1
|
Cheo FY, Lim CHF, Chan KS, Shelat VG. The impact of waiting time and delayed treatment on the outcomes of patients with hepatocellular carcinoma: A systematic review and meta-analysis. Ann Hepatobiliary Pancreat Surg 2024; 28:1-13. [PMID: 38092430 PMCID: PMC10896687 DOI: 10.14701/ahbps.23-090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/27/2023] [Accepted: 08/30/2023] [Indexed: 02/06/2024] Open
Abstract
Hepatocellular carcinoma (HCC) is the sixth most diagnosed cancer worldwide. Healthcare resource constraints may predispose treatment delays. We aim to review existing literature on whether delayed treatment results in worse outcomes in HCC. PubMed, Embase, The Cochrane Library, and Scopus were systematically searched from inception till December 2022. Primary outcomes were overall survival (OS) and disease-free survival (DFS). Secondary outcomes included post-treatment mortality, readmission rates, and complications. Fourteen studies with a total of 135,389 patients (delayed n = 25,516, no delay n = 109,873) were included. Age, incidence of male patients, Child-Pugh B cirrhosis, and Barcelona Clinic Liver Cancer Stage 0/A HCC were comparable between delayed and no delay groups. Tumor size was significantly smaller in delayed versus no delay group (mean difference, -0.70 cm; 95% confidence interval [CI]: -1.14, 0.26; p = 0.002). More patients received radiofrequency ablation in delayed versus no delay group (OR, 1.22; 95% CI: 1.16, 1.27; p < 0.0001). OS was comparable between delayed and no delay in HCC treatment (hazard ratio [HR], 1.13; 95% CI: 0.99, 1.29; p = 0.07). Comparable DFS between delayed and no delay groups (HR, 0.99; 95% CI: 0.75, 1.30; p = 0.95) was observed. Subgroup analysis of studies that defined treatment delay as > 90 days showed comparable OS in the delayed group (HR, 1.04; 95% CI: 0.93, 1.16; p = 0.51). OS and DFS for delayed treatment were non-inferior compared to no delay, but might be due to better tumor biology/smaller tumor size in the delayed group.
Collapse
Affiliation(s)
- Feng Yi Cheo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Kai Siang Chan
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Vishal Girishchandra Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| |
Collapse
|
2
|
Stanneart J, Nunez KG, Sandow T, Gimenez J, Fort D, Hibino M, Cohen AJ, Thevenot PT. Imaging Delay Following Liver-Directed Therapy Increases Progression Risk in Early- to Intermediate-Stage Hepatocellular Carcinoma. Cancers (Basel) 2024; 16:212. [PMID: 38201639 PMCID: PMC10777927 DOI: 10.3390/cancers16010212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/19/2023] [Accepted: 12/27/2023] [Indexed: 01/12/2024] Open
Abstract
Hepatocellular carcinoma (HCC) remains one of the leading causes of cancer-related deaths in the world. Patients with early-stage HCC are treated with liver-directed therapies to bridge or downstage for liver transplantation (LT). In this study, the impact of HCC care delay on HCC progression among early-stage patients was investigated. Early-stage HCC patients undergoing their first cycle of liver-directed therapy (LDT) for bridge/downstaging to LT between 04/2016 and 04/2022 were retrospectively analyzed. Baseline variables were analyzed for risk of disease progression and time to progression (TTP). HCC care delay was determined by the number of rescheduled appointments related to HCC care. The study cohort consisted of 316 patients who received first-cycle LDT. The HCC care no-show rate was associated with TTP (p = 0.004), while the overall no-show rate was not (p = 0.242). The HCC care no-show rate and HCC care delay were further expanded as no-show rates and rescheduled appointments for imaging, laboratory, and office visits, respectively. More than 60% of patients experienced HCC care delay for imaging and laboratory appointments compared to just 8% for office visits. Multivariate analysis revealed that HCC-specific no-show rates and HCC care delay for imaging (p < 0.001) were both independently associated with TTP, highlighting the importance of minimizing delays in early-stage HCC imaging surveillance to reduce disease progression risk.
