Race not rural residency is predictive of surgical treatment for hepatocellular carcinoma: Analysis of the Texas Cancer Registry

Patterns of care and outcomes for hepatocellular carcinoma and pancreatic cancer based on rurality of patient's residence in a rural midwestern state

BACKGROUND

Although advancements in surgical planning and multidisciplinary care have improved the survival of patients with hepatopancreatic cancers in recent years, the impact of the rurality of patient residence on care received and survival is not well known. We aimed to assess the association between the rurality of a patient's residence and cancer-specific survival outcomes among patients with hepatocellular carcinoma (HCC) and pancreatic cancer (PC) in Iowa, hypothesizing that patients in rural areas would experience lower survival.

METHODS

Adult patients diagnosed with HCC or PC between 2010 and 2020 were identified using the Iowa Cancer Registry. Chi-square tests were used to compare categorical variables by rural/urban status. Logistic regression was used to examine factors associated with receiving surgery. Multivariable-adjusted Cox proportional hazards regression was used to determine associations with cancer-specific mortality.

RESULTS

Of 1877 patients with HCC, 58%, 27%, and 16% resided in metropolitan, micropolitan, and rural areas, respectively. Approximately 70% of patients in rural areas traveled ≥50 miles for definitive care. Additionally, those residing in rural areas had the highest proportion of patients receiving definitive care at non-Commission on Cancer (CoC) centers (12.6% metro vs 14% micro vs 22.2% rural, P < .001). In a multivariable-adjusted analysis of patients with stage I to III disease, definitive care at a non-CoC center was independently associated with lower odds of surgery (odds ratio [OR] = 0.23; 95% CI, 0.12-0.45; P < .0001) and higher mortality risk (OR = 1.39; 95% CI, 1.07-1.79; P = .01), though rural residence was not. For PC, 5465 patients were diagnosed, and 51%, 28%, and 20% resided in metropolitan, micropolitan, and rural areas, respectively. Similar to HCC, although rural residence was neither associated with odds of surgery nor with mortality risk, receiving definitive care at non-CoC accredited centers was associated with significantly lower odds of receiving surgery (OR = 0.17; 95% CI, 0.11-0.26; P < .0001) and higher mortality risk (OR = 1.48; 95% CI, 1.23-1.77; P < .0001).

CONCLUSION

Rural residents with hepatopancreatic cancer have the highest proportion of patients receiving definitive care at non-CoC centers, which is associated with lower odds of receiving surgery and higher odds of mortality. This highlights the importance of standardizing complex cancer care and the need to foster collaboration between specialized and non-specialized centers.

Race norming and biases in surgical oncology care

Disparities in surgical oncology care may be due to race/ethnicity. Race norming, defined as the adjustment of medical assessments based on an individual's race/ethnicity, and implicit bias are specifically explored in this focused systematic review. We aim to examine how race norming and bias impact oncologic care and postsurgical outcomes, particularly in Black patient populations, while providing potential strategies to improve equitable and inclusive care.

A Longitudinal Analysis of Mortality Related to Chronic Viral Hepatitis and Hepatocellular Carcinoma in the United States

(1) Background: Hepatocellular carcinoma (HCC) contributes to the significant burden of cancer mortality in the United States (US). Despite highly efficacious antivirals, chronic viral hepatitis (CVH) remains an important cause of HCC. With advancements in therapeutic modalities, along with the aging of the population, we aimed to assess the contribution of CVH in HCC-related mortality in the US between 1999-2020. (2) Methods: We queried all deaths related to CVH and HCC in the multiple-causes-of-death files from the CDC Wide-ranging Online Data for Epidemiologic Research (WONDER) database between 1999-2020. Using the direct method of standardization, we adjusted all mortality information for age and compared the age-adjusted mortality rates (AAMRs) across demographic populations and by percentile rankings of social vulnerability. Temporal shifts in mortality were quantified using log-linear regression models. (3) Results: A total of 35,030 deaths were identified between 1999-2020. The overall crude mortality increased from 0.27 in 1999 to 8.32 in 2016, followed by a slight reduction to 7.04 in 2020. The cumulative AAMR during the study period was 4.43 (95% CI, 4.39-4.48). Males (AAMR 7.70) had higher mortality rates compared to females (AAMR 1.44). Mortality was higher among Hispanic populations (AAMR 6.72) compared to non-Hispanic populations (AAMR 4.18). Higher mortality was observed in US counties categorized as the most socially vulnerable (AAMR 5.20) compared to counties that are the least socially vulnerable (AAMR 2.53), with social vulnerability accounting for 2.67 excess deaths per 1,000,000 person-years. (4) Conclusions: Our epidemiological analysis revealed an overall increase in CVH-related HCC mortality between 1999-2008, followed by a stagnation period until 2020. CVH-related HCC mortality disproportionately affected males, Hispanic populations, and Black/African American populations, Western US regions, and socially vulnerable counties. These insights can help aid in the development of strategies to target vulnerable patients, focus on preventive efforts, and allocate resources to decrease HCC-related mortality.

