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Abboud Y, Malhotra R, Maan MHA, Mathew A, Abboud I, Pan CW, Alsakarneh S, Jaber F, Mohamed I, Kim D, Pyrsopoulos NT. Hepatocellular carcinoma national burden across different geographical regions in the United States between 2001 and 2020. World J Methodol 2024; 14:95598. [DOI: 10.5662/wjm.v14.i4.95598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Revised: 05/12/2024] [Accepted: 06/03/2024] [Indexed: 07/26/2024] Open
Abstract
BACKGROUND While prior data showed an increasing incidence of hepatocellular carcinoma (HCC) in the United States, there are limited comprehensive and comparative data on the geographical variations of HCC trends in different demographic-specific populations.
AIM To evaluate sex and age-specific incidence rates and time trends in different geographical regions in the United States.
METHODS Age-adjusted HCC incidence rates were collected from the United States Cancer Statistics (USCS) database which covers approximately 98% of the population in the United States. HCC rates were stratified by sex, age, and geographical region. annual percentage change (APC) and average APC (AAPC) were estimated using Joinpoint Regression. A pairwise comparison was conducted between sex-specific trends.
RESULTS There were 467344 patients diagnosed with HCC in the United States in the USCS database between 2001 and 2020. The rates and trends varied by geographical region. When looking at the West region (115336 patients), incidence rates of HCC were overall increasing and also increasing in older adults. However, when evaluating younger adults, HCC incidence rates decreased in men but not in women with a sex-specific absolute AAPC-difference of 2.15 (P = 0.005). When evaluating the Midwest region (84612 patients), similar results were seen. While incidence rates were increasing in the overall population and in older adults as well, they were decreasing in younger men but not in women with a sex-specific absolute AAPC-difference of 1.61 (P < 0.001). For the Northeast region (87259 patients), the analysis showed similar results with decreasing HCC incidence rates in younger men but not counterpart women (Sex-specific AAPC-difference = 3.26, P < 0.001). Lastly, when evaluating the south (180137 patients), the results were also decreasing in younger men but not in women (Sex-specific AAPC-difference = 2.55, P < 0.001).
CONCLUSION Nationwide analysis covering around 98% of the United States population shows an increasing incidence of HCC across all geographical regions, most notably in the South. While younger men experienced decreasing HCC incidence, younger women had a stable trend and this was noted across all regions as well. Our study offers insight into the epidemiology of HCC in different demographic groups across various United States geographical regions. While the reasons contributing to our findings are unclear, they can be related to sex and regional disparities in healthcare access and utilization. Future research is warranted to characterize the temporal change in HCC risk factors across different United States regions.
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Affiliation(s)
- Yazan Abboud
- Department of Internal Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, United States
| | - Raj Malhotra
- Department of Internal Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, United States
| | | | - Anna Mathew
- Department of Internal Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, United States
| | - Ibrahim Abboud
- University of California Riverside School of Medicine, Riverside, CA 92521, United States
| | - Chun-Wei Pan
- Department of Internal Medicine, John H Stroger Hospital of Cook County, Chicago, IL 60612, United States
| | - Saqr Alsakarneh
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas, MO 64108, United States
| | - Fouad Jaber
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas, MO 64108, United States
| | - Islam Mohamed
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas, MO 64108, United States
| | - David Kim
- Department of Internal Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, United States
| | - Nikolaos T Pyrsopoulos
- Division of Gastroenterology and Hepatology, Rutgers New Jersey Medical School, Newark, NJ 07101, United States
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Van Haren RM, Kovacic MB, Delman AM, Pratt CG, Griffith A, Arbili L, Harvey K, Kohli E, Pai A, Topalian A, Rai SN, Shah SA, Kues J. Disparities Associated with Decision to Undergo Oncologic Surgery: A Prospective Mixed-Methods Analysis. Ann Surg Oncol 2024; 31:5757-5764. [PMID: 38869765 PMCID: PMC11300547 DOI: 10.1245/s10434-024-15610-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 05/28/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND Underrepresented minority patients with surgical malignancies experience disparities in outcomes. The impact of provider-based factors, including communication, trust, and cultural competency, on outcomes is not well understood. This study examines modifiable provider-based barriers to care experienced by patients with surgical malignancies. METHODS A parallel, prospective, mixed-methods study enrolled patients with lung or gastrointestinal malignancies undergoing surgical consultation. Surveys assessed patients' social needs and patient-physician relationship. Semi-structured interviews ascertained patient experiences and were iteratively analyzed, identifying key themes. RESULTS The cohort included 24 patients (age 62 years; 63% White and 38% Black/African American). The most common cancers were lung (n = 18, 75%) and gastroesophageal (n = 3, 13%). Survey results indicated that food insecurity (n = 5, 21%), lack of reliable transportation (n = 4, 17%), and housing instability (n = 2, 8%) were common. Lack of trust in their physician (n = 3, 13%) and their physician's treatment recommendation (n = 3, 13%) were identified. Patients reported a lack of empathy (n = 3, 13%), lack of cultural competence (n = 3, 13%), and inadequate communication (n = 2, 8%) from physicians. Qualitative analysis identified five major themes regarding the decision to undergo surgery: communication, trust, health literacy, patient fears, and decision-making strategies. Five patients (21%) declined the recommended surgery and were more likely Black (100% vs. 21%), lower income (100% vs. 16%), and reported poor patient-physician relationship (40% vs. 5%; all p < 0.05). CONCLUSIONS Factors associated with declining recommended cancer surgery were underrepresented minority race and poor patient-physician relationships. Interventions are needed to improve these barriers to care and racial disparities.
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Affiliation(s)
- Robert M Van Haren
- University of Cincinnati Cancer Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Melinda Butsch Kovacic
- University of Cincinnati Cancer Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Department of Rehabilitation, Exercise, and Nutrition Sciences, University of Cincinnati College of Allied Health Sciences, Cincinnati, OH, USA
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Aaron M Delman
- University of Cincinnati Cancer Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Catherine G Pratt
- University of Cincinnati Cancer Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Azante Griffith
- University of Cincinnati Cancer Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Lana Arbili
- University of Cincinnati Cancer Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Krysten Harvey
- University of Cincinnati Cancer Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Eshika Kohli
- University of Cincinnati Cancer Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Ahna Pai
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Alique Topalian
- University of Cincinnati Cancer Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Shesh N Rai
- University of Cincinnati Cancer Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Shimul A Shah
- University of Cincinnati Cancer Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - John Kues
- University of Cincinnati Cancer Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Agudile EP, Vega EA, Salirrosas O, Agudile UM, Chirban AM, Lathan C, Sorescu GP, Odisio BC, Panettieri E, Conrad C. Temporal trends of health disparity in the utilization of curative-intent treatments for hepatocellular carcinoma: are we making progress? J Gastrointest Surg 2024; 28:1392-1399. [PMID: 38754809 DOI: 10.1016/j.gassur.2024.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 04/17/2024] [Accepted: 05/11/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Liver-directed treatments - ablative therapy (AT), surgical resection (SR), liver transplantation (LT), and transarterial chemoembolization (TACE) - improve the overall survival of patients with early-stage hepatocellular carcinoma (HCC). Although racial and socioeconomic disparities affect access to liver-directed therapies, the temporal trends for the curative-intent treatment of HCC remain to be elucidated. METHODS This study performed chi-square, logistic regression, and temporal trends analyses on data from the Nationwide Inpatient Sample from 2011 to 2019. The outcome of interest was the rate of AT, SR, LT (curative-intent treatments), and TACE utilization, and the primary predictors were racial/ethnic group and socioeconomic status (SES; insurance status). RESULTS African American and Hispanic patients had lower odds of receiving AT (African American: odds ratio [OR], 0.78; P < .001; Hispanic: OR, 0.84; P = .005) and SR (African American: OR, 0.71; P < .001; Hispanics: OR, 0.64; P < .001) than White patients. Compared with White patients, the odds of LT was lower in African American patients (OR, 0.76; P < .001) but higher in Hispanic patients (OR, 1.25; P = .001). Low SES was associated with worse odds of AT (OR, 0.79; P = .001), SR (OR, 0.66; P < .001), and LT (OR, 0.84; P = .028) compared with high SES. Although curative-intent treatments showed significant upward temporal trends among White patients (10.6%-13.9%; P < .001) and Asian and Pacific Islander/other patients (14.4%-15.7%; P = .007), there were nonsignificant trends among African American patients (10.9%-10.1%; P = .825) or Hispanic patients (12.2%-13.7%; P = .056). CONCLUSION Our study demonstrated concerning disparities in the utilization of curative-intent treatment for HCC based on race/ethnicity and SES. Moreover, racial/ethnic disparities have widened rather than improved over time.
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Affiliation(s)
- Emeka P Agudile
- Department of Medicine, Steward Carney Hospital, Dorchester, Massachusetts, United States; Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States
| | - Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, United States
| | - Oscar Salirrosas
- Department of Surgery, St. Elizabeth's Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, United States
| | - Ukamaka M Agudile
- Department of Medicine, Steward Carney Hospital, Dorchester, Massachusetts, United States
| | - Ariana M Chirban
- Department of Surgery, St. Elizabeth's Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, United States; Department of Surgery, School of Medicine, University of California San Diego, La Jolla, California, United States
| | - Christopher Lathan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard School of Medicine, Boston, Massachusetts, United States
| | - George P Sorescu
- Department of Medicine, Lemuel Shattuck Hospital, Boston, Massachusetts, United States
| | - Bruno C Odisio
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Elena Panettieri
- Department of Surgery, St. Elizabeth's Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, United States; Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Claudius Conrad
- Division of Surgical Oncology, Carle Illinois College of Medicine, University of Illinois Urbana Champaign, Illinois, United States.