Collapse
Affiliation(s)
- Jordin Stanneart
- University of Queensland Medical School, Brisbane, QLD 4072, Australia;
| | - Kelley G. Nunez
- Institute of Translational Research, Ochsner Health System, New Orleans, LA 70121, USA; (K.G.N.); (M.H.)
| | - Tyler Sandow
- Interventional Radiology, Ochsner Health System, New Orleans, LA 70121, USA; (T.S.); (J.G.)
| | - Juan Gimenez
- Interventional Radiology, Ochsner Health System, New Orleans, LA 70121, USA; (T.S.); (J.G.)
| | - Daniel Fort
- Center for Applied Health Services Research, Ochsner Health System, New Orleans, LA 70121, USA;
| | - Mina Hibino
- Institute of Translational Research, Ochsner Health System, New Orleans, LA 70121, USA; (K.G.N.); (M.H.)
| | - Ari J. Cohen
- Multi-Organ Transplant Institute, Ochsner Health System, New Orleans, LA 70121, USA;
- Faculty of Medicine, University of Queensland, Brisbane, QLD 4072, Australia
| | - Paul T. Thevenot
- Institute of Translational Research, Ochsner Health System, New Orleans, LA 70121, USA; (K.G.N.); (M.H.)
| |
Collapse
|
3
|
Sliwinski S, Werneburg E, Faqar-Uz-Zaman SF, Detemble C, Dreilich J, Mohr L, Zmuc D, Beyer K, Bechstein WO, Herrle F, Malkomes P, Reissfelder C, Ritz JP, Vilz T, Fleckenstein J, Schnitzbauer AA. A toolbox for a structured risk-based prehabilitation program in major surgical oncology. Front Surg 2023; 10:1186971. [PMID: 37435472 PMCID: PMC10332323 DOI: 10.3389/fsurg.2023.1186971] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 04/17/2023] [Indexed: 07/13/2023] Open
Abstract
Prehabilitation is a multimodal concept to improve functional capability prior to surgery, so that the patients' resilience is strengthened to withstand any peri- and postoperative comorbidity. It covers physical activities, nutrition, and psychosocial wellbeing. The literature is heterogeneous in outcomes and definitions. In this scoping review, class 1 and 2 evidence was included to identify seven main aspects of prehabilitation for the treatment pathway: (i) risk assessment, (ii) FITT (frequency, interventions, time, type of exercise) principles of prehabilitation exercise, (iii) outcome measures, (iv) nutrition, (v) patient blood management, (vi) mental wellbeing, and (vii) economic potential. Recommendations include the risk of tumor progression due to delay of surgery. Patients undergoing prehabilitation should perceive risk assessment by structured, quantifiable, and validated tools like Risk Analysis Index, Charlson Comorbidity Index (CCI), American Society of Anesthesiology Score, or Eastern Co-operative Oncology Group scoring. Assessments should be repeated to quantify its effects. The most common types of exercise include breathing exercises and moderate- to high-intensity interval protocols. The program should have a duration of 3-6 weeks with 3-4 exercises per week that take 30-60 min. The 6-Minute Walking Testing is a valid and resource-saving tool to assess changes in aerobic capacity. Long-term assessment should include standardized outcome measurements (overall survival, 90-day survival, Dindo-Clavien/CCI®) to monitor the potential of up to 50% less morbidity. Finally, individual cost-revenue assessment can help assess health economics, confirming the hypothetic saving of $8 for treatment for $1 spent for prehabilitation. These recommendations should serve as a toolbox to generate hypotheses, discussion, and systematic approaches to develop clinical prehabilitation standards.
