Treatment for hepatocellular carcinoma (HCC) is selected according to an algorithm, and transcatheter arterial chemoembolization (TACE) is one treatment option, particularly for patients with intermediate Barcelona Clinic Liver Cancer stage B HCC (1), in whom it is considered a standard treatment. However, TACE is also associated with physical and psychological pain and may be associated with decreased hepatic reserve. Currently, team-based medicine is useful in various types of treatment, and the usefulness of preoperative visits has been reported even for surgeries performed in operating rooms (2-4).

Patients undergoing TACE, a minimally invasive interventional radiology (IVR) procedure generally performed under conscious conditions, may experience pain, discomfort, and anxiety (5), and the effectiveness of preoperative visits prior to TACE performed in an abdominal angiography room remains unclear. In this study, we aimed to determine whether preoperative visits by radiology nurses to patients scheduled to undergo TACE could contribute to improved patient quality of life (QOL).

The study comprised 70 patients who were scheduled to undergo TACE for HCC [preoperative visit group, n=48; control group (no preoperative visits), n=22]. Scores derived from the Medical Outcomes Study Questionnaire Short Form 36 Health Survey (SF-36) (6) were used for QOL assessment at admission and discharge.

The inclusion criteria comprised: 1) patients scheduled to undergo TACE; 2) patients who had no diseases requiring hospitalization other than HCC; and 3) patients with Eastern Cooperative Oncology Group performance status scores between 0 and 2.

The exclusion criteria comprised: 1) patients with other cancer complications, and 2) those with incomplete SF-36 questionnaires.

QOL evaluation. The SF-36, administered at admission to patients undergoing TACE and then at discharge, was used to assess QOL. The SF-36 includes four items assessing physical QOL, namely, physical function (PF), role-physical (RP), bodily pain (BP), and general health perception (GH); and four items assessing mental health QOL, namely, vitality (VT), social functioning (SF), role-emotional (RE), and mental health (MH) (6).

Between-group comparison of SF-36 score fluctuation values at admission and discharge. Between-group differences in SF-36 score fluctuations at admission and discharge according to factors in the SF-36 were compared.

Ethics approval and informed consent. The study protocols were approved by the Institutional Review Board of Saiseikai Niigata Hospital and conducted in accordance with the principles of the Declaration of Helsinki (as revised in 2013). Prior to participation in this study, written informed consent was obtained from all patients.

Data analysis. Categorical variables are expressed as numbers and percentages, and continuous variables are expressed as medians and interquartile ranges. Differences in the percentages between the groups were analyzed using a chi-square test. Differences in quantitative values were analyzed using a Mann–Whitney U-test. All data analyses were performed using EZR (Saitama Medical Centre, Jichi Medical University, Shimotsuke, Japan), a graphical user interface for R version 3.2.2 software (The R Foundation for Statistical Computing, Vienna, Austria) (7). All p-values were derived from two-tailed tests, with statistical significance set at p<0.05.

The mean age in the preoperative visit group (37 men, 11 women) was 69.75±8.88 years, and that in the control group (14 men, 8 women) was 72.45±9.40 years (p=0.612).

The Child-Pugh (A/B-C) classification was 27/21 in the preoperative visit group and 15/7 in the control group (p=0.118). In the preoperative visit and control groups, background liver disease-related factors were hepatitis B virus (HBV, n=9 and n=3, respectively), hepatitis C virus (HCV, n=7 and n=10, respectively), nonalcoholic steatohepatitis (NASH, n=10 and n=3, respectively), alcohol-associated liver disease (ALC, n=18 and n=5, respectively), and primary biliary cholangitis/autoimmune hepatitis (PBC/AIH, n=4 and n=1, respectively) (p=0.547). No significant differences in first HCC occurrence or HCC recurrence were observed between the groups with (18/30) and without (7/15) preoperative visits, respectively (p=0.790) (Table I).

Overall, the control group had lower SF-36 scores at admission and discharge, with significant decreases in PF (admission, 42.87±14.46; discharge, 34.71±19.70; p=0.023) and MH (admission, 51.32±6.67; discharge, 45.26±11.35; p=0.035). In the preoperative visit group, PF (admission, 42.31±14.23; discharge, 41.54±14.12; p=0.989) and MH (admission, 48.45±10.97; discharge, 49.59±10.05; p=0.399) were maintained and improved (Table II).

In the subgroup analysis, a significant decrease was observed in PF in older patients in the control group (admission 40.89±14.55; discharge, 31.46±19.25; p=0.027) and in MH in patients with recurrent HCC in the control group (admission, 53.79±6.99; discharge, 46.59±9.64; p=0.019) (Table III).