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Gordan JD, Kennedy EB, Abou-Alfa GK, Beal E, Finn RS, Gade TP, Goff L, Gupta S, Guy J, Hoang HT, Iyer R, Jaiyesimi I, Jhawer M, Karippot A, Kaseb AO, Kelley RK, Kortmansky J, Leaf A, Remak WM, Sohal DPS, Taddei TH, Wilson Woods A, Yarchoan M, Rose MG. Systemic Therapy for Advanced Hepatocellular Carcinoma: ASCO Guideline Update. J Clin Oncol 2024; 42:1830-1850. [PMID: 38502889 DOI: 10.1200/jco.23.02745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 12/28/2023] [Indexed: 03/21/2024] Open
Abstract
PURPOSE To update an evidence-based guideline to assist in clinical decision-making for patients with advanced hepatocellular carcinoma (HCC). METHODS ASCO convened an Expert Panel to update the 2020 guideline on systemic therapy for HCC. The panel updated the systematic review to include randomized controlled trials (RCTs) published through October 2023 and updated recommendations. RESULTS Ten new RCTs met the inclusion criteria and were added to the evidence base. RECOMMENDATIONS Atezolizumab + bevacizumab (atezo + bev) or durvalumab + tremelimumab (durva + treme) may be offered first-line for patients with advanced HCC, Child-Pugh class A liver disease, and Eastern Cooperative Oncology Group performance status 0-1. Where there are contraindications to these therapies, sorafenib, lenvatinib, or durvalumab may be offered first-line. Following first-line treatment with atezo + bev, second-line therapy with a tyrosine kinase inhibitor (TKI), ramucirumab (for patients with alpha-fetoprotein [AFP] ≥400 ng/mL), durva + treme, or nivolumab + ipilimumab (nivo + ipi) may be recommended for appropriate candidates. Following first-line therapy with durva + treme, second-line therapy with a TKI is recommended. Following first-line treatment with sorafenib or lenvatinib, second-line therapy options include cabozantinib, regorafenib for patients who previously tolerated sorafenib, ramucirumab (AFP ≥400 ng/mL), nivo + ipi, or durvalumab; atezo + bev or durva + treme may be considered for patients who did not have access to these therapies in the first-line setting, and do not have contraindications. Pembrolizumab or nivolumab are also options for appropriate patients following sorafenib or lenvatinib. Third-line therapy may be considered in Child-Pugh class A patients with good PS, using one of the agents listed previously that has a nonidentical mechanism of action with previously received therapy. A cautious approach to systemic therapy is recommended for patients with Child-Pugh class B advanced HCC. Further guidance on choosing between options is included within the guideline.Additional information is available at www.asco.org/gastrointestinal-cancer-guidelines.
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Affiliation(s)
- John D Gordan
- University of California, San Francisco, San Francisco, CA
| | | | - Ghassan K Abou-Alfa
- Memorial Sloan Kettering Cancer Center and Weill Medical College at Cornell University, New York, NY
- Trinity College Dublin Medical School, Dublin, Ireland
| | | | | | | | - Laura Goff
- Vanderbilt Ingram Cancer Center, Nashville, TN
| | | | | | | | - Renuka Iyer
- Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | | | | | | | | | - R Kate Kelley
- University of California, San Francisco, San Francisco, CA
| | | | - Andrea Leaf
- VA New York Harbor Healthcare System, Brooklyn, NY
| | - William M Remak
- California Hepatitis C Task Force, California Chronic Care Coalition, FAIR Foundation, San Francisco, CA
| | | | - Tamar H Taddei
- Yale University School of Medicine and VA Connecticut Healthcare System, West Haven, CT
| | | | | | - Michal G Rose
- Yale Cancer Center and VA Connecticut Healthcare System, West Haven, CT
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Doddi S, Salichs O, Hibshman T, Bhargava P. Trends of liver cell carcinoma mortality in the United States by demographics and geography. Curr Probl Diagn Radiol 2024; 53:208-214. [PMID: 37891079 DOI: 10.1067/j.cpradiol.2023.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND Liver cancer is a complex disease that presents many challenges in its diagnosis, treatment, and prevention. It's mortality rate in the United States is a significant and warrants attention. OBJECTIVE To assess the trend of mortality rate due to HCC in the US from 1999 to 2020 by demographic groups for differences in trend of mortality. METHODS We used the CDC wonder database to collect mortality rate data due to HCC as a multiple cause of death in the US from 1999 to 2020 by sex, race, age, and state of residence. The SEER Joinpoint program was used to calculate trends, defined as average annual percent change (AAPC) and to identify disparities between groups. All age-adjusted rates (AAMR) are reported per 100,000. RESULTS From 1999 to 2020, we found that women observed an uptrend (AAPC1.6%) and men observed a slightly higher uptrend in mortality (AAPC 1.8%). In addition, AI/AN population had a significant uptrend (AAPC 2.3%). The AAPI population observed a downtrend (AAPC -2.6%). The Black or African American population observed an uptrend (AAPC 1.8%) The white population also observed an uptrend (AAPC 2.2%). In the 2010 to 2020 time period, Mississippi had the lowest AAMR of any state with 15.2, while Hawaii had with the highest with 38.8. CONCLUSION This investigation assesses mortality rates and trends due to HCC cancer in the US and found significant differences in mortality rates and mortality rate trends due to HCC by demographic status in the US. Addressing the disparities in HCC incidence and mortality by race, ethnicity, state, and region, as well as improving access to screening, surveillance, and effective treatments, can reduce the burden of HCC and improve outcomes for patients.
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Affiliation(s)
- Sishir Doddi
- University of Toledo College of Medicine, Toledo, Ohio, USA.
| | - Oscar Salichs
- University of Toledo College of Medicine, Toledo, Ohio, USA
| | - Taryn Hibshman
- University of Toledo College of Medicine, Toledo, Ohio, USA
| | - Puneet Bhargava
- Department of Radiology, University of Washington, Seattle, Washington, USA
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Mezzacappa C, Rossi R, Jaffe A, Taddei TH, Strazzabosco M. Community-Level Factors Associated with Hepatocellular Carcinoma Incidence and Mortality: An Observational Registry Study. Cancer Epidemiol Biomarkers Prev 2024; 33:270-278. [PMID: 38059831 PMCID: PMC10872555 DOI: 10.1158/1055-9965.epi-23-0902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 10/23/2023] [Accepted: 12/05/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) incidence and outcomes vary across populations in the United States, but few studies evaluate local drivers of observed disparities. We measured HCC incidence at the community level and assessed community-level HCC risk factors with the goal of informing resource allocation to improve early case detection, which is associated with improved outcomes. METHODS Clinical and demographic data including census tract of residence for all adults diagnosed with HCC in the Connecticut Tumor Registry between 2008 and 2019 were combined with publicly available U.S. Census and Centers for Disease Control and Prevention (CDC) data at the ZIP Code tabulation area (ZCTA) level. The average annual incidence of HCC was calculated for each ZCTA and associations between community-level characteristics, HCC incidence, stage at diagnosis, and survival were evaluated. RESULTS Average annual HCC incidence during the study period was 8.9/100,000 adults and varied from 0 to 97.7 per 100,000 adults by ZCTA. At the community level, lower rates of high school graduation, higher rates of poverty, and rural community type were associated with higher HCC incidence. Persons with HCC living in the highest incidence ZCTAs were diagnosed at a younger age and were less likely to be alive at 1, 2, and 5 years after diagnosis. CONCLUSIONS Community-level socioeconomic factors are strongly associated with HCC incidence and survival in Connecticut. IMPACT This reproducible geo-localization approach using cancer registry, Census, and CDC data can be used to identify communities most likely to benefit from health system investments to reduce disparities in HCC.
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Affiliation(s)
- Catherine Mezzacappa
- Yale Liver Center, Section of Digestive Diseases, Department of Internal Medicine, Yale School of Medicine
| | - Raiza Rossi
- Yale Liver Center, Section of Digestive Diseases, Department of Internal Medicine, Yale School of Medicine
| | - Ariel Jaffe
- Yale Liver Center, Section of Digestive Diseases, Department of Internal Medicine, Yale School of Medicine
- Yale Cancer Center
| | - Tamar H Taddei
- Yale Liver Center, Section of Digestive Diseases, Department of Internal Medicine, Yale School of Medicine
- Yale Cancer Center
- VA Connecticut Healthcare System
| | - Mario Strazzabosco
- Yale Liver Center, Section of Digestive Diseases, Department of Internal Medicine, Yale School of Medicine
- Yale Cancer Center
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Patel TH, Brewer JR, Fan J, Cheng J, Shen YL, Xiang Y, Zhao H, Lemery SJ, Pazdur R, Kluetz PG, Fashoyin-Aje LA. FDA Approval Summary: Tremelimumab in Combination with Durvalumab for the Treatment of Patients with Unresectable Hepatocellular Carcinoma. Clin Cancer Res 2024; 30:269-273. [PMID: 37676259 PMCID: PMC10841291 DOI: 10.1158/1078-0432.ccr-23-2124] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/22/2023] [Accepted: 08/29/2023] [Indexed: 09/08/2023]
Abstract
On October 21, 2022, the FDA approved tremelimumab (Imjudo) in combination with durvalumab for adult patients with unresectable hepatocellular carcinoma. The approval was based on the results from the HIMALAYA study, in which patients with unresectable hepatocellular carcinoma who were naïve to previous systemic treatment were randomly assigned to receive one of three study arms: tremelimumab in combination with durvalumab (n = 393), durvalumab (n = 389), or sorafenib (n = 389). The primary objective of improvement in overall survival (OS) for tremelimumab in combination with durvalumab compared with sorafenib met statistical significance with a stratified HR of 0.78 [95% confidence interval (CI), 0.66-0.92; P = 0.0035]. The median OS was 16.4 months (95% CI, 14.2-19.6) with tremelimumab in combination with durvalumab and 13.8 months (95% CI, 12.3-16.1) with sorafenib. Adverse reactions occurring in ≥20% of patients receiving tremelimumab in combination with durvalumab were rash, fatigue, diarrhea, pruritus, musculoskeletal pain, and abdominal pain. The recommended tremelimumab dose for patients weighing 30 kg or more is 300 mg, i.v., as a single dose in combination with durvalumab 1,500 mg at cycle 1/day 1, followed by durvalumab 1,500 mg, i.v., every 4 weeks. For those weighing less than 30 kg, the recommended tremelimumab dose is 4 mg/kg, i.v., as a single dose in combination with durvalumab 20 mg/kg, i.v., followed by durvalumab 20 mg/kg, i.v., every 4 weeks.