Collapse
Affiliation(s)
- Svenja Sliwinski
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Elisabeth Werneburg
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Sara Fatima Faqar-Uz-Zaman
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Charlotte Detemble
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Julia Dreilich
- Institute of Sports Medicine, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Lisa Mohr
- Institute of Sports Medicine, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Dora Zmuc
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
- Institute of Sports Medicine, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Katharina Beyer
- Department of General, Visceral and Vascular Surgery, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Berlin, Germany
- German Association for General and Visceral Surgery (DGAV), Surgical Work Force for Perioperative Medicine, Berlin, Germany
| | - Wolf O. Bechstein
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Florian Herrle
- German Association for General and Visceral Surgery (DGAV), Surgical Work Force for Perioperative Medicine, Berlin, Germany
- Romed Klinik Prien am Chiemsee, Klinik für Allgemein- und Viszeralchirurgie, Prien am Chiemsee, Germany
| | - Patrizia Malkomes
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Christoph Reissfelder
- German Association for General and Visceral Surgery (DGAV), Surgical Work Force for Perioperative Medicine, Berlin, Germany
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Joerg P. Ritz
- German Association for General and Visceral Surgery (DGAV), Surgical Work Force for Perioperative Medicine, Berlin, Germany
- Helios Clinics Schwerin, Department for General and Visceral Surgery, Schwerin, Germany
| | - Tim Vilz
- German Association for General and Visceral Surgery (DGAV), Surgical Work Force for Perioperative Medicine, Berlin, Germany
- Department of General, Visceral, Thoracic, and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Johannes Fleckenstein
- Institute of Sports Medicine, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
- Department of Pain Medicine, Hospital Landsberg am Lech, Landsberg am Lech, Germany
| | - Andreas A. Schnitzbauer
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital Frankfurt, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
- German Association for General and Visceral Surgery (DGAV), Surgical Work Force for Perioperative Medicine, Berlin, Germany
| |
Collapse
|
4
|
Schneider C, Bogatu D, Leahy J, Zen Y, Ross P, Sarker D, Suddle A, Agarwal K, Srinivasan P, Prachalias AA, Heaton N, Menon K. Predictors of recurrence following laparoscopic minor hepatectomy for hepatocellular carcinoma in the UK. Surg Oncol 2023; 49:101965. [PMID: 37348195 DOI: 10.1016/j.suronc.2023.101965] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 05/10/2023] [Accepted: 06/07/2023] [Indexed: 06/24/2023]
Abstract
AIMS Minor hepatectomy, which is increasingly carried out laparoscopically (LLR), is a cornerstone of curative treatment for hepatocellular carcinoma (HCC). The majority of relevant publications however originate from regions with endemic viral hepatitis. Although the incidence of HCC in the UK is increasing, little is known about outcomes following LLR. METHODS Consecutive patients undergoing minor (involving ≤2 segments) LLR or open resection (OLR) at our institute between 2014 and 2021 were compared. Selection from a plethora of factors potentially impacting on overall (OS) and disease free survival (DFS) was optimised with Lasso regression. To enable analysis of patients having repeat resection, multivariate frailty modelling was utilised to calculate hazard ratios (HR). RESULTS The analysis of 111 liver resections included 55 LLR and 56 OLR. LLR was associated with a shorter hospital stay (5 ± 2 vs. 7 ± 2 days; p < 0.001) and a lower comprehensive complication index (4.43 vs. 9.96; p = 0.006). Mean OS (52.3 ± 2.3 vs. 49.9 ± 3.0 months) and DFS (33.9 ± 3.4 vs. 36.5 ± 3.6 months; p = 0.59) were comparable between LLR and OLR, respectively (median not reached). Presence of mixed cholangiocarcinoma/HCC, satellite lesions and AFP level predicted OS and DFS. In addition tumour size was predictive of DFS. CONCLUSIONS In the studied population minor LLR was associated with shorter hospital stay and fewer complications while offering non-inferior long-term outcomes. A number of predictors for disease free survival have been elucidated that may aid in identifying patients with a high risk of disease recurrence and need for further treatment.
Collapse
Affiliation(s)
- C Schneider
- Department of Hepatopancreatico-biliary Surgery, King's College Hospital, London, United Kingdom
| | - D Bogatu
- Department of Hepatopancreatico-biliary Surgery, King's College Hospital, London, United Kingdom
| | - J Leahy
- Department of Hepatopancreatico-biliary Surgery, King's College Hospital, London, United Kingdom
| | - Y Zen
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - P Ross
- Department of Oncology, Guy's and St Thomas' NHS Foundation Trust, United Kingdom
| | - D Sarker
- Department of Oncology, Guy's and St Thomas' NHS Foundation Trust, United Kingdom
| | - A Suddle
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - K Agarwal
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - P Srinivasan
- Department of Hepatopancreatico-biliary Surgery, King's College Hospital, London, United Kingdom
| | - A A Prachalias
- Department of Hepatopancreatico-biliary Surgery, King's College Hospital, London, United Kingdom
| | - N Heaton
- Department of Hepatopancreatico-biliary Surgery, King's College Hospital, London, United Kingdom
| | - K Menon
- Department of Hepatopancreatico-biliary Surgery, King's College Hospital, London, United Kingdom.