Importance of Diversity, Equity, and Inclusion in the Hepatopancreatobiliary Workforce

Diversity is a catalyst for progress that prevents institutional stagnation and, by extension, averts descent to mediocrity. This review focuses on the available data concerning hepatopancreatobiliary (HPB) surgical workforce demographics and identifies evidence-based strategies that may enhance justice, equity, diversity, and inclusion for HPB surgeons and their patients. We report that the current United States HPB surgical workforce does not reflect the population it serves. We review data describing disparity-perpetuating hurdles confronting physicians from minority groups underrepresented in medicine at each stage of training. We further examine evidence showing widespread racial and socioeconomic disparities in HPB surgical care and review the effects of workforce diversity and physician-patient demographic concordance on healthcare outcomes. Evidence-based mitigators of structural racism and segregation are reviewed, including tailored interventions that can address social determinants of health toward the achievement of true excellence in HPB surgical care. Lastly, select evidence-based data driving surgical workforce solutions are reviewed, including intentional compensation plans, mentorship, and sponsorship.

Association Between Urbanicity and Outcomes Among Patients with Spinal Cord Ependymomas in the United States

BACKGROUND

Spinal cord ependymomas (SCEs) represent the most common intramedullary spinal cord tumors among adults. Research shows that access to neurosurgical care and patient outcomes can be greatly influenced by patient location. This study investigates the association between the outcomes of patients with SCE in metropolitan and nonmetropolitan areas.

METHODS

Cases of SCE between 2004 and 2019 were identified within the Central Brain Tumor Registry of the United States, a combined dataset including the Centers for Disease Control and Prevention's National Program of Cancer Registries and National Cancer Institute's Surveillance, Epidemiology, and End Results Program data. Multivariable logistic regression models were constructed to evaluate the association between urbanicity and SCE treatment, adjusted for age at diagnosis, sex, race and ethnicity. Survival data was available from 42 National Program of Cancer Registries (excluding Kansas and Minnesota, for which county data are unavailable), and Cox proportional hazard models were used to understand the effect of surgical treatment, county urbanicity, age at diagnosis, and the interaction effect between age at diagnosis and surgery, on the survival time of patients.

RESULTS

Overall, 7577 patients were identified, with 6454 (85%) residing in metropolitan and 1223 (15%) in nonmetropolitan counties. Metropolitan and nonmetropolitan counties had different age, sex, and race/ethnicity compositions; however, demographics were not associated with differences in the type of surgery received when stratified by urbanicity. Irrespective of metropolitan status, individuals who were American Indian/Alaska Native non-Hispanic and Hispanic (all races) were associated with reduced odds of receiving surgery. Individuals who were Black non-Hispanic and Hispanic were associated with increased odds of receiving comprehensive treatment. Diagnosis of SCE at later ages was linked with elevated mortality (hazard ratio = 4.85, P < 0.001). Gross total resection was associated with reduced risk of death (hazard ratio = 0.37, P = 0.004), and age did not interact with gross total resection to influence risk of death.

CONCLUSIONS

The relationship between patients' residential location and access to neurosurgical care is critical to ensuring equitable distribution of care. This study represents an important step in delineating areas of existing disparities.

Recent Improvements in Racial Disparity in the Treatment of Hepatocellular Carcinoma: How Times Have Changed

BACKGROUND

Race has been shown to impact receipt of and outcomes following hepatobiliary surgery. We sought to determine if racial disparities in the management of hepatocellular carcinoma persist.