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Affiliation(s)
- Timil H Patel
- Office of Oncologic Diseases, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Jamie R Brewer
- Office of Oncologic Diseases, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Jiaxin Fan
- Office of Biostatistics, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Joyce Cheng
- Office of Biostatistics, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Yuan-Li Shen
- Office of Biostatistics, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Yue Xiang
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Hong Zhao
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Steven J Lemery
- Office of Oncologic Diseases, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
- Oncology Center of Excellence, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Richard Pazdur
- Office of Oncologic Diseases, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
- Oncology Center of Excellence, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Paul G Kluetz
- Office of Oncologic Diseases, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
- Oncology Center of Excellence, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Lola A Fashoyin-Aje
- Office of Oncologic Diseases, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
- Oncology Center of Excellence, U.S. Food and Drug Administration, Silver Spring, Maryland
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8
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Malik MS, Subrize MW, Ou J, Curry MP, Parikh ND, Novack V, Weinstein JL, Ahmed M, Sarwar A. Association between Patient Experience Scores and Low Utilization of Hepatocellular Carcinoma Treatment in the United States: A Surveillance, Epidemiology, and End Results-Consumer Assessment of Healthcare Providers and Systems Analysis (SEER-CAHPS). J Vasc Interv Radiol 2024; 35:102-112.e5. [PMID: 37696431 DOI: 10.1016/j.jvir.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 08/30/2023] [Accepted: 09/02/2023] [Indexed: 09/13/2023] Open
Abstract
PURPOSE To study the experiences of patients with hepatocellular carcinoma (HCC) contributing to treatment discrepancy in the United States. MATERIALS AND METHODS Using Surveillance, Epidemiology, and End Results data from National Cancer Institute (NCI), Medicare (2002-2015) beneficiaries with HCC who completed a Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey were included. Six CAHPS items (3 global scores: global care rating [GCR], primary doctor rating [PDR], and specialist rating [SR]; 3 composite scores: getting needed care [GNC], getting care quickly [GCQ], and doctor communication [DC]) assessed patient experience. Covariates assessed between treated and nontreated groups included patient, disease, hospital, and CAHPS items. RESULTS Among 548 patients with HCC, 211 (39%) received treatment and 337 (61%) did not receive treatment. Forty-two percent (GCR), 29% (PDR), 30% (SR), 36% (GNC), 78% (GCQ), and 35% (DC) of patients reported less-than-excellent experiences on the respective CAHPS items. Chronic liver disease (CLD) was present in 52% and liver decompensation (LD) in 60%. A minority of the hospitals were NCI-designated cancer centers (47%), transplant centers (27%), and referral centers (9%). On univariable analysis, patients with at least a high school degree (odds ratio [OR], 1.9), admittance to a ≥400-bed hospital (OR, 2.7), CLD (OR, 3.0), or LD (OR, 1.7) were more likely to receive treatment, whereas older patients (≥75 years) (OR, 0.5) were less likely to receive treatment. On multivariable, patients with CLD (OR, 6.8) and an excellent experience in GNC with a specialist (OR, 10.6) were more likely to receive treatment. CONCLUSIONS HCC treatment discrepancy may be associated with patient-related factors, such as lack of specialist care (GNC), and disease-related factors, such as absence of underlying CLD.
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Affiliation(s)
- M Saad Malik
- Division of Interventional, Department of Radiology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts.
| | - Michael W Subrize
- Division of Interventional, Department of Radiology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts
| | - Jiangda Ou
- Division of Interventional, Department of Radiology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts
| | - Michael P Curry
- Division of Gastroenterology & Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts
| | - Neehar D Parikh
- Division of Gastroenterology & Hepatology, Department of Medicine, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Victor Novack
- Center for Healthcare Delivery Sciences, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Department of Medicine, Clinical Research Center, Soroka University Medical Center, Beer-Sheva, Israel
| | - Jeffrey L Weinstein
- Division of Interventional, Department of Radiology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts
| | - Muneeb Ahmed
- Division of Interventional, Department of Radiology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts
| | - Ammar Sarwar
- Division of Interventional, Department of Radiology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts
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Chavda V, Zajac KK, Gunn JL, Balar P, Khadela A, Vaghela D, Soni S, Ashby CR, Tiwari AK. Ethnic differences in hepatocellular carcinoma prevalence and therapeutic outcomes. Cancer Rep (Hoboken) 2023; 6 Suppl 1:e1821. [PMID: 37344125 PMCID: PMC10440848 DOI: 10.1002/cnr2.1821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 03/17/2023] [Accepted: 04/10/2023] [Indexed: 06/23/2023] Open
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is a leading cause of cancer-related death worldwide. The incidence of HCC is affected by genetic and non-genetic factors. Genetically, mutations in the genes, tumor protein P53 (TP53), catenin beta 1 (CTNNB1), AT-rich interaction domain 1A (ARIC1A), cyclin dependent kinase inhibitor 2A (CDKN2A), mannose 6-phosphate (M6P), smooth muscle action against decapentaplegic (SMAD2), retinoblastoma gene (RB1), cyclin D, antigen presenting cells (APC), AXIN1, and E-cadherin, have been shown to contribute to the occurrence of HCC. Non-genetic factors, including alcohol consumption, exposure to aflatoxin, age, gender, presence of hepatitis B (HBV), hepatitis C (HCV), and non-alcoholic fatty liver disease (NAFLD), increase the risk of HCC. RECENT FINDINGS The severity of the disease and its occurrence vary based on geographical location. Furthermore, men and minorities have been shown to be disproportionately affected by HCC, compared with women and non-minorities. Ethnicity has been reported to significantly affect tumorigenesis and clinical outcomes in patients diagnosed with HCC. Generally, differences in gene expression and/or the presence of comorbid medical diseases affect or influence the progression of HCC. Non-Caucasian HCC patients are significantly more likely to have poorer survival outcomes, compared to their Caucasian counterparts. Finally, there are a number of factors that contribute to the success rate of treatments for HCC. CONCLUSION Assessment and treatment of HCC must be consistent using evidence-based guidelines and standardized outcomes, as well as international clinical practice guidelines for global consensus. Standardizing the assessment approach and method will enable comparison and improvement of liver cancer research through collaboration between researchers, healthcare providers, and advocacy groups. In this review, we will focus on discussing epidemiological factors that result in deviations and changes in treatment approaches for HCC.
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Affiliation(s)
- Vivek Chavda
- Department of Pharmaceutics and Pharmaceutical TechnologyL M College of PharmacyAhmedabadIndia
| | - Kelsee K. Zajac
- Department of Pharmacology and Experimental Therapeutics, College of Pharmacy and Pharmaceutical SciencesUniversity of ToledoOhioUSA
| | - Jenna Lynn Gunn
- Department of Pharmacology and Experimental Therapeutics, College of Pharmacy and Pharmaceutical SciencesUniversity of ToledoOhioUSA
| | - Pankti Balar
- Pharmacy SectionL M College of PharmacyAhmedabadIndia
| | - Avinash Khadela
- Department of PharmacologyL M College of PharmacyAhmedabadIndia
| | - Dixa Vaghela
- Pharmacy SectionL M College of PharmacyAhmedabadIndia
| | - Shruti Soni
- PharmD SectionL M College of PharmacyAhmedabadIndia
| | - Charles R. Ashby
- Department of Pharmaceutical Sciences, College of PharmacySt. John's UniversityNew YorkNew YorkUSA
| | - Amit K. Tiwari
- Department of Pharmacology and Experimental Therapeutics, College of Pharmacy and Pharmaceutical SciencesUniversity of ToledoOhioUSA
- Department of Cancer Biology, College of Medicine and Life SciencesUniversity of ToledoToledoOhioUSA
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10
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Dhanasekaran R, Suzuki H, Lemaitre L, Kubota N, Hoshida Y. Molecular and immune landscape of hepatocellular carcinoma to guide therapeutic decision-making. Hepatology 2023:01515467-990000000-00480. [PMID: 37300379 PMCID: PMC10713867 DOI: 10.1097/hep.0000000000000513] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 05/12/2023] [Indexed: 06/12/2023]
Abstract
Liver cancer, primarily HCC, exhibits highly heterogeneous histological and molecular aberrations across tumors and within individual tumor nodules. Such intertumor and intratumor heterogeneities may lead to diversity in the natural history of disease progression and various clinical disparities across the patients. Recently developed multimodality, single-cell, and spatial omics profiling technologies have enabled interrogation of the intertumor/intratumor heterogeneity in the cancer cells and the tumor immune microenvironment. These features may influence the natural history and efficacy of emerging therapies targeting novel molecular and immune pathways, some of which had been deemed undruggable. Thus, comprehensive characterization of the heterogeneities at various levels may facilitate the discovery of biomarkers that enable personalized and rational treatment decisions, and optimize treatment efficacy while minimizing the risk of adverse effects. Such companion biomarkers will also refine HCC treatment algorithms across disease stages for cost-effective patient management by optimizing the allocation of limited medical resources. Despite this promise, the complexity of the intertumor/intratumor heterogeneity and ever-expanding inventory of therapeutic agents and regimens have made clinical evaluation and translation of biomarkers increasingly challenging. To address this issue, novel clinical trial designs have been proposed and incorporated into recent studies. In this review, we discuss the latest findings in the molecular and immune landscape of HCC for their potential and utility as biomarkers, the framework of evaluation and clinical application of predictive/prognostic biomarkers, and ongoing biomarker-guided therapeutic clinical trials. These new developments may revolutionize patient care and substantially impact the still dismal HCC mortality.