In the preoperative visit group, a decrease in SF was observed in patients with Child-Pugh A classification (admission, 52.96±7.40; discharge, 48.91±11.24; p=0.040) and in patients who had first HCC occurrence (admission, 46.64±11.72; discharge, 39.12±15.55; p=0.050) (Table IV). In a comparative study of SF-36 score changes at admission and discharge, MH was maintained in the preoperative visit group (1.13±9.66) but was significantly decreased in the control group (–6.06±11.90 p=0.026) (Table V). Factor analysis showed a significant decrease in MH with HCC recurrence (admission, 1.34±9.71; discharge, –7.20±9.05; p=0.006) and among older adults (admission, 0.97±6.21; discharge, –4.47±10.16; p=0.041) when comparing the preoperative visit group to the control group (Table VI).

To the best of our knowledge, this is the first study to investigate the effect of preoperative nurse visits on the QOL of patients with HCC scheduled to undergo TACE. We specifically investigated the significance of preoperative visits for BCLC B (intermediate) stage HCC on QOL. Notably, the significance of QOL has been reported in the treatment of various types of cancers (8-14).

A BCLC algorithm has been proposed for the treatment of HCC (1). TACE, the standard treatment in the BCLC B (intermediate) stage, is a part of IVR. Compared with surgical treatment, IVR is noninvasive while providing the same or better therapeutic effects. As such, IVR plays a significant role in improving patient QOL, particularly in those with advanced cancer.

However, with advances in systemic therapy, some patients eligible for TACE are instead administered systemic therapy, which is a more invasive form of therapy. This study was conducted to investigate the effect of invasive TACE procedures on QOL.

In this study, an overall decrease in each SF-36 score was observed pre- and post-treatment in the control group, particularly in relation to PF and MH (p<0.05). Moreover, the control group exhibited a significant decrease in PF among the older adult group and MH in the HCC recurrence group (p<0.05), as well as a decrease in PF/VT in men, VT/SF in the older adult group, and PF in the HCC recurrence group; however, these differences were not significant. The preoperative nursing visit group exhibited a decrease in SF scores only in the first HCC occurrence/Child-Pugh A classification group pre- and post-treatment.

In the control group, QOL scores decreased overall, and there was a significant decrease in PF and MH scores (p<0.05). This finding was more pronounced in the older adults and those with HCC recurrence. Furthermore, the difference in scores between the groups was significantly lower in the MH group than in the PF/MH group, and this tendency was more pronounced in the older adult/HCC recurrence group.

A preoperative visit for the purpose of preoperative orientation provides an opportunity to obtain an overview of the patient and information necessary for nursing care in the IVR room. A preoperative visit has an important role in IVR nursing, such as providing patient information (15). This type of visit was introduced to alleviate preoperative anxiety in patients undergoing IVR and to share information in relation to medical care. The preoperative visit’s purpose was intended to reduce patient anxiety and relieve tension through addressing as many related factors as possible, and to check for physical and mental risk factors involved during treatment so that the TACE procedure could be performed safely and with patient peace of mind. Meanwhile, the evaluation of TACE treatment efficacy and the development of more effective TACE methods have recently advanced (16,17). The preoperative visit was also used to identify various anxieties that the patients may have had in relation to the IVR treatment, help them visualize the preoperative-to-postoperative process, and promote mental and physical preparation for IVR treatment.

Study limitations. The sample size was relatively small, and the study was retrospective in design. Further multicenter, prospective studies focusing on QOL are needed. Furthermore, there were several issues in relation to the preoperative visits, namely, time constraints given the clinical load on medical staff, who may not have had sufficient time to comprehensively undertake these preoperative visits. This may have led to inadequate responses to patient questions and concerns. Furthermore, a one-size-fits-all approach may lack individualization based on each patient's background and specific needs.

TACE is an effective treatment for HCC, but its effect on QOL varies between patients. Treatment and side-effects must be appropriately managed, and patients should receive support in maintaining and improving their QOL. Appropriately timed preoperative visits, regular follow-up, and support systems are likely to contribute to improved patient QOL.

The Authors have no conflicts of interest to declare in relation to this study.

Conceptualization: Toru Ishikawa; Data Curation: Toru Ishikawa, Atsuko Suzuki, Hiromi Yamamoto, Nao Kobayashi, Eriko Nakagawa; Formal Analysis: Toru Ishikawa; Investigation: Toru Ishikawa, Atsuko Suzuki, Hiromi Yamamoto, Narumi Arita, Yusuke Matsuhashi, Nao Kobayashi, Eriko Nakagawa, Nanako Terai, Asami Hoshii, Terasu Honma; Methodology: Toru Ishikawa; Project Administration: Toru Ishikawa; Resources: Toru Ishikawa; Software: Toru Ishikawa; Visualization: Toru Ishikawa; Writing – Original Draft: Toru Ishikawa; Writing – Review & Editing: Toru Ishikawa, Atsuko Suzuki, Hiromi Yamamoto, Narumi Arita, Yusuke Matsuhashi, Nao Kobayashi, Eriko Nakagawa, Nanako Terai, Asami Hoshii, Terasu Honma.

The Authors would like to thank Editage (www.editage.com) for English language editing.

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