METHODS

Information on patients with hepatocellular carcinoma diagnosed between 2012 and 2016 was obtained from the Surveillance, Epidemiology, and End Results database. The sample was stratified by race/ethnicity, and associations between tumor characteristics, treatment, and survival were assessed.

RESULTS

Of 33,672 patients, the mean age was 65 years, and 77% were male. By race, 17,150 (51%) were white, 4755 (14%) black, 6850 (20%) Hispanic, and 4917 (15%) Asian. When assessing the likelihood of treatment versus no treatment for tumors less than 5 cm, no difference was observed between whites and blacks in any year, but Hispanics were less likely than whites to receive treatment in most years. Asians were more likely to receive treatment every year. When assessing the likelihood of transplant versus surgical resection, blacks were less likely than whites to undergo transplant in all years except 2016. Hispanics were equally likely, while Asians were less likely to undergo transplant in all years. For years 2012 to 2016 collectively, Asians had better 5-year survival rates than other races after undergoing ablation and resection. No difference in the risk of death was observed among blacks, whites, or Hispanics after undergoing ablation, resection, or transplant.

CONCLUSION

Racial disparities for blacks and Hispanics have improved. Although Asians were less likely to undergo transplant, they had better survival after undergoing resection or ablation.

Presentation, Management, and Outcomes Across the Rural-Urban Continuum for Hepatocellular Carcinoma

Background

Hepatocellular carcinoma is 1 of few cancers with rising incidence and mortality in the United States. Little is known about disease presentation and outcomes across the rural-urban continuum.

Methods

Using the population-based Surveillance, Epidemiology, and End Results registry, we identified adults with incident hepatocellular carcinoma between 2000 and 2016. Urban, suburban, and rural residence at time of cancer diagnosis were categorized by the Census Bureau’s percent of the population living in nonurban areas. We examined association between place of residence and overall survival. Secondary outcomes were late tumor stage and receipt of therapy.

Results

Of 83 368 incident cases of hepatocellular carcinoma, 75.8%, 20.4%, and 3.8% lived in urban, suburban, and rural communities, respectively. Median survival was 7 months (interquartile range = 2-24). All stage and stage-specific survival differed by place of residence, except for distant stage. In adjusted models, rural and suburban residents had a respective 1.09-fold (95% confidence interval [CI] = 1.04 to 1.14; P < .001) and 1.08-fold (95% CI = 1.05 to 1.10; P < .001) increased hazard of overall mortality as compared with urban residents. Furthermore, rural and suburban residents had 18% (odds ratio [OR] = 1.18, 95% CI = 1.10 to 1.27; P < .001) and 5% (OR = 1.05, 95% CI = 1.02 to 1.09; P = .003) higher odds of diagnosis at late stage and were 12% (OR = 0.88, 95% CI = 0.80 to 0.94; P < .001) and 8% (OR = 0.92, 95% CI = 0.88 to 0.95; P < .001) less likely to receive treatment, respectively, compared with urban residents.

Conclusions

Residence in a suburban and rural community at time of diagnosis was independently associated with worse indicators across the cancer continuum for liver cancer. Further research is needed to elucidate the primary drivers of these rural-urban disparities.

Older Patients With Hepatocellular Carcinoma Are Less Knowledgeable About Survivorship Issues: Outcomes from a Survey-based Study

BACKGROUND AND AIMS

As the incidence and survival for hepatocellular carcinoma increase, the number of patients having been treated for liver cancer would be expected to increase as well. Little is known about the experience of the survivors of hepatocellular carcinoma.

METHODS

The authors conducted a 3-tool survey of hepatocellular carcinoma survivors at a large, academic, and tertiary referral medical center to assess potential areas of disparities in the survivorship experience. The instruments aimed to assess knowledge of survivorship issues (Perceived Efficacy in Patient-Physician Interactions Questionnaire-1), preparedness for the survivorship experience (Perceived Efficacy in Patient-Physician Interactions Questionnaire-2), and self-efficacy in procuring medical information while navigating the patient-provider relationship (Perceived Efficacy in Patient-Physician Interactions Questionnaire). The authors compared mean test scores for each instrument, with higher scores indicating a more positive response, by patient characteristics and used s linear regression model to examine associations between sociodemographics and survey scores.