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Affiliation(s)
| | - Hiroyuki Suzuki
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume, Fukuoka
| | - Lea Lemaitre
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, California
| | - Naoto Kubota
- Liver Tumor Translational Research Program, Simmons Comprehensive Cancer Center, Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Yujin Hoshida
- Liver Tumor Translational Research Program, Simmons Comprehensive Cancer Center, Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
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11
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Rezaee-Zavareh MS, Liang J, Yang JD. Ethnic disparities in the epidemiology, treatment, and outcome of patients with hepatocellular carcinoma in the United States. HEPATOMA RESEARCH 2023; 9:18. [PMID: 38371172 PMCID: PMC10871674 DOI: 10.20517/2394-5079.2023.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
There are significant ethnic disparities in incidence, tumor stage, curative therapy receipt, and survival among patients with hepatocellular carcinoma (HCC) in the US. While previous models had predicted an increasing trend in the incidence rate of HCC until 2030 in the US, recent studies have shown that HCC incidence plateaued in 2013 and then started to decline in 2015. The decreasing trend has been observed in all ethnicities except for American Indians/Alaska Natives, whose incidence rates of HCC continue to rise. Current evidence shows that African-Americans and Hispanics are two groups that are more likely to be diagnosed with late-stage HCC, and this finding has been consistent in different socioeconomic statuses of the patients. These two ethnic minority groups are also among those who are less likely to have curative therapy for early-stage HCC. Finally, advances in early diagnosis and treatment approaches have led to an improvement in HCC survival for all ethnicities; however, African-Americans continue to have the worst survival. More studies to find the causes of these disparities and interventions to eliminate them are urgently needed.
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Affiliation(s)
| | - Jeff Liang
- Department of Internal Medicine, Cedars-Sinai Medical Center, Los Angeles 90048, CA, USA
| | - Ju Dong Yang
- Department of Internal Medicine, Cedars-Sinai Medical Center, Los Angeles 90048, CA, USA
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles 90048, CA, USA
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles 90048, CA, USA
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles 90048, CA, USA
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12
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Bodek DD, Everwine MM, Lunsford KE, Okoronkwo N, Patel PA, Pyrsopoulos N. Racial Disparities in Liver Transplantation for Hepatocellular Carcinoma: Analysis of the National Inpatient Sample From 2007 to 2014. J Clin Gastroenterol 2023; 57:311-316. [PMID: 35180149 DOI: 10.1097/mcg.0000000000001675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 01/05/2022] [Indexed: 12/10/2022]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) remains a deadly disease, with patients' best hope for a cure being liver transplantation; however, access to health care resources, such as donor organs, between ethnic groups has historically been unbalanced. Ensuring equitable access to donor livers is crucial to minimize disparities in HCC outcomes. As a result, we sought to better elucidate the differences in transplantation rates among various ethnic groups. MATERIALS AND METHODS The National Inpatient Sample (NIS) was utilized to evaluate for disparities in liver transplantation in patients whose primary or secondary diagnosis was recorded as HCC or hepatoma. The study included admissions between 2007 and 2014 to centers with at least 1 documented liver transplant. RESULTS A total of 7244 transplants were performed over 70,406 weighted admissions. Black race was associated with lower transplantation rates, with an adjusted odds ratio of 0.46 (95% confidence interval: 0.42-0.51, P <0.01) when accounting for a number of possible confounders including socioeconomic and geographic factors. CONCLUSIONS Our study observed decreased rates of liver transplant in blacks compared with whites for HCC. Furthermore, improved economic status and private insurance had a significantly higher odds ratio for transplantation. Hospital-level studies are needed to clarify confounding factors not apparent in large administrative datasets and help better investigate factors that lead to less optimal transplant rates among blacks. Interventions may include more optimal screening policies and procedures, improved interdisciplinary management, and earlier referrals.
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Affiliation(s)
| | | | - Keri E Lunsford
- Division of Liver Transplant and HPB Surgery, Department of Surgery and Center for Immunity and Inflammation
| | - Nneoma Okoronkwo
- Department of Gastroenterology, Rutgers New Jersey Medical School, Newark, NJ
| | - Pavan A Patel
- Department of Gastroenterology, Rutgers New Jersey Medical School, Newark, NJ
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13
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Weaver B, Lidofsky S, Scriver G, Lester-Coll N. Insurance Status Correlates with Access to Procedural Therapy for Patients with Early-Stage Hepatocellular Carcinoma: A Retrospective Cohort Study of the National Cancer Database. J Vasc Interv Radiol 2022; 34:824-831.e1. [PMID: 36596321 DOI: 10.1016/j.jvir.2022.12.476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 12/15/2022] [Accepted: 12/26/2022] [Indexed: 01/01/2023] Open
Abstract
PURPOSE To compare access to specific procedural therapies across insurance types for patients with American Joint Commission on Cancer (AJCC) Stage I or II hepatocellular carcinoma (HCC). MATERIALS AND METHODS Using the National Cancer Database, patients diagnosed with Stage I or II HCC between 2004 and 2019 were identified. Parametric and nonparametric testing was used to compare the rates of procedural modalities and time to therapy across insurance types. Univariate and multivariate logistic regression analyses were used to identify the likelihood of receiving specific procedural therapy based on insurance status. RESULTS In total, 105,703 patients with AJCC Stage I or II HCC were identified. The rates of ablative therapy were similar across insurance types (18.1% total, 17.2% private insurance, 15.3% uninsured, 18.1% Medicaid, and 18.8% Medicare). In the logistic regression analysis, patients with private insurance were more likely to receive a transplant or undergo resection or procedural therapy of any kind. Patients with Medicare insurance were more likely to undergo ablation (odds ratio, 1.11; 95% confidence interval, 1.07-1.15; P < .001) than those with private insurance. CONCLUSIONS Patients with private insurance were more likely to receive most forms of procedural therapy for early-stage HCC, with the notable exception of ablative therapy, which patients with Medicare were slightly more likely to receive.
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Affiliation(s)
- Benjamin Weaver
- Larner College of Medicine at the University of Vermont, University of Vermont, Burlington, Vermont.
| | - Steven Lidofsky
- Larner College of Medicine at the University of Vermont, University of Vermont, Burlington, Vermont; University of Vermont Medical Center, Burlington, Vermont
| | - Geoffrey Scriver
- Larner College of Medicine at the University of Vermont, University of Vermont, Burlington, Vermont; University of Vermont Medical Center, Burlington, Vermont
| | - Nataniel Lester-Coll
- Larner College of Medicine at the University of Vermont, University of Vermont, Burlington, Vermont; University of Vermont Medical Center, Burlington, Vermont
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14
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Herren OM, Gillman AS, Marshall VJ, Das R. Understanding the Changing Landscape of Health Disparities in Chronic Liver Diseases and Liver Cancer. GASTRO HEP ADVANCES 2022; 2:505-520. [PMID: 37347072 PMCID: PMC10281758 DOI: 10.1016/j.gastha.2022.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/23/2023]
Abstract
Liver disease and liver cancer disparities in the U.S. are reflective of complex multiple determinants of health. This review describes the disproportionate burden of liver disease and liver cancer among racial, ethnic, sexual, and gender minority, rural, low socioeconomic status (SES) populations, and place-based contexts. The contributions of traditional and lifestyle-related risk factors (e.g., alcohol consumption, evitable toxin exposure, nutrition quality) and comorbid conditions (e.g., viral hepatitis, obesity, type II diabetes) to disparities is also explored. Biopsychosocial mechanisms defining the physiological consequences of inequities underlying these health disparities, including inflammation, allostatic load, genetics, epigenetics, and social epigenomics are described. Guided by the National Institute on Minority Health and Health Disparities (NIMHD) framework, integrative research of unexplored social and biological mechanisms of health disparities, appropriate methods and measures for early screening, diagnosis, assessment, and strategies for timely treatment and maintaining multidisciplinary care should be actively pursued. We review emerging research on adverse social determinants of liver health, such as structural racism, discrimination, stigma, SES, rising care-related costs, food insecurity, healthcare access, health literacy, and environmental exposures to pollutants. Limited research on protective factors of liver health is also described. Research from effective, multilevel, community-based interventions indicate a need for further intervention efforts that target both risk and protective factors to address health disparities. Policy-level impacts are also needed to reduce disparities. These insights are important, as the social contexts and inequities that influence determinants of liver disease/cancer have been worsened by the coronavirus disease-2019 pandemic and are forecasted to amplify disparities.
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Affiliation(s)
- Olga M. Herren
- Extramural Scientific Programs, Division of Integrative Biological and Behavioral Sciences
| | - Arielle S. Gillman
- Extramural Scientific Programs, Division of Integrative Biological and Behavioral Sciences
| | - Vanessa J. Marshall
- Office of the Director National Institute on Minority Health and Health Disparities (NIMHD), Bethesda, MD
| | - Rina Das
- Extramural Scientific Programs, Division of Integrative Biological and Behavioral Sciences
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15
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Ruffolo LI, Zambrano D, Dale BS, Nimmagadda SV, Hack M, Gaba H, Belt BA, Burchard PR, LanzDuret-Hernandez JM, Dokus MK, Aponte JP, Tomiyama K, Nair A, Pineda-Solis K, Hernandez-Alejandro R. Inferior Survival Is Associated With Socioeconomic Deprivation in Hepatocellular Carcinoma. J Surg Res 2022; 279:228-239. [DOI: 10.1016/j.jss.2022.05.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 04/14/2022] [Accepted: 05/06/2022] [Indexed: 10/31/2022]
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16
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Reynolds J, Hashimi S, Nguyen N, Infield J, Weir A, Khattak A. The Effect of Race on Outcomes in Veterans With Hepatocellular Carcinoma at a Single Center. Fed Pract 2022; 39:S64-S67a. [PMID: 36426109 PMCID: PMC9662307 DOI: 10.12788/fp.0304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Black patients have a higher incidence and mortality associated with hepatocellular carcinoma (HCC) compared with that of White patients in many retrospective analyses. This study sought to determine whether veterans treated for HCC at the Memphis Veterans Affairs Medical Center (VAMC) in Tennessee showed similar disparities in terms of stage at diagnosis, type of therapy received, and overall survival (OS). METHODS A retrospective review evaluated 132 White and 95 Black patients treated for HCC between 2009 and 2021. We evaluated the impact on OS of age, sex, comorbidities, tumor stage, α-fetoprotein level, method of diagnosis, first-line treatment, systemic treatment, and surgical options offered. Kaplan-Meier analysis was used to investigate differences in OS and cumulative hazard ratio for death. Cox regression multivariate analysis evaluated discrepancies among investigated variables. RESULTS The study found no significant difference in OS between Black and White veterans with HCC. Significant differences were found in who received surgical treatment and systemic therapy. More White veterans received any form of treatment compared with Black veterans (P < .001), and White veterans were more likely to undergo surgical resection and transplant (P = .052). There was no significant difference between age or stage at diagnosis, receipt of systemic therapy, alcohol, tobacco or drug use, HIV coinfection, or cirrhosis. CONCLUSIONS Black veterans with HCC at the Memphis VAMC were less likely to receive any form of treatment, surgical resection, or transplant compared with White veterans, but this did not have a statistically significant effect on OS.