| |
Collapse
|
5
|
Moten AS, Dickson PV, Deneve JL, Shibata D, Stanfill AG, Glazer ES. Impact of Social Determinants of Health on Outcomes Following Resection for Hepatocellular Carcinoma. Ann Surg Oncol 2023; 30:738-747. [PMID: 36319871 DOI: 10.1245/s10434-022-12735-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 10/10/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND We sought to determine the impact of social determinants of health (SDoH) on outcomes of patients undergoing resection for hepatocellular carcinoma (HCC). PATIENTS AND METHODS Patients with HCC in the National Cancer Database who underwent resection from 2009 to 2018 were identified. SDoH associated with length of stay (LOS), 30-day readmission, and 30-day mortality were analyzed using regression analyses adjusted for confounding variables. RESULTS Among 9235 patients, the median age (range) was 65.0 (18-90) years, 72.1% were male, and 57.9% were White. A total of 3% were uninsured, 11.1% had Medicaid, 21% resided in regions with a median household income within the lowest quartile of the US population, and 27.0% resided in regions within the lowest quartile of education level. The odds for having longer LOS were lower among patients with the highest regional education level compared with those with the lowest level [odds ratio (OR) 0.86, 95% confidence interval (CI) 0.77-0.97]. The risk of readmission was lower among patients with Medicare (OR 0.52; 95% CI 0.33-0.81), Medicaid (OR 0.52; 95% CI 0.31-0.87), or private insurance (OR 0.56; 95% CI 0.35-0.88) compared with uninsured patients. Thirty-day overall mortality was less likely among patients with Medicare (OR 0.45; 95% CI 0.27-0.75), Medicaid (OR 0.53; 95% CI 0.30-0.93), or private insurance (OR 0.40; 95% CI 0.24-0.66), and among patients with high regional income (OR 0.58; 95% CI 0.44-0.77). CONCLUSIONS Adjusted regression analyses identified SDoH that were associated with HCC outcomes. Increased awareness of how SDoH relate to outcomes may inform strategies that attempt to account for these associations and improve patient outcomes.
Collapse
Affiliation(s)
- Ambria S Moten
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Paxton V Dickson
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jeremiah L Deneve
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - David Shibata
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA.,Center for Cancer Research, College of Medicine, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Ansley G Stanfill
- Department of Acute and Tertiary Care, College of Nursing, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Evan S Glazer
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA. .,Center for Cancer Research, College of Medicine, The University of Tennessee Health Science Center, Memphis, TN, USA.
| |
Collapse
|
6
|
Bannangkoon K, Hongsakul K, Tubtawee T, Janjindamai P. Effect of COVID-19 Pandemic-Related Delays in Chemoembolization on the Survival of Patients with Hepatocellular Carcinoma. Can J Gastroenterol Hepatol 2023; 2023:8114732. [PMID: 37090102 PMCID: PMC10121341 DOI: 10.1155/2023/8114732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 03/12/2023] [Accepted: 03/23/2023] [Indexed: 04/25/2023] Open
Abstract
Background and Aims COVID-19 has led to potential delays in liver cancer treatment, which may have undesirable effects on the prognosis of patients. We aimed to quantify the COVID-19 pandemic impact on the survival of patients with hepatocellular carcinoma (HCC) who underwent transarterial chemoembolization (TACE). Methods A retrospective study was conducted in patients with HCC who underwent TACE at a tertiary care center during the prelockdown (March to July 2019) and lockdown (March to July 2020) periods. Demographic data, tumor characteristics, functional status, and vital status were collected from the hospital medical records. The endpoints were TACE interval, treatment response, and survival after TACE. Cox proportional hazards regression determined the significant preoperative factors influencing survival. Results Compared to prelockdown, a significant delay occurred during the lockdown in repeated TACE treatments (76.7 vs. 63.5 days, P=0.007). The trend suggested a significant decrease in patients with HCC in the repeated TACE group (-33.3%). After screening, 145 patients were included (prelockdown (n = 87), lockdown (n = 58)). There was no significant difference in the 1-month objective response rate between the prelockdown and lockdown groups (65.5% vs. 64.4%, P=1.00). During follow-up, 56 (64.4%) and 34 (58.6%) deaths occurred in the prelockdown and lockdown groups, respectively (P=0.600). Multivariate analysis revealed no association between the lockdown group and decreased survival (HR 0.88, 95% CI 0.57-1.35, P=0.555). Conclusions The impact of the COVID-19 pandemic on liver cancer care resulted in significant decreases and delays in repeated TACE treatments in 2020 compared to 2019. However, treatment delays did not seem to significantly impact survival.