RESULTS

In total, 110 patients took at least 1 survey. In the multiple linear regression model, the authors found that for every increase in patient age by 10 years, knowledge of survivorship issues decreased by a total score of 1.3 (P=0.02). In this model, the authors found no significant differences between male and female respondents, English and non-English speakers, and liver transplant recipients and nonliver transplant recipients. Survivors who had completed a 4-year college degree had significantly higher knowledge of survivorship issues than those who did not use χ testing, but this finding did not maintain significance in the multiple linear regression model.

CONCLUSIONS

In a population of 110 ethnically diverse hepatocellular carcinoma survivors, the authors found older patients had gaps in knowledge of survivorship issues. Particular attention should be paid to older populations during liver cancer treatment.

Racial and Sex Disparities in Hepatocellular Carcinoma in the USA

PURPOSE OF REVIEW

In this review, we aim to provide a summary of the current literature on race and gender disparities in hepatocellular carcinoma (HCC) incidence, stage at diagnosis, treatment and prognosis in the United States.

RECENT FINDINGS

HCC incidence rates are rising in the U.S. in all racial/ethnic groups except for Asian/Pacific Islanders, with disproportionate rises and the highest rates among Hispanics compared to Blacks and non-Hispanic whites. There are striking sex disparities in HCC incidence and mortality; however, with the shifting epidemiology of HCC risk factors in the U.S, there is recent evidence that HCC is trending towards less male predominance, particularly among younger birth cohorts. Despite significant advances in HCC treatment over the past decade, disparities in HCC surveillance and treatment receipt persist among racial and ethnic minorities and the socioeconomically disadvantaged. Black patients continue to experience worse survival outcomes than non-Black patients with HCC.

SUMMARY

There are significant racial and gender disparities in HCC incidence, treatment, and mortality in the U.S. Though these disparities are well-documented, data are still limited on the specific determinants driving disparities in HCC. To achieve health equity for all patients with HCC, we must advance beyond simply reporting on disparities and begin implementing targeted interventions to eliminate disparities.

Understanding Gaps in the Hepatocellular Carcinoma Cascade of Care: Opportunities to Improve Hepatocellular Carcinoma Outcomes

Hepatocellular carcinoma (HCC) is a leading cause of morbidity and mortality. Existing studies have highlighted significant disparities in HCC outcomes, particularly among vulnerable populations, including ethnic minorities, safety-net populations, underinsured patients, and those with low socioeconomic status and high risk behaviors. The majority of these studies have focused on HCC surveillance. Although HCC surveillance is one of the most important first steps in HCC monitoring and management, it is only one step in the complex HCC cascade of care that evolves from surveillance to diagnosis and tumor staging that leads to access to HCC therapies. In this current review, we explore the disparities that exist along this complex HCC cascade of care and further highlight potential interventions that have been implemented to improve HCC outcomes. These interventions focus on patient, provider, and system level factors and provide a potential framework for health systems to implement quality improvement initiatives to improve HCC monitoring and management.

Disparities in Hepatocellular Carcinoma Surveillance: Dissecting the Roles of Patient, Provider, and Health System Factors

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related deaths worldwide and remains one of the most rapidly rising cancers among the US adults. While overall HCC survival is poor, early diagnosis via timely and consistent implementation of routine HCC surveillance among at-risk individuals leads to earlier tumor stage at diagnosis, which is directly correlated with improved options for potentially curative therapies, translating into improved overall survival. Despite this well-established understanding of the benefits of HCC surveillance, surveillance among cirrhosis patients remains suboptimal in a variety of practice settings. While the exact reasons underlying the unacceptably low rates of routine HCC surveillance are complex, it likely reflects multifactorial contributions at the patient, provider, and health care system levels. Furthermore, these multilevel challenges affect ethnic minorities disproportionately, which is particularly concerning given that ethnic minorities already experience existing barriers in timely access to consistent medical care, and these populations are disproportionately affected by HCC burden in the United States. In this review, we provide an updated evaluation of the existing literature on rates of HCC surveillance in the United States. We specifically highlight the existing literature on the impact of patient-specific, provider-specific, and health care system-specific factors in contributing to challenges in effective implementation of HCC surveillance.

One in five hepatocellular carcinoma patients in the United States are Hispanic while less than 40% were eligible for liver transplantation

AIM

To evaluate trends and disparities in hepatocellular carcinoma (HCC) outcomes among Hispanic patients in the United States with a focus on tumor stage at diagnosis.