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Affiliation(s)
| | - Sarah Hashimi
- The University of Tennessee Health Science Center, Memphis
| | - Ngan Nguyen
- The University of Tennessee Health Science Center, Memphis
| | - Jordan Infield
- The University of Tennessee Health Science Center, Memphis
- Duke University Health System, Durham, North Carolina
| | - Alva Weir
- The University of Tennessee Health Science Center, Memphis
- Memphis Veterans Affairs Medical Center, Tennessee
| | - Amna Khattak
- The University of Tennessee Health Science Center, Memphis
- Memphis Veterans Affairs Medical Center, Tennessee
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17
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Nash R, Russell MC, Miller-Kleinhenz JM, Collin LJ, Ross-Driscoll K, Switchenko JM, McCullough LE. Understanding gastrointestinal cancer mortality disparities in a racially and geographically diverse population. Cancer Epidemiol 2022; 77:102110. [PMID: 35144126 PMCID: PMC8923985 DOI: 10.1016/j.canep.2022.102110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 01/13/2022] [Accepted: 01/16/2022] [Indexed: 11/02/2022]
Abstract
BACKGROUND Gastrointestinal (GI) cancers represent a diverse group of diseases. We assessed differences in geographic and racial disparities in cancer-specific mortality across subtypes, overall and by patient characteristics, in a geographically and racially diverse US population. METHODS Clinical, sociodemographic, and treatment characteristics for patients diagnosed during 2009-2014 with colorectal cancer (CRC), pancreatic cancer, hepatocellular carcinoma (HCC), or gastric cancer in Georgia were obtained from the Surveillance, Epidemiology, and End Results Program database. Patients were classified by geography (rural or urban county) and race and followed for cancer-specific death. Multivariable Cox proportional hazards models were used to calculate stratified hazard ratios (HR) and 95% confidence intervals (CIs) for associations between geography or race and cancer-specific mortality. RESULTS Overall, 77% of the study population resided in urban counties and 33% were non-Hispanic Black (NHB). For all subtypes, NHB patients were more likely to reside in urban counties than non-Hispanic White patients. Residing in a rural county was associated with an overall increased hazard of cancer-specific mortality for HCC (HR = 1.15, 95% CI = 1.02-1.31), pancreatic (HR = 1.11, 95% CI = 1.03-1.19), and gastric cancer (HR = 1.17, 95% CI = 1.03-1.32) but near-null for CRC. Overall racial disparities were observed for CRC (HR = 1.18, 95% CI = 1.11-1.25) and HCC (HR = 1.12, 95% CI = 1.01-1.24). Geographic disparities were most pronounced among HCC patients receiving surgery. Racial disparities were pronounced among CRC patients receiving any treatment. CONCLUSION Geographic disparities were observed for the rarer GI cancer subtypes, and racial disparities were pronounced for CRC. Treatment factors appear to largely drive both disparities.
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Affiliation(s)
- Rebecca Nash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
| | - Maria C Russell
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Lindsay J Collin
- Department of Population Health Sciences, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Katherine Ross-Driscoll
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Jeffrey M Switchenko
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Lauren E McCullough
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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18
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VoPham T, Bertrand KA, Fisher JA, Ward MH, Laden F, Jones RR. Emissions of dioxins and dioxin-like compounds and incidence of hepatocellular carcinoma in the United States. ENVIRONMENTAL RESEARCH 2022; 204:112386. [PMID: 34800530 PMCID: PMC8671236 DOI: 10.1016/j.envres.2021.112386] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 10/19/2021] [Accepted: 11/12/2021] [Indexed: 05/07/2023]
Abstract
Ambient dioxin exposure from industrial sources, excluding exposures from occupations and accidental releases/contamination, may be associated with risk of developing hepatocellular carcinoma (HCC). The objective of this study was to examine the association between county-level ambient dioxin air emissions from industrial sources and HCC risk in the US. We obtained information on 90,359 incident HCC cases diagnosed between 2000 and 2016 from population-based cancer registries across the US in the Surveillance, Epidemiology, and End Results (SEER) database. Dioxin emissions from 1987 to 2007 from a nationwide spatial database of historical dioxin-emitting facilities were linked to the SEER county of residence at diagnosis using a geographic information system (GIS). Poisson regression with robust variance estimation was used to calculate incidence rate ratios (IRRs) and 95% confidence intervals (CIs) for the association between county-level dioxin emissions and HCC rates adjusting for individual-level age at diagnosis, sex, race/ethnicity, year of diagnosis, SEER registry, and county-level information on health conditions, lifestyle factors, and socioeconomic status. There was no association between dioxin emissions based on the number of dioxin-emitting facilities within a county or average annual emissions within a county and HCC risk. In analyses by facility type, there were positive associations between county-level dioxin emissions from coal-fired power plants (adjusted IRR 1.09, 95% CI 1.01-1.17), but not with the number of these facilities. Similarly, positive associations for industrial boilers and sewage sludge incinerators were evident, but not consistent across both exposure metrics. Future research should incorporate individual-level data to further explore the findings suggested by these ecologic analyses.
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Affiliation(s)
- Trang VoPham
- Epidemiology Program, Public Health Sciences Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue N, Seattle, WA, 98109, United States; Department of Epidemiology, University of Washington School of Public Health, 3980 15th Avenue NE, Seattle, WA, 98195, United States.
| | - Kimberly A Bertrand
- Slone Epidemiology Center at Boston University, 72 East Concord Street L-7, Boston, MA, 02118, United States
| | - Jared A Fisher
- Occupational and Environmental Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Department of Health and Human Services, 9609 Medical Center Drive MSC 9776, Bethesda, MD, 20850, United States
| | - Mary H Ward
- Occupational and Environmental Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Department of Health and Human Services, 9609 Medical Center Drive MSC 9776, Bethesda, MD, 20850, United States
| | - Francine Laden
- Exposure, Epidemiology, and Risk Program, Department of Environmental Health, Harvard T.H. Chan School of Public Health, Department of Environmental Health, Harvard T.H. Chan School of Public Health, 655 Huntington Avenue, Boston, MA, 02115, United States; Department of Epidemiology, Harvard T.H. Chan School of Public Health, 655 Huntington Avenue, Boston, MA, 02115, United States; Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 181 Longwood Avenue, Boston, MA, 02115, United States
| | - Rena R Jones
- Occupational and Environmental Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Department of Health and Human Services, 9609 Medical Center Drive MSC 9776, Bethesda, MD, 20850, United States
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19
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Kubota N, Fujiwara N, Hoshida Y. Liver cancer risk-predictive molecular biomarkers specific to clinico-epidemiological contexts. Adv Cancer Res 2022; 156:1-37. [PMID: 35961696 PMCID: PMC7616039 DOI: 10.1016/bs.acr.2022.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Hepatocellular carcinoma (HCC) risk prediction is increasingly important because of the low annual HCC incidence in patients with the rapidly emerging non-alcoholic fatty liver disease or cured HCV infection. To date, numerous clinical HCC risk biomarkers and scores have been reported in literature. However, heterogeneity in clinico-epidemiological context, e.g., liver disease etiology, patient race/ethnicity, regional environmental exposure, and lifestyle-related factors, obscure their real clinical utility and applicability. Proper characterization of these factors will help refine HCC risk prediction according to certain clinical context/scenarios and contribute to improved early HCC detection. Molecular factors underlying the clinical heterogeneity encompass various features in host genetics, hepatic and systemic molecular dysregulations, and cross-organ interactions, which may serve as clinical-context-specific biomarkers and/or therapeutic targets. Toward the goal to enable individual-risk-based HCC screening by incorporating the HCC risk biomarkers/scores, their assessment in patient with well-defined clinical context/scenario is critical to gauge their real value and to maximize benefit of the tailored patient management for substantial improvement of the poor HCC prognosis.
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Affiliation(s)
- Naoto Kubota
- Liver Tumor Translational Research Program, Simmons Comprehensive Cancer Center, Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Naoto Fujiwara
- Liver Tumor Translational Research Program, Simmons Comprehensive Cancer Center, Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States; Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yujin Hoshida
- Liver Tumor Translational Research Program, Simmons Comprehensive Cancer Center, Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States.
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20
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Rich NE, Carr C, Yopp AC, Marrero JA, Singal AG. Racial and Ethnic Disparities in Survival Among Patients With Hepatocellular Carcinoma in the United States: A Systematic Review and Meta-Analysis. Clin Gastroenterol Hepatol 2022; 20:e267-e288. [PMID: 33387668 PMCID: PMC8243558 DOI: 10.1016/j.cgh.2020.12.029] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 12/22/2020] [Accepted: 12/24/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Hepatocellular carcinoma (HCC) is the fastest rising cause of cancer-related death in the United States; however, HCC incidence and mortality are not equally distributed among racial and ethnic groups. Our aim was to characterize the direction and magnitude of racial and ethnic disparities in overall survival and early tumor detection among patients with HCC. METHODS We searched MEDLINE, EMBASE and Cochrane databases from inception through August 2020 for studies reporting HCC outcomes (early stage presentation and overall survival) by race and ethnicity. We calculated pooled hazard ratios (HRs) and odds ratios (ORs) for each racial and ethnic group (White, Black, Hispanic, Asian) using the DerSimonian and Laird method for a random-effects model. RESULTS We identified 35 articles comprising 563,097 patients (53.0% White, 17.3% Black, 18.4% Hispanic, 5.0% Asian). Compared with White patients, Black patients had worse survival (pooled HR 1.08; 95% CI, 1.05 - 1.12), whereas Hispanic (pooled HR 0.92; 95% CI, 0.87 - 0.97) and Asian (pooled HR 0.81; 95% CI, 0.73 - 0.88) patients had better survival. Among articles reporting tumor stage (n = 20), Black patients had lower odds of early stage HCC compared with White patients (OR, 0.66; 95% CI, 0.54 - 0.78). Conversely, there was no difference in odds of early HCC detection for Asian (OR, 1.01; 95% CI, 0.97 - 1.05) or Hispanic patients (OR, 0.87; 95% CI, 0.74 - 1.01) compared with White patients. The most common limitation of studies was risk of residual confounding from socioeconomic status and liver dysfunction. CONCLUSIONS There are significant racial and ethnic disparities in HCC prognosis in the United States, with Black patients having worse overall survival and Hispanic and Asian patients having better overall survival compared with White patients. Interventions are needed to reduce disparities in early HCC detection to improve HCC prognosis.