Collapse
Affiliation(s)
- Kittipitch Bannangkoon
- Department of Radiology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
| | - Keerati Hongsakul
- Department of Radiology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
| | - Teeravut Tubtawee
- Department of Radiology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
| | - Phurich Janjindamai
- Department of Radiology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
| |
Collapse
|
7
|
Govalan R, Luu M, Lauzon M, Kosari K, Ahn JC, Rich NE, Nissen N, Roberts LR, Singal AG, Yang JD. Therapeutic Underuse and Delay in Hepatocellular Carcinoma: Prevalence, Associated Factors, and Clinical Impact. Hepatol Commun 2021; 6:223-236. [PMID: 34558830 PMCID: PMC8710787 DOI: 10.1002/hep4.1795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/10/2021] [Accepted: 07/02/2021] [Indexed: 12/24/2022] Open
Abstract
Prognosis of hepatocellular carcinoma (HCC) could be affected by lack of or delayed therapy. We aimed to characterize the prevalence, correlates, and clinical impact of therapeutic underuse and delay in patients with HCC. Patients with HCC diagnosed between 2010 and 2017 were analyzed from the United States National Cancer Database. Logistic regression analysis identified factors associated with no and delayed (>90 days after diagnosis) HCC treatment. Cox proportional hazards regression with landmark analysis assessed the association between therapeutic delay and overall survival (OS), accounting for immortal time bias. Of 116,299 patients with HCC, 24.2% received no treatment and 18.4% of treated patients had delayed treatment. Older age, Black, Hispanic, lower socioeconomic status, earlier year of diagnosis, treatment at nonacademic centers, Northeast region, increased medical comorbidity, worse liver dysfunction, and higher tumor burden were associated with no treatment. Among treated patients, younger age, Hispanic, Black, treatment at academic centers, West region, earlier tumor stage, and receipt of noncurative treatment were associated with treatment delays. In multivariable Cox regression with a landmark of 150 days, patients with and without treatment delays had similar OS (adjusted hazard ratio [aHR], 1.01; 95% confidence interval [CI], 0.98‐1.04) with a median survival of 33.7 vs. 32.1 months, respectively. However, therapeutic delay was associated with worse OS in patients who had tumor, nodes, and metastases (TNM) stage 1 (aHR, 1.06; 95% CI, 1.01‐1.11) or received curative treatment (aHR, 1.12; 95% CI, 1.05‐1.18). Conclusion: One‐fourth of patients with HCC receive no therapy and one‐fifth of treated patients experience treatment delays. Both were associated with demographic, socioeconomic, and clinical characteristics of patients as well as facility type and region. The association between therapeutic delay and survival was stage and treatment dependent.
Collapse
Affiliation(s)
| | - Michael Luu
- Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Marie Lauzon
- Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Kambiz Kosari
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Joseph C Ahn
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Nicole E Rich
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX, USA.,Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Nicholas Nissen
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Lewis R Roberts
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Amit G Singal
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX, USA.,Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ju Dong Yang
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| |
Collapse
|
8
|
Rao A, Rich NE, Marrero JA, Yopp AC, Singal AG. Diagnostic and Therapeutic Delays in Patients With Hepatocellular Carcinoma. J Natl Compr Canc Netw 2021; 19:1063-1071. [PMID: 34077908 DOI: 10.6004/jnccn.2020.7689] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 11/23/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Delays in diagnosis and treatment have been reported for many cancers, with resultant stage migration and worse survival; however, few data exist in patients with hepatocellular carcinoma (HCC). These data are of particular importance in light of the COVID-19 pandemic, which has caused disruptions in healthcare processes and may continue to impact cancer care for the foreseeable future. The aim of our study was to characterize the prevalence and clinical significance of diagnostic and treatment delays in patients with HCC. METHODS We performed a retrospective cohort study of consecutive patients diagnosed with HCC between January 2008 and July 2017 at 2 US health systems. Diagnostic and treatment delays were defined as >90 days between presentation and HCC diagnosis and between diagnosis and treatment, respectively. We used multivariable logistic regression to identify factors associated with diagnostic and treatment delays and Cox proportional hazard models to identify correlates of overall survival. RESULTS Of 925 patients with HCC, 39.0% were diagnosed via screening, 33.1% incidentally, and 27.9% symptomatically. Median time from presentation to diagnosis was 37 days (interquartile range, 18-94 days), with 120 patients (13.0%) experiencing diagnostic delays. Median time from HCC diagnosis to treatment was 46 days (interquartile range, 29-74 days), with 17.2% of patients experiencing treatment delays. Most (72.5%) diagnostic delays were related to provider-level factors (eg, monitoring indeterminate nodules), whereas nearly half (46.2%) of treatment delays were related to patient-related factors (eg, missed appointments). In multivariable analyses, treatment delays were not associated with increased mortality (hazard ratio, 0.90; 95% CI, 0.60-1.35); these results were consistent across subgroup analyses by Barcelona Clinic Liver Cancer stage and treatment modality. CONCLUSIONS Diagnostic and therapeutic delays exceeding 3 months are common in patients with HCC; however, observed treatment delays do not seem to significantly impact overall survival.