METHODS

We retrospectively evaluated all Hispanic adults (age > 20) with HCC diagnosed from 2004 to 2014 using United States Surveillance, Epidemiology, and End Results (SEER) cancer registry data. Tumor stage was assessed by SEER-specific staging systems and whether HCC was within Milan criteria at diagnosis. Multivariate logistic regression models evaluated for predictors of HCC within Milan criteria at diagnosis.

RESULTS

Overall, Hispanics accounted for 19.8% of all HCC (73.3% men, 60.9% had Medicare or commercial insurance, 33.5% Medicaid, and 5.6% uninsured). Thirty-eight percent of Hispanic HCC patients were within Milan criteria at diagnosis. With latter time periods, significantly more patients were diagnosed with HCC within Milan criteria, and in 2013-2014, 42.6% had HCC within Milan criteria. On multivariate regression, Hispanic males (OR vs females: 0.76, 95%CI: 0.68-0.83, P < 0.001), Hispanics > 65 years (OR vs age < 50: 0.67, 95%CI: 0.58-0.79, P < 0.001), and uninsured patients (OR vs Medicare/commercial: 0.49, 95%CI: 0.40-0.59, P < 0.001) were significantly less likely to have HCC within Milan criteria at diagnosis.

CONCLUSION

While one in five HCC patients in the United States are of Hispanic ethnicity, only 38% were within Milan criteria at time of diagnosis, and thus over 60% were ineligible for liver transplantation, one of the primary curative options for HCC patients. Improved efforts at HCC screening and surveillance are needed among this group to improve early detection.

Racial disparities in the survival time of patients with hepatocellular carcinoma and intrahepatic cholangiocarcinoma between Chinese patients and patients of other racial groups: A population-based study from 2004 to 2013

The aim of the present study was to investigate the racial disparities in the presentation, treatment and survival time of patients with hepatocellular carcinoma (HCC) or intrahepatic cholangiocarcinoma (ICC) between Chinese and other racial groups from the Surveillance, Epidemiology, and End Results (SEER) database between January 1st 2004, and December 31st 2013. Key covariates, including clinical presentation, treatment and survival time, were recorded and compared, demonstrating the racial differences. Kaplan-Meier analysis and Cox regression models were performed to identify these disparities in survival time. A total of 30,954 patients were identified in the SEER database. Among these, 27,767 (89.7%) had HCC and 3,187 (10.3%) had ICC. In the HCC cohort, Chinese patients had the highest survival time. Compared with the mortality risk of Chinese patients, the mortality risk of Other Asian, non-Hispanic white, Hispanic and African-American patients increased by 16.8, 35.1, 28.3 and 33.3%, respectively. Compared with other groups, Chinese patients were more likely to present with localized stage, and without vascular invasion, adjacent invasion and metastasis. In the ICC cohort, the Chinese group had improved survival time, compared with the other groups following univariate analysis, although no significant differences were observed between Chinese and Other Asian and Hispanic patients following adjusting for contributing factors. Furthermore, there was no significant differences in the presentation between the groups, which differed from the HCC analysis. In conclusion, race/ethnicity was a significant independent prognostic factor in the HCC cohort, whereas it was not significant in the ICC cohort. The synergistic effect of contributing factors, including demographic, socioeconomic, biological and treatment differences, caused the racial disparity observed in primary liver cancer survival time.

Medicaid and Uninsured Hepatocellular Carcinoma Patients Have More Advanced Tumor Stage and Are Less Likely to Receive Treatment

GOALS

To evaluate the impact of insurance status on tumor stage at diagnosis, treatment received, and overall survival among adults with hepatocellular carcinoma (HCC).

BACKGROUND

Insurance status affects access to care, which impacts timely access to cancer screening for early detection and treatment.

STUDY

Using the 2007 to 2012 Surveillance, Epidemiology, and End Results (SEER) database, we retrospectively evaluated US adults with HCC. Insurance status included Medicare/commercial insurance (MC), Medicaid (MA), and no insurance (NI). HCC tumor stage was evaluated using SEER staging system and Milan criteria. HCC treatment and survival were evaluated using multivariate logistic regression and Cox proportional hazards models.