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Affiliation(s)
- Nicole E Rich
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas; Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, Texas.
| | - Christian Carr
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Adam C Yopp
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas; Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, Texas
| | - Jorge A Marrero
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas; Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, Texas
| | - Amit G Singal
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas; Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, Texas
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21
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Kronenfeld JP, Goel N. An Analysis of Individual and Contextual-Level Disparities in Screening, Treatment, and Outcomes for Hepatocellular Carcinoma. J Hepatocell Carcinoma 2021; 8:1209-1219. [PMID: 34611524 PMCID: PMC8487287 DOI: 10.2147/jhc.s284430] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 09/02/2021] [Indexed: 12/11/2022] Open
Abstract
Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver and affects patients of all genders, races, ethnicities, and socioeconomic status. While the causes of HCC are numerous, the primary etiology is cirrhosis from alcohol and non-alcoholic fatty liver disease in the United States and from infectious agents such as Hepatitis B and Hepatitis C in the developing world. In patients at-risk for developing HCC, screening is recommended with ultrasound imaging and alpha fetoprotein laboratory tests. In socioeconomically vulnerable patients, however, individual-level barriers (eg, insurance status) and contextual-level disparities (eg, health facilities) may not be readily available, thus limiting screening. Additional challenges faced by racial/ethnic minorities can further challenge the spectrum of HCC care and lead to inadequate screening, delayed diagnosis, and unequal access to treatment. Efforts to improve these multilevel factors that lead to screening and treatment disparities are critical to overcoming challenges. Providing health insurance to those without access, improving societal challenges that confine patients to a lower socioeconomic status, and reducing challenges to seeking healthcare can decrease the morbidity and mortality of these patients. Additionally, engaging with communities and allowing them to collaborate in their own healthcare can also help to attenuate these inequities. Through collaborative multidisciplinary change, we can make progress in tackling disparities in vulnerable populations to achieve health equity
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Affiliation(s)
- Joshua P Kronenfeld
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Neha Goel
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
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22
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Yu C, Liang Y, Jin Y, Li Q. LncRNA GAS5 enhances radiosensitivity of hepatocellular carcinoma and restricts tumor growth and metastasis by miR-144-5p/ATF2. Am J Transl Res 2021; 13:10896-10907. [PMID: 34650771 PMCID: PMC8506991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 07/28/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND This study aimed to evaluate the biologic role of growth arrest-specific 5 (GAS5) in radiosensitivity of hepatocellular carcinoma (HCC). METHODS The levels of GAS5, miR-144-5p, and activating transcription factor 2 (ATF2) were quantified in HCC tissues and cell lines. RNA immunoprecipitation (RIP) and RNA pull-down assays were used to test the interaction between GAS5 and miR-144-5p. The regulatory relationship between miR-144-5p and ATF2 was identified by the dual-luciferase reporter (DLR) assay. A nude mouse model of HCC was induced to verify the effect of GAS5 on radiosensitivity of HCC in vivo. RESULTS Lower levels of GAS5 and ATF2, and higher levels of miR-144-5p, were found in radiation-resistant human HCC tissues and cell lines. Overexpression of ATF2 or GAS5 enhanced the radiosensitivity of HCC cell lines, while knockdown of ATF2 or GAS5 decreased the radiosensitivity. In addition, GAS5 acted as a miR-144-5p sponge, and miR-144-5p inversely regulated ATF2. Also, GAS5 mediated ATF2 levels through miR-144-5p, and increased the radiosensitivity of HCC by suppressing miR-144-5p both in vivo and in vitro. CONCLUSION Overexpression of GAS5 upregulates ATF2 through miR-144-5p and is able to enhance the radiosensitivity of HCC.
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Affiliation(s)
- Chuanyun Yu
- Oncology Radiotherapy Center, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and ScienceXiangyang 441021, Hubei, China
| | - Yi Liang
- Oncology Radiotherapy Center, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and ScienceXiangyang 441021, Hubei, China
| | - Yiqiang Jin
- Department of Oncology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and ScienceXiangyang 441021, Hubei, China
| | - Qinghuan Li
- Oncology Radiotherapy Center, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and ScienceXiangyang 441021, Hubei, China
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23
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Varghese RS, Barefoot ME, Jain S, Chen Y, Zhang Y, Alley A, Kroemer AH, Tadesse MG, Kumar D, Sherif ZA, Ressom HW. Integrative Analysis of DNA Methylation and microRNA Expression Reveals Mechanisms of Racial Heterogeneity in Hepatocellular Carcinoma. Front Genet 2021; 12:708326. [PMID: 34557219 PMCID: PMC8453167 DOI: 10.3389/fgene.2021.708326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 08/05/2021] [Indexed: 11/13/2022] Open
Abstract
Pathologic alterations in epigenetic regulation have long been considered a hallmark of many cancers, including hepatocellular carcinoma (HCC). In a healthy individual, the relationship between DNA methylation and microRNA (miRNA) expression maintains a fine balance; however, disruptions in this harmony can aid in the genesis of cancer or the propagation of existing cancers. The balance between DNA methylation and microRNA expression and its potential disturbance in HCC can vary by race. There is emerging evidence linking epigenetic events including DNA methylation and miRNA expression to cancer disparities. In this paper, we evaluate the epigenetic mechanisms of racial heterogenity in HCC through an integrated analysis of DNA methylation, miRNA, and combined regulation of gene expression. Specifically, we generated DNA methylation, mRNA-seq, and miRNA-seq data through the analysis of tumor and adjacent non-tumor liver tissues from African Americans (AA) and European Americans (EA) with HCC. Using mixed ANOVA, we identified cytosine-phosphate-guanine (CpG) sites, mRNAs, and miRNAs that are significantly altered in HCC vs. adjacent non-tumor tissue in a race-specific manner. We observed that the methylome was drastically changed in EA with a significantly larger number of differentially methylated and differentially expressed genes than in AA. On the other hand, the miRNA expression was altered to a larger extent in AA than in EA. Pathway analysis functionally linked epigenetic regulation in EA to processes involved in immune cell maturation, inflammation, and vascular remodeling. In contrast, cellular proliferation, metabolism, and growth pathways are found to predominate in AA as a result of this epigenetic analysis. Furthermore, through integrative analysis, we identified significantly differentially expressed genes in HCC with disparate epigenetic regulation, associated with changes in miRNA expression for AA and DNA methylation for EA.
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Affiliation(s)
- Rency S. Varghese
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, United States
| | - Megan E. Barefoot
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, United States
| | - Sidharth Jain
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, United States
| | - Yifan Chen
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, United States
| | - Yunxi Zhang
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, United States
| | - Amber Alley
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, United States
| | | | - Mahlet G. Tadesse
- Department of Mathematics and Statistics, Georgetown University, Washington, DC, United States
| | - Deepak Kumar
- Department of Pharmaceutical Sciences, North Carolina Central University, Durham, NC, United States
| | - Zaki A. Sherif
- Department of Biochemistry and Molecular Biology, College of Medicine, Howard University, Washington, DC, United States
| | - Habtom W. Ressom
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, United States
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24
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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: 11] [Impact Index Per Article: 3.7] [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.
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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
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25
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Kronenfeld JP, Ryon EL, Goldberg D, Lee RM, Yopp A, Wang A, Lee AY, Luu S, Hsu C, Silberfein E, Russell MC, Merchant NB, Goel N. Survival inequity in vulnerable populations with early-stage hepatocellular carcinoma: a United States safety-net collaborative analysis. HPB (Oxford) 2021; 23:868-876. [PMID: 33487553 PMCID: PMC8205960 DOI: 10.1016/j.hpb.2020.11.1150] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/12/2020] [Accepted: 11/24/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Access to health insurance and curative interventions [surgery/liver-directed-therapy (LDT)] affects survival for early-stage hepatocellular carcinoma (HCC). The aim of this multi-institutional study of high-volume safety-net hospitals (SNHs) and their tertiary-academic-centers (AC) was to identify the impact of type/lack of insurance on survival disparities across hospitals, particularly SNHs whose mission is to minimize insurance related access-to-care barriers for vulnerable populations. METHODS Early-stage HCC patients (2012-2014) from the US Safety-Net Collaborative were propensity-score matched by treatment at SNH/AC. Overall survival (OS) was the primary outcome. Multivariable Cox proportional-hazard analysis was performed accounting for sociodemographic/clinical parameters. RESULTS Among 925 patients, those with no insurance (NI) had decreased curative surgery, compared to those with government insurance (GI) and private insurance [PI, (PI-SNH:60.5% vs. GI-SNH:33.1% vs. NI-SNH:13.6%, p < 0.001)], and decreased median OS (PI-SNH:32.1 vs. GI-SNH:22.8 vs. NI-SNH:9.4 months, p = 0.002). On multivariable regression controlling for sociodemographic/clinical parameters, NI-SNH (HR:2.5, 95% CI:1.3-4.9, p = 0.007) was the only insurance type/hospital system combination with significantly worse OS. CONCLUSION NI-SNH patients received less curative treatment than other insurance/hospitals types suggesting that treatment barriers, beyond access-to-care, need to be identified and addressed to achieve survival equity in early-stage HCC for vulnerable populations (NI-SNH).