Collapse
Affiliation(s)
| | - Nicole E Rich
- 1Department of Internal Medicine.,2Harold C. Simmons Comprehensive Cancer Center
| | - Jorge A Marrero
- 1Department of Internal Medicine.,3Department of Population and Data Sciences, and
| | - Adam C Yopp
- 2Harold C. Simmons Comprehensive Cancer Center.,4Department of Surgery, UT Southwestern Medical Center and Parkland Health and Hospital System, Dallas, Texas
| | - Amit G Singal
- 1Department of Internal Medicine.,2Harold C. Simmons Comprehensive Cancer Center.,3Department of Population and Data Sciences, and
| |
Collapse
|
9
|
He Y, Liang T, Mo S, Chen Z, Zhao S, Zhou X, Yan L, Wang X, Su H, Zhu G, Han C, Peng T. Effect of timing of surgical resection of primary hepatocellular carcinoma on survival outcomes in elderly patients and prediction of clinical models. BMC Gastroenterol 2021; 21:230. [PMID: 34020603 PMCID: PMC8139139 DOI: 10.1186/s12876-021-01815-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 05/16/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The effect of time delay from diagnosis to surgery on the prognosis of elderly patients with liver cancer is not well known. We investigated the effect of surgical timing on the prognosis of elderly hepatocellular carcinoma patients undergoing surgical resection and constructed a Nomogram model to predict the overall survival of patients. METHODS A retrospective analysis was performed on elderly patients with primary liver cancer after hepatectomy from 2012 to 2018. The effect of surgical timing on the prognosis of elderly patients with liver cancer was analyzed using the cut-off times of 18 days, 30 days, and 60 days. Cox was used to analyze the independent influencing factors of overall survival in patients, and a prognostic model was constructed. RESULTS A total of 232 elderly hepatocellular carcinoma patients who underwent hepatectomy were enrolled in this study. The cut-off times of 18, 30, and 60 days were used. The duration of surgery had no significant effect on overall survival. Body Mass Index, Child-Pugh classification, Tumor size Max, and Length of stay were independent influencing factors for overall survival in the elderly Liver cancer patients after surgery. These factors combined with Liver cirrhosis and Venous tumor emboli were incorporated into a Nomogram. The nomogram was validated using the clinical data of the study patients, and exhibited better prediction for 1-year, 3-year, and 5-year overall survival. CONCLUSIONS We demonstrated that the operative time has no significant effect on delayed operation in the elderly patients with hepatocellular carcinoma, and a moderate delay may benefit some patients. The constructed Nomogram model is a good predictor of overall survival in elderly patients with hepatectomy.
Collapse
Affiliation(s)
- Yongfei He
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi Province, China
| | - Tianyi Liang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi Province, China
| | - Shutian Mo
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi Province, China
| | - Zijun Chen
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi Province, China
| | - Shuqi Zhao
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi Province, China
| | - Xin Zhou
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi Province, China
| | - Liping Yan
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi Province, China
| | - Xiangkun Wang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi Province, China
| | - Hao Su
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi Province, China
| | - Guangzhi Zhu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi Province, China
| | - Chuangye Han
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi Province, China
| | - Tao Peng
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi Province, China.