RESULTS

Among 32,388 HCC patients (71.2% MC, 23.9% MA, and 4.9% NI), patients with MA or NI were significantly less likely to have localized tumor stage at time of diagnosis compared with MC [NI vs. MC; odds ratio, 0.41; 95% confidence interval (CI), 0.78-0.92; P<0.001]. MA and NI patients were less likely to receive treatment, and specifically less likely to receive surgical resection or liver transplantation compared with MC patients, even after correcting for tumor stage at diagnosis (odds of surgical resection or liver transplant in NI vs. MC: odds ratio, 0.26; 95% CI, 0.21-0.33; P<0.001). NI patients (hazard ratio, 1.39; 95% CI, 1.29-1.50; P<0.001) had significantly lower survival compared with MC patients.

CONCLUSIONS

Among US adults with HCC, MA, or NI patients had more advanced tumor stage at diagnosis, lower rates treatment, and significantly lower overall survival. Ensuring equal insurance coverage may improve access to care and mitigate some disparities in HCC outcomes.

The Impact of Race on Survival After Hepatocellular Carcinoma in a Diverse American Population

BACKGROUND AND AIMS

Hepatocellular carcinoma (HCC) incidence is increasing at differential rates depending on race. We aimed to identify associations between race and survival after HCC diagnosis in a diverse American population.

METHODS

Using the cancer registry from Sylvester Comprehensive Cancer Center, University of Miami and Jackson Memorial Hospitals, we performed retrospective analysis of 999 patients diagnosed with HCC between 9/24/2004 and 12/19/2014. We identified clinical characteristics by reviewing available electronic medical records. The association between race and survival was analyzed using Cox proportional hazards regression.

RESULTS

Median survival in days was 425 in Blacks, 904.5 in non-Hispanic Whites, 652 in Hispanics, 570 in Asians, and 928 in others, p < 0.01. Blacks and Asians presented at more advanced stages with larger tumors. Although Whites had increased severity of liver disease at diagnosis compared to other races, they had 36% reduced rate of death compared to Blacks, [hazard ratio (HR) 0.64, 95% confidence interval (CI) 0.51-0.8, p < 0.01]. After adjusting for significant covariates, Whites had 22% (HR 0.78, 95% CI 0.61-0.99, p 0.04) reduced risk of death, compared to Blacks. Transplant significantly reduced rate of death; however, only 13.3% of Blacks had liver transplant, compared to 40.1% of Whites, p < 0.01.

CONCLUSIONS

In this diverse sample of patients, survival among Blacks is the shortest after HCC diagnosis. Survival differences reflect a more advanced tumor stage at presentation rather than severity of underlying liver disease precluding treatment. Improving survival in minority populations, in whom HCC incidence is rapidly increasing, requires identification and modification of factors contributing to late-stage presentation.

Factors associated with ethnical disparity in overall survival for patients with hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is an important cause of cancer-related death worldwide. Ethnical disparity in overall survival has been demonstrated for HCC patients in the United States (U.S.). We aimed to evaluate the contributors to this survival disparity. The SEER database was used to identify HCC patients from 2004 to 2012. Kaplan-Meier curves and Cox proportional hazard models were used to evaluate overall survival by ethnicity and the contributors to ethnical survival disparity. A total of 33 062 patients were included: 15 986 Non-Hispanic Whites, 6535 Hispanic Whites, 4842 African Americans, and 5699 Asians. Compared to Non-Hispanic Whites, African Americans had worse survival (HR, 1.18; 95%CI, 1.14-1.23), while Asians had a better survival (HR, 0.85; 95%CI, 0.82-0.89), and Hispanic Whites had a similar survival (HR, 1.01; 95%CI, 0.97-1.05). Multivariate Cox analysis identified that tumor presentation- and treatment-related factors significantly contributed to the ethnical survival disparity. Especially, tumor size was the most important contributor (HR, 1.11; 95%CI, 1.07-1.16). There is no ethnical survival disparity in patients undergoing liver transplantation and sub-analysis of patients within the Milan criteria for liver transplantation demonstrated no significant survival disparity between African Americans and non-Hispanic Whites in transplantation adjustment analysis (HR, 1.23; 95%CI, 1.11-1.35 in non-adjustment analysis to HR, 1.05; 95%CI, 0.95-1.15 after adjustment). Finally, no important contributor to the superior overall survival in Asians was identified. In conclusion, poor tumor presentation at diagnosis, limited benefit from resection and restricted utilization of liver transplantation are important contributors to poorer survival of African Americans with HCC.