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Affiliation(s)
- Joshua P Kronenfeld
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 410, Miami, FL 33136, USA
| | - Emily L Ryon
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 410, Miami, FL 33136, USA
| | - David Goldberg
- Division of Digestive Health and Liver Disease, Department of Medicine, University of Miami Miller School of Medicine, 1475 NW 12th Ave, Miami, FL 33136, USA
| | - Rachel M Lee
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, 1365-C Clifton Road NE Atlanta, 30322, Georgia
| | - Adam Yopp
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical School, 2201 Inwood Rd 3rd Floor Suite 500, Dallas, TX 75390, USA
| | - Annie Wang
- Division of Surgical Oncology, Department of Surgery, NYU Langone Health, 160 East 34th Street, 3rd Floor, New York, NY, 10016, USA
| | - Ann Y Lee
- Division of Surgical Oncology, Department of Surgery, NYU Langone Health, 160 East 34th Street, 3rd Floor, New York, NY, 10016, USA
| | - Sommer Luu
- Division of Surgical Oncology, Department of Surgery, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
| | - Cary Hsu
- Division of Surgical Oncology, Department of Surgery, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
| | - Eric Silberfein
- Division of Surgical Oncology, Department of Surgery, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
| | - Maria C Russell
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, 1365-C Clifton Road NE Atlanta, 30322, Georgia
| | - Nipun B Merchant
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 410, Miami, FL 33136, USA
| | - Neha Goel
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 410, Miami, FL 33136, USA.
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26
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Poulson MR, Blanco BA, Geary AD, Kenzik KM, McAneny DB, Tseng JF, Sachs TE. The role of racial segregation in treatment and outcomes among patients with hepatocellular carcinoma. HPB (Oxford) 2021; 23:854-860. [PMID: 33536151 PMCID: PMC8527332 DOI: 10.1016/j.hpb.2020.12.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 12/08/2020] [Accepted: 12/22/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND There is a long history of segregation in the U.S.A with enduring impacts on cancer outcomes today. We evaluated the impact of segregation on racial disparities in Hepatocellular Carcinoma (HCC) treatment and outcomes. METHODS We obtained data on black and white patients with HCC from the SEER program (2005-2015) within the 100 most populous participating counties. Our exposure was the index of dissimilarity (IoD), a validated measure of segregation. Outcomes were overall survival, advanced stage at diagnosis (Stage III/IV) and surgery for localized disease (Stage I/II). Cancer-specific survival was assessed using Kaplan-Meier estimates. RESULTS Black patients had a 1.18 times increased risk (95%CI 1.14,1.22) of presenting at advanced stage as compared to white patients and these disparities disappeared at low levels of segregation. In the highest quartile of IoD, black patients had a significantly lower survival than white (17 months vs 27 months, p < 0.001), and this difference disappeared at the lowest quartile of IoD. CONCLUSIONS Our data illustrate that structural racism in the form racial segregation has a significant impact on racial disparities in the treatment of HCC. Urban and health policy changes can potentially reduce disparities in HCC outcomes.
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Affiliation(s)
| | - B Aldana Blanco
- Department of Surgery, Boston University/Boston Medical Center, USA
| | - Alaina D Geary
- Department of Surgery, Boston University/Boston Medical Center, USA
| | - Kelly M Kenzik
- Department of Surgery, Boston University/Boston Medical Center, USA; Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David B McAneny
- Department of Surgery, Boston University/Boston Medical Center, USA
| | - Jennifer F Tseng
- Department of Surgery, Boston University/Boston Medical Center, USA
| | - Teviah E Sachs
- Department of Surgery, Boston University/Boston Medical Center, USA.
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27
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Zhou K, Pickering TA, Gainey CS, Cockburn M, Stern MC, Liu L, Unger JB, El-Khoueiry AB, Terrault NA. Presentation, Management, and Outcomes Across the Rural-Urban Continuum for Hepatocellular Carcinoma. JNCI Cancer Spectr 2021; 5:pkaa100. [PMID: 33442663 PMCID: PMC7791625 DOI: 10.1093/jncics/pkaa100] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 09/30/2020] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- Kali Zhou
- Department of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Trevor A Pickering
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA, USA
| | - Christina S Gainey
- Department of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Myles Cockburn
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA, USA.,Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Mariana C Stern
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA, USA.,Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Lihua Liu
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA, USA.,Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Jennifer B Unger
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA, USA.,Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Anthony B El-Khoueiry
- Department of Medicine, University of Southern California, Los Angeles, CA, USA.,Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Norah A Terrault
- Department of Medicine, University of Southern California, Los Angeles, CA, USA
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28
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Zavala VA, Bracci PM, Carethers JM, Carvajal-Carmona L, Coggins NB, Cruz-Correa MR, Davis M, de Smith AJ, Dutil J, Figueiredo JC, Fox R, Graves KD, Gomez SL, Llera A, Neuhausen SL, Newman L, Nguyen T, Palmer JR, Palmer NR, Pérez-Stable EJ, Piawah S, Rodriquez EJ, Sanabria-Salas MC, Schmit SL, Serrano-Gomez SJ, Stern MC, Weitzel J, Yang JJ, Zabaleta J, Ziv E, Fejerman L. Cancer health disparities in racial/ethnic minorities in the United States. Br J Cancer 2021; 124:315-332. [PMID: 32901135 PMCID: PMC7852513 DOI: 10.1038/s41416-020-01038-6] [Citation(s) in RCA: 483] [Impact Index Per Article: 161.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 07/16/2020] [Accepted: 08/03/2020] [Indexed: 02/06/2023] Open
Abstract
There are well-established disparities in cancer incidence and outcomes by race/ethnicity that result from the interplay between structural, socioeconomic, socio-environmental, behavioural and biological factors. However, large research studies designed to investigate factors contributing to cancer aetiology and progression have mainly focused on populations of European origin. The limitations in clinicopathological and genetic data, as well as the reduced availability of biospecimens from diverse populations, contribute to the knowledge gap and have the potential to widen cancer health disparities. In this review, we summarise reported disparities and associated factors in the United States of America (USA) for the most common cancers (breast, prostate, lung and colon), and for a subset of other cancers that highlight the complexity of disparities (gastric, liver, pancreas and leukaemia). We focus on populations commonly identified and referred to as racial/ethnic minorities in the USA-African Americans/Blacks, American Indians and Alaska Natives, Asians, Native Hawaiians/other Pacific Islanders and Hispanics/Latinos. We conclude that even though substantial progress has been made in understanding the factors underlying cancer health disparities, marked inequities persist. Additional efforts are needed to include participants from diverse populations in the research of cancer aetiology, biology and treatment. Furthermore, to eliminate cancer health disparities, it will be necessary to facilitate access to, and utilisation of, health services to all individuals, and to address structural inequities, including racism, that disproportionally affect racial/ethnic minorities in the USA.
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Affiliation(s)
- Valentina A Zavala
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Paige M Bracci
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - John M Carethers
- Departments of Internal Medicine and Human Genetics, and Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
| | - Luis Carvajal-Carmona
- University of California Davis Comprehensive Cancer Center and Department of Biochemistry and Molecular Medicine, School of Medicine, University of California Davis, Sacramento, CA, USA
- Genome Center, University of California Davis, Davis, CA, USA
| | | | - Marcia R Cruz-Correa
- Department of Cancer Biology, University of Puerto Rico Comprehensive Cancer Center, San Juan, Puerto Rico
| | - Melissa Davis
- Division of Breast Surgery, Department of Surgery, NewYork-Presbyterian/Weill Cornell Medical Center, New York, NY, USA
| | - Adam J de Smith
- Center for Genetic Epidemiology, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Julie Dutil
- Cancer Biology Division, Ponce Research Institute, Ponce Health Sciences University, Ponce, Puerto Rico
| | - Jane C Figueiredo
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Rena Fox
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Kristi D Graves
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
| | - Scarlett Lin Gomez
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA
| | - Andrea Llera
- Laboratorio de Terapia Molecular y Celular, IIBBA, Fundación Instituto Leloir, CONICET, Buenos Aires, Argentina
| | - Susan L Neuhausen
- Department of Population Sciences, Beckman Research Institute of City of Hope, Duarte, CA, USA
| | - Lisa Newman
- Division of Breast Surgery, Department of Surgery, NewYork-Presbyterian/Weill Cornell Medical Center, New York, NY, USA
- Interdisciplinary Breast Program, New York-Presbyterian/Weill Cornell Medical Center, New York, NY, USA
| | - Tung Nguyen
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Julie R Palmer
- Slone Epidemiology Center at Boston University, Boston, MA, USA
| | - Nynikka R Palmer
- Department of Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, USA
| | - Eliseo J Pérez-Stable
- Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
- Office of the Director, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
| | - Sorbarikor Piawah
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Erik J Rodriquez
- Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | | | - Stephanie L Schmit
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Silvia J Serrano-Gomez
- Grupo de investigación en biología del cáncer, Instituto Nacional de Cancerología, Bogotá, Colombia
| | - Mariana C Stern
- Departments of Preventive Medicine and Urology, Keck School of Medicine of USC, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Jeffrey Weitzel
- Department of Population Sciences, Beckman Research Institute of City of Hope, Duarte, CA, USA
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Jun J Yang
- Department of Pharmaceutical Sciences, Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jovanny Zabaleta
- Department of Pediatrics and Stanley S. Scott Cancer Center LSUHSC, New Orleans, LA, USA
| | - Elad Ziv
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Laura Fejerman
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.