| |
Collapse
|
10
|
Tsilimigras DI, Hyer JM, Diaz A, Moris D, Bagante F, Ratti F, Marques HP, Soubrane O, Lam V, Poultsides GA, Popescu I, Alexandrescu S, Martel G, Workneh A, Guglielmi A, Hugh T, Aldrighetti L, Endo I, Pawlik TM. Impact of time-to-surgery on outcomes of patients undergoing curative-intent liver resection for BCLC-0, A and B hepatocellular carcinoma. J Surg Oncol 2020; 123:381-388. [PMID: 33174627 DOI: 10.1002/jso.26297] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 10/28/2020] [Accepted: 11/01/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND The impact of a prolonged time-to-surgery (TTS) among patients with resectable hepatocellular carcinoma (HCC) is not well defined. METHODS Patients who underwent curative-intent hepatectomy for BCLC-0, A and B HCC between 2000 and 2017 were identified using a multi-institutional database. The impact of prolonged TTS on overall survival (OS) and disease-free survival (DFS) was examined. RESULTS Among 775 patients who underwent resection for HCC, 537 (69.3%) had early surgery (TTS < 90 days) and 238 (30.7%) patients had a delayed surgery (TTS ≥ 90 days). Patient- and tumor-related characteristics were similar between the two groups except for a higher proportion of patients undergoing major liver resection in the early surgery group (31.3% vs. 23.8%, p = .04). The percentage of patients with delayed surgery varied from 8.8% to 59.1% among different centers (p < .001). Patients with TTS < 90 days had similar 5-year OS (63.7% vs. 64.9; p = .79) and 5-year DFS (33.5% vs. 42.4; p = .20) with that of patients with TTS ≥ 90 days. On multivariable analysis, delayed surgery was not associated with neither worse OS (BCLC-0/A: adjusted hazards ratio [aHR] = 0.90; 95% confidence interval [CI]: 0.65-1.25 and BCLC-B: aHR = 0.72; 95%CI: 0.30-1.74) nor DFS (BCLC-0/A: aHR = 0.78; 95%CI: 0.60-1.01 and BCLC-B: aHR = 0.67; 95% CI: 0.36-1.25). CONCLUSION Approximately one in three patients diagnosed with resectable HCC had a prolonged TTS. Delayed surgery was not associated with worse outcomes among patients with resectable HCC.
Collapse
Affiliation(s)
| | - J Madison Hyer
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Adrian Diaz
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Demetrios Moris
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Fabio Bagante
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.,Department of Surgery, University of Verona, Verona, Italy
| | | | - Hugo P Marques
- Department of Surgery, Curry Cabral Hospital, Lisbon, Portugal
| | - Olivier Soubrane
- Department of Hepatobiliopancreatic Surgery, APHP, Beaujon Hospital, Clichy, France
| | - Vincent Lam
- Department of Surgery, Westmead Hospital, Sydney, Australia
| | | | - Irinel Popescu
- Department of Surgery, Fundeni Clinical Institute, Bucharest, Romania
| | | | | | - Aklile Workneh
- Department of Surgery, University of Ottawa, Ottawa, Canada
| | | | - Tom Hugh
- Department of Surgery, School of Medicine, The University of Sydney, Sydney, Australia
| | | | - Itaru Endo
- Department of Surgery, Yokohama City University School of Medicine, Yokohama, Japan
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| |
Collapse
|
11
|
Wei M, Chen S, Li J, Li B, Shen J, Peng Z, Zhou Q, Zou Y, He X, Li S, Li D, Peng B, Lai J, Peng S, Qin B, Kuang M. Prognostic Role of Time to Surgery in Hepatocellular Carcinoma at Barcelona Clinic Liver Cancer Stage 0-A. Ann Surg Oncol 2020; 27:3740-3753. [PMID: 32424586 DOI: 10.1245/s10434-020-08499-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Indexed: 01/20/2023]
Abstract
BACKGROUND Postsurgical recurrence is common in early-stage hepatocellular carcinoma (HCC). Prolonged time to surgery (TTS) may lead to tumor progression. However, the impact of TTS on HCC prognosis is controversial in Western studies and unknown in China. We aim to investigate the impact of TTS on the prognosis of Chinese HCC patients at Barcelona Clinic Liver Cancer (BCLC) stage 0-A who underwent surgery. PATIENTS AND METHODS We retrospectively enrolled 967 BCLC 0-A HCC patients who underwent surgery at three tertiary centers in China. Primary outcomes were recurrence-free survival (RFS) and overall survival (OS). Restricted cubic spline (RCS) was used to select the cutoff value of TTS. Propensity score matching (PSM) was performed to reduce confounding bias, and a time-dependent Cox model was utilized to investigate factors influencing TTS. RESULTS The median TTS of BCLC 0-A HCC patients was 13 days (interquartile range: 10-21 days). For patients with TTS ≤ 70 days, the cutoff value of TTS was 13 days according to RCS. After PSM, corresponding 1-, 3-, and 5-year RFS of the TTS > 13 days and TTS ≤ 13 days groups were 75.6%, 55.3%, 46.4% and 71.2%, 52.3%, 38.8%, respectively (P = 0.103). Corresponding 1-, 3-, and 5-year OS of TTS > 13 days and TTS ≤ 13 days groups were 93.7%, 82.8%, 69.6% and 92.4%, 78.5%, 68.4%, respectively (P = 0.580). Time-dependent Cox analysis revealed that age and tumor size were factors influencing TTS. CONCLUSIONS Our study suggests that, for patients with TTS ≤ 70 days, prolonged TTS had no impact on BCLC 0-A Chinese HCC patients receiving surgery.
