Julie An, MD, radiology resident at the University of California, San Diego, has been awarded the Strategic Radiology-RSNA Research Seed Grant. Dr. An will use the $34,000 grant to help fund a prospective, randomized controlled trial to investigate the use of electronic alerts to improve compliance with imaging-based hepatocellular carcinoma (HCC) surveillance in at-risk patients.

A major source of morbidity and mortality internationally, HCC is treatable if caught early. Guidelines recommend ultrasound surveillance every six months in patients with cirrhosis or chronic hepatitis, considered at the highest risk of developing HCC. Despite the effectiveness of surveillance in improving survival, many at-risk patients are not undergoing surveillance or surveilled at appropriate intervals.  

Strategic Radiology (SR) member practices committed to funding an RSNA Research & Education Foundation named grant of $800,000 in 2012 and anticipates reaching that goal this year. Achieving that goal will enable SR to award a seed grant to a deserving investigator every year for the next 18 years.

Dr. An hopes to build on what she learns to improve other imaging-based cancer surveillance projects. She agreed to share some insights about her motivation, objectives, and ambition as she launches a promising career in academic radiology.

Strategic Radiology: Was there a precipitating event during your residency that inspired your subject of inquiry?

Dr An: This radiology-led initiative will hopefully lead to meaningful changes for many patients. When I was an intern, I served as a primary care physician for many patients who were in need of imaging exams. During this time, I saw just how difficult it was as the primary care doctors to manage the competing issues for their patients. This led to some patients not getting their recommended screening/surveillance exams such as liver ultrasounds, DEXA scans, and mammography—or getting them at delayed intervals.

The vast array of imaging exams can be difficult to keep track of for each patient, especially for patients with many imaging needs and tests that should be ordered in regular intervals. With today’s technology, we may be able to automate reminders to our clinicians and help them in ordering the most appropriate exams for their patients. As radiologists, we can do our part and take ownership in resolving certain barriers which specifically relate to our scope of practice. 

Strategic Radiology: How did you choose this particular disease to begin with?

Dr. An: We chose HCC surveillance because it has been a cancer with historically low screening/surveillance rate, and many patients in our community are at increased risks. In the U.S., less than 20% of eligible patients undergo regular surveillance prior to HCC diagnosis. Patients diagnosed with HCC who adhere to 6-month interval surveillance have significant reduction in mortality compared to those with delayed or no surveillance.

We also have a fantastic working relationship with our Hepatology and Primary Care colleagues who are onboard with our project. Their support made it feasible to carry out this system-wide initiative. Lastly, my mentors Drs. Claude Sirlin and Kathryn Fowler are internationally known leaders in liver imaging. They helped develop LI-RADS and are just an incredible wealth of knowledge on liver disease and liver imaging. Their passion for helping improve the care of patients and their teachings on HCC surveillance is what ultimately helped me select this topic.

Strategic Radiology: Your project to improve follow-up compliance for HCC patients has a strong IT component. Do you have a special interest in imaging informatics and if so, how did that evolve? 

Dr. An: My interest in imaging information has increased with my time in training and during my work on this project. Because of the opportunities this project has allowed, I have been able to forge collaborations with informaticists at my institution who have helped me gain a better understanding of the vast health IT infrastructure at UCSD. I’m still quite early in my career and training, but when time allows, I will look to pursue more specific training in imaging and health-care IT. 

Strategic Radiology: Who else do you expect to involve in your project?

Dr. An: Our team is comprised of many talented individuals:

• Amy Sitapati, MD, Professor of Medicine, Department of Internal Medicine and Primary Care, Chief Medical Information Officer, Director of Population Health, University of California, San Diego
• Michael Kalichman, PhD, Adjunct Professor, Department of Psychiatry, Director of Research Ethics Program, University of California, San Diego
• Rohit Loomba, MD, Professor of Medicine, Department of Gastroenterology and Hepatology, Division of Epidemiology, Director of the Nonalcoholic Fatty Liver Disease (NAFLD) Translational Research Unit, University of California, San Diego 
• Paul Murphy, MD, Assistant Professor of Radiology, Body Imaging Section, University of California, San Diego
• Alexander Norbash, MD, Chair and Professor of Radiology, Interventional Neuroradiology Section, University of California, San Diego
• Ruth Carlos, MD, Professor of Radiology, Department of Radiology, University of Michigan
• Soudabeh Fazeli Dehkordy, MD, MPH, Radiology Resident, University of California, San Diego
• Yuko Kono, MD, PhD, Professor of Medicine and Radiology, Department of Gastroenterology and Hepatology, Department of Radiology, University of California, San Diego
• Kathryn Fowler, MD, Professor of Radiology, Department of Radiology, University of California, San Diego

Strategic Radiology: Do you anticipate further work in this area as you begin your career in academic radiology?

Dr An: Automated alerts may be a resource-efficient method and if successful, future EMR based approaches could be applied to patients as well. Successful completion of this pilot study will allow exploration of whether this framework can be expanded to allow patient alerts and if it might be applicable to other radiology surveillance scenarios, or if an alternative framework is needed.

My ultimate goal is to become a diagnostic radiologist and clinician-scientist whose work leads to policy and practice change that can improve the health of our population. As health care shifts its focus from quantity to quality and as technology continues to bring tremendous change, our specialty has an opportunity to expand and demonstrate our value— in cancer imaging and beyond.