weekends and across the trust sites to give patients flexibility on where and when they can attend.
We have guidelines for when patients cancel multiple appointments. Our patients can have many morbidities, and it is good to remember to be sympathetic to them. However, we also can’t delay other patient care. When a patient on surveillance cancels their appointments multiple times without valid reasons, our administrative team contacts them to schedule a final appointment. If the patient fails to attend this appointment, the request is sent back to the referring physician, who will then determine whether to remove the patient from the programme.
NICE guidelines recommend greater than 60 per cent attend six-monthly surveillance scans. With these simple steps we improved attendance and we are currently meeting 85 per cent.
The team meets regularly to support each other, discuss any issues and plan future projects. Sonography can be isolating, and this not only confirms consistency within the programme, it also checks on staff wellbeing.
Sadly, some patients are not suitable for ultrasound; this can be down to a high BMI or an exceptionally nodular liver. When this occurs, we recommend within the report that the patient has MRI screening instead and advise the referrer they have been removed from the ultrasound pathway.
Issues and how to fix them
HCC surveillance programmes have notoriously high DNA rates. Some DNA’s are unavoidable; however, we put several simple measures in place to improve attendance.
We ask patient site and/or time preference and add it to the booking notes. These are easy questions at the end of the examination, but they have had the biggest impact out of all our measures. We offer appointments between 8am and 8pm, at weekends and across the trust sites to give patients flexibility on where and when they can attend.
We have guidelines for when patients cancel multiple appointments. Our patients can have many morbidities, and it is good to remember to be sympathetic to them. However, we also can’t delay other patient care. When a patient on surveillance cancels their appointments multiple times without valid reasons, our administrative team contacts them to schedule a final appointment. If the patient fails to attend this appointment, the request is sent back to the referring physician, who will then determine whether to remove the patient from the programme.
NICE guidelines recommend greater than 60 per cent attend six-monthly surveillance scans. With these simple steps we improved attendance and we are currently meeting 85 per cent.
The team meets regularly to support each other, discuss any issues and plan future projects. Sonography can be isolating, and this not only confirms consistency within the programme, it also checks on staff wellbeing.
Sadly, some patients are not suitable for ultrasound; this can be down to a high BMI or an exceptionally nodular liver. When this occurs, we recommend within the report that the patient has MRI screening instead and advise the referrer they have been removed from the ultrasound pathway.
Request received from consultant/CNS
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What happens when we find a lesion?
Benign lesions, such as simple hemangiomas or cysts, do not change the patient’s pathway and they will be recalled for their ultrasound surveillance scan in six months.
The report is urgently highlighted to the referrer with recommendations for further imaging. They then request a contrast MRI scan, and then if required a biopsy. Contrast CT can be used if MRI is not suitable. If the lesions are determined to be benign the patient returns for ultrasound follow-ups.
Guidelines suggest recalling the patient between threee and six months for a follow-up ultrasound. Currently, we offer a recall at three months as this allows wriggle room with capacity demands and the patient’s own needs.
However, contrast-enhanced ultrasound (CEUS) can provide rapid essential information. CEUS has been used for diagnostic purposes for years, and yet we are slow to uptake this in HCC surveillance.
CEUS uses intravenous microbubbles to detect and characterise indeterminate lesions. In comparison with MRI, it is quicker to perform, cheaper and has instantaneous results. Research by Auer et al 2019 proved that CEUS had the highest accuracy when diagnosing lesion <1cm over CT and MRI. CEUS can be performed during a routine surveillance scan, improving early detection and reducing patient waiting times. Furthermore, it minimises unnecessary two-week wait referrals if the lesion proves to be benign.
We are hoping to see a rapid uptake of CEUS soon and looking to run a pilot study at Worcestershire Acute NHS Trust.
The work done at Worcestershire Acute NHS Trust demonstrates how a dedicated, resourceful team can overcome challenges to implement a successful, robust HCC surveillance programme, which can be a valuable blueprint for other NHS trusts. The steps taken to educate staff, refine the booking system and create a patient-centered approach has led to substantial improvements in patient attendance rates, surpassing the NICE targets. Through ongoing audits, collaboration and flexibility, the programme has not only met but exceeded its targets, demonstrating that a well-structured surveillance can improve early detection rates.
References:
Auer, T. A., Fischer, T., Marticorena Garcia, S. R., Penzkofer, T., Jung, E.-M., Hamm, B., & Lerchbaumer, M. H. (2020). Value of contrast-enhanced ultrasound (CEUS) in focal liver lesions (FLL) with inconclusive findings on cross-sectional imaging. Hemorheology and Microcirculation, 74(3), 327-339. https://doi.org/10.3233/CH-190718
National Institute for Health and Care Excellence (NICE). (2017). Liver disease: Quality standard (QS152). Retrieved from https://www.nice.org.uk/guidance/qs152
National Institute for Health and Care Excellence (NICE). (2012). SonoVue (sulphur hexafluoride microbubbles) – contrast agent for contrast-enhanced ultrasound imaging of the liver: Diagnostics guidance (DG5). Retrieved from https://www.nice.org.uk/guidance/dg5
NHS England. (2024, June 24). Hepatocellular carcinoma surveillance: Minimum standards. Retrieved November 12, 2024, from https://www.england.nhs.uk/long-read/hepatocellular-carcinoma-surveillance-minimum-standards/
European Association for the Study of the Liver (EASL). EASL Clinical Practice Guidelines: Management of Hepatocellular Carcinoma. Journal of Hepatology. 2018;69(1):182-236.
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