Collapse
Affiliation(s)
- Mengchao Wei
- Department of Liver Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Shuling Chen
- Division of Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jiali Li
- Department of General Surgery, Dongguan People's Hospital, Dongguan, China
| | - Bin Li
- Clinical Trials Unit, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jingxian Shen
- Department of Medical Imaging, Cancer Center of Sun Yat-sen University, Guangzhou, China
| | - Zhenwei Peng
- Clinical Trials Unit, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Department of Radiation Oncology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Qian Zhou
- Clinical Trials Unit, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ying Zou
- Department of Medical Oncology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiaofang He
- Department of Radiation Oncology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Shaoqiang Li
- Department of Liver Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Dongming Li
- Department of Liver Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Baogang Peng
- Department of Liver Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jiaming Lai
- Department of Pancreatobiliary Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Sui Peng
- Clinical Trials Unit, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Beijiao Qin
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Ming Kuang
- Department of Liver Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China. .,Division of Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China. .,Cancer Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China. .,Institute of Precision Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
| |
Collapse
|
12
|
Kabir T, Syn N, Ramkumar M, Yeo EYJ, Teo JY, Koh YX, Lee SY, Cheow PC, Chow PKH, Chung AYF, Ooi LL, Chan CY, Goh BKP. Effect of surgical delay on survival outcomes in patients undergoing curative resection for primary hepatocellular carcinoma: Inverse probability of treatment weighting using propensity scores and propensity score adjustment. Surgery 2019; 167:417-424. [PMID: 31677800 DOI: 10.1016/j.surg.2019.09.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Revised: 09/28/2019] [Accepted: 09/30/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND The evidence is conflicting regarding the effect of delays from the time of diagnosis to surgery on the survival in patients with hepatocellular carcinoma. We sought to investigate the impact of time to surgery on overall survival for patients who underwent curative resection for primary hepatocellular carcinoma. METHODS We performed a retrospective review of all patients who underwent liver resection for primary hepatocellular carcinoma between the years 2000 and 2015. Using 30-, 60-, and 90-day cutoffs, we investigated the effect of time to surgery on survival outcomes by dichotomizing the patients and using inverse probability of treatment weighting to ensure comparability. We also investigated time to surgery in prognostic subgroups by modeling the statistical interaction between time to surgery and the relevant prognostic variable in multivariable Cox models. RESULTS A total of 863 patients underwent liver resection for primary hepatocellular carcinoma during the study period. Using 30-, 60-, and 90-day cutoffs, time to surgery did not have a significant bearing on overall survival. For elderly patients (>70 years), patients with Child-Pugh B liver disease, American Society of Anesthesiologists status 2/3, tumor size >5cm, tumor size ≥10cm and presence of extrahepatic invasion, hazard ratio decreased and overall survival improved as time to surgery increased. However, for patients with liver cirrhosis or portal hypertension, increasing time to surgery was found to portend higher risks of death. CONCLUSION Time to surgery does not have a significant bearing on overall survival, and modest delays even appear to be associated with improved survival in specific subsets of patients. The importance of these findings is that patients with hepatocellular carcinoma should be fully optimized before and not rushed to surgery because of concerns of tumor progression and a diminished survival.
Collapse
Affiliation(s)
- Tousif Kabir
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital; Department of General Surgery, Sengkang General Hospital, Singapore
| | | | - M Ramkumar
- Yong Loo Lin School of Medicine, Singapore
| | | | - Jin-Yao Teo
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital; Duke NUS Medical School, Singapore
| | - Ye-Xin Koh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital; Duke NUS Medical School, Singapore
| | - Ser-Yee Lee
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital; Duke NUS Medical School, Singapore
| | - Peng-Chung Cheow
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital; Duke NUS Medical School, Singapore
| | - Pierce K H Chow
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital; Duke NUS Medical School, Singapore
| | - Alexander Y F Chung
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital; Duke NUS Medical School, Singapore
| | - London L Ooi
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital; Duke NUS Medical School, Singapore
| | - Chung-Yip Chan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital; Duke NUS Medical School, Singapore
| | - Brian K P Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital; Duke NUS Medical School, Singapore.
| |
Collapse
|