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Singh A, Zhong Y, Nahlawi L, Park CS, De T, Alarcon C, Perera MA. Incorporation of DNA methylation into eQTL mapping in African Americans. PACIFIC SYMPOSIUM ON BIOCOMPUTING. PACIFIC SYMPOSIUM ON BIOCOMPUTING 2021; 26:244-255. [PMID: 33691021 PMCID: PMC7958994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Epigenetics is a reversible molecular mechanism that plays a critical role in many developmental, adaptive, and disease processes. DNA methylation has been shown to regulate gene expression and the advent of high throughput technologies has made genome-wide DNA methylation analysis possible. We investigated the effect of DNA methylation on eQTL mapping (methylation-adjusted eQTLs), by incorporating DNA methylation as a SNP-based covariate in eQTL mapping in African American derived hepatocytes. We found that the addition of DNA methylation uncovered new eQTLs and eGenes. Previously discovered eQTLs were significantly altered by the addition of DNA methylation data suggesting that methylation may modulate the association of SNPs to gene expression. We found that methylation-adjusted eQTLs that were less significant compared to PC-adjusted eQTLs were enriched in lipoprotein measurements (FDR=0.0040), immune system disorders (FDR = 0.0042), and liver enzyme measurements (FDR=0.047), suggesting that DNA methylation modulates the genetic regulation of these phenotypes. Our methylation-adjusted eQTL analysis also uncovered novel SNP-gene pairs. For example, we found that the SNP, rs1332018, was associated to GSTM3. GSTM3 expression has been linked to Hepatitis B which African Americans suffer from disproportionately. Our methylation-adjusted method adds new understanding to the genetic basis of complex diseases that disproportionally affect African Americans.
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Gordan JD, Kennedy EB, Abou-Alfa GK, Beg MS, Brower ST, Gade TP, Goff L, Gupta S, Guy J, Harris WP, Iyer R, Jaiyesimi I, Jhawer M, Karippot A, Kaseb AO, Kelley RK, Knox JJ, Kortmansky J, Leaf A, Remak WM, Shroff RT, Sohal DPS, Taddei TH, Venepalli NK, Wilson A, Zhu AX, Rose MG. Systemic Therapy for Advanced Hepatocellular Carcinoma: ASCO Guideline. J Clin Oncol 2020; 38:4317-4345. [PMID: 33197225 DOI: 10.1200/jco.20.02672] [Citation(s) in RCA: 372] [Impact Index Per Article: 93.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2020] [Indexed: 12/18/2022] Open
Abstract
PURPOSE To develop an evidence-based clinical practice guideline to assist in clinical decision making for patients with advanced hepatocellular carcinoma (HCC). METHODS ASCO convened an Expert Panel to conduct a systematic review of published phase III randomized controlled trials (2007-2020) on systemic therapy for advanced HCC and provide recommended care options for this patient population. RESULTS Nine phase III randomized controlled trials met the inclusion criteria. RECOMMENDATIONS Atezolizumab + bevacizumab (atezo + bev) may be offered as first-line treatment of most patients with advanced HCC, Child-Pugh class A liver disease, Eastern Cooperative Oncology Group Performance Status (ECOG PS) 0-1, and following management of esophageal varices, when present, according to institutional guidelines. Where there are contraindications to atezolizumab and/or bevacizumab, tyrosine kinase inhibitors sorafenib or lenvatinib may be offered as first-line treatment of patients with advanced HCC, Child-Pugh class A liver disease, and ECOG PS 0-1. Following first-line treatment with atezo + bev, and until better data are available, second-line therapy with a tyrosine kinase inhibitor may be recommended for appropriate candidates. Following first-line therapy with sorafenib or lenvatinib, second-line therapy options for appropriate candidates include cabozantinib, regorafenib for patients who previously tolerated sorafenib, or ramucirumab (for patients with α-fetoprotein ≥ 400 ng/mL), or atezo + bev where patients did not have access to this option as first-line therapy. Pembrolizumab or nivolumab are also reasonable options for appropriate patients following sorafenib or lenvatinib. Consideration of nivolumab + ipilimumab as an option for second-line therapy and third-line therapy is discussed. Further guidance on choosing between therapy options is included within the guideline. Additional information is available at www.asco.org/gastrointestinal-cancer-guidelines.
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Affiliation(s)
- John D Gordan
- University of California, San Francisco, San Francisco, CA
| | | | - Ghassan K Abou-Alfa
- Memorial Sloan Kettering Cancer Center, Weill Medical College at Cornell University, New York, NY
| | | | - Steven T Brower
- Lefcourt Family Cancer Treatment and Wellness Center, Englewood, NJ
| | | | - Laura Goff
- Vanderbilt Ingram Cancer Center, Nashville, TN
| | | | | | | | - Renuka Iyer
- Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | | | | | | | | | - R Kate Kelley
- University of California, San Francisco, San Francisco, CA
| | | | | | - Andrea Leaf
- VA New York Harbor Healthcare System, Brooklyn, NY
| | - William M Remak
- California Hepatitis C Task Force, California Chronic Care Coalition, FAIR Foundation, San Francisco, CA
| | | | | | - Tamar H Taddei
- Yale University School of Medicine and VA Connecticut Healthcare System, West Haven, CT
| | | | - Andrea Wilson
- Blue Faery: The Adrienne Wilson Liver Cancer Association, Birmingham, AL
| | - Andrew X Zhu
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - Michal G Rose
- Yale Cancer Center and VA Connecticut Healthcare System, West Haven, CT
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31
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Casak SJ, Donoghue M, Fashoyin-Aje L, Jiang X, Rodriguez L, Shen YL, Xu Y, Jiang X, Liu J, Zhao H, Pierce WF, Mehta S, Goldberg KB, Theoret MR, Kluetz PG, Pazdur R, Lemery SJ. FDA Approval Summary: Atezolizumab Plus Bevacizumab for the Treatment of Patients with Advanced Unresectable or Metastatic Hepatocellular Carcinoma. Clin Cancer Res 2020; 27:1836-1841. [PMID: 33139264 DOI: 10.1158/1078-0432.ccr-20-3407] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 10/07/2020] [Accepted: 10/30/2020] [Indexed: 12/30/2022]
Abstract
On May 29, 2020, the FDA approved atezolizumab for use in combination with bevacizumab, for the treatment of adult patients with unresectable locally advanced or metastatic hepatocellular carcinoma (HCC) with no prior systemic treatment. The approval was based on data from Study IMbrave150, which randomly allocated (2:1) patients to receive either atezolizumab plus bevacizumab (atezolizumab-bevacizumab) or sorafenib. Overall survival (OS) and independently assessed progression-free survival (PFS) in the intent-to-treat population were the primary endpoints. At the time of the primary analysis, the estimated median OS could not be estimated in the atezolizumab-bevacizumab arm and was 13.2 months in the sorafenib arm [HR, 0.58; 95% confidence interval (CI), 0.42-0.79]. The estimated median PFS was 6.8 months (95% CI, 5.8-8.3) and 4.3 months (95% CI, 4.0-5.6) in the atezolizumab-bevacizumab and sorafenib arms, respectively. Adverse reactions occurring in >20% of patients receiving atezolizumab-bevacizumab were hypertension, fatigue/asthenia, and proteinuria. Adverse reactions occurring in >20% of patients receiving sorafenib were palmar-plantar erythrodysesthesia, diarrhea, hypertension, and decreased appetite. Hemorrhage was reported more frequently in patients receiving atezolizumab-bevacizumab (25%) than in patients receiving sorafenib (17%). An evaluation for the presence of varices is recommended within 6 months of initiation of atezolizumab-bevacizumab in patients with HCC. Approval of atezolizumab-bevacizumab is likely to change the treatment paradigm for HCC, given that treatment with atezolizumab-bevacizumab resulted in improved OS and PFS compared with sorafenib, an accepted standard of care for first-line treatment of patients with unresectable HCC.See related commentary by Castet et al., p. 1827.
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Affiliation(s)
- Sandra J Casak
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland.
| | - Martha Donoghue
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Lola Fashoyin-Aje
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Xiaoping Jiang
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Lisa Rodriguez
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Yuan-Li Shen
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Yuan Xu
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Xiling Jiang
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Jiang Liu
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Hong Zhao
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - William F Pierce
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Shubhangi Mehta
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Kirsten B Goldberg
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland.,Oncology Center of Excellence, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Marc R Theoret
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland.,Oncology Center of Excellence, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Paul G Kluetz
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland.,Oncology Center of Excellence, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Richard Pazdur
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland.,Oncology Center of Excellence, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Steven J Lemery
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
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Kronenfeld JP, Ryon EL, Goldberg D, Lee RM, Yopp A, Wang A, Lee AY, Luu S, Hsu C, Silberfein E, Russell MC, Livingstone AS, Merchant NB, Goel N. Disparities in Presentation at Time of Hepatocellular Carcinoma Diagnosis: A United States Safety-Net Collaborative Study. Ann Surg Oncol 2020; 28:1929-1936. [PMID: 32975686 DOI: 10.1245/s10434-020-09156-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 08/30/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND While hepatocellular carcinoma (HCC) is ideally diagnosed outpatient by screening at-risk patients, many are diagnosed in Emergency Departments (ED) due to undiagnosed liver disease and/or limited access-to-healthcare. This study aims to identify sociodemographic/clinical factors associated with being diagnosed with HCC in the ED to identify patients who may benefit from improved access-to-care. METHODS HCC patients diagnosed between 2012 and 2014 in the ED or an outpatient setting [Primary Care Physician (PCP) or hepatologist] were identified from the US Safety-Net Collaborative database and underwent retrospective chart-review. Multivariable regression identified predictors for an ED diagnosis. RESULTS Among 1620 patients, median age was 60, 68% were diagnosed outpatient, and 32% were diagnosed in the ED. ED patients were more likely male, Black/Hispanic, uninsured, and presented with more decompensated liver disease, aggressive features, and advanced clinical stage. On multivariable regression, controlling for age, gender, race/ethnicity, poverty, insurance, and PCP/navigator access, predictors for ED diagnosis were male (odds ratio [OR] 1.6, 95% confidence interval [CI]: 1.1-2.2, p = 0.010), black (OR 1.7, 95% CI: 1.2-2.3, p = 0.002), Hispanic (OR 1.6, 95% CI: 1.1-2.6, p = 0.029), > 25% below poverty line (OR 1.4, 95% CI: 1.1-1.9, p = 0.019), uninsured (OR 3.9, 95% CI: 2.4-6.1, p < 0.001), and lack of PCP (OR 2.3, 95% CI: 1.5-3.6, p < 0.001) or navigator (OR 1.8, 95% CI: 1.3-2.5, p = 0.001). CONCLUSIONS The sociodemographic/clinical profile of patients diagnosed with HCC in EDs differs significantly from those diagnosed outpatient. ED patients were more likely racial/ethnic minorities, uninsured, and had limited access to healthcare. This study highlights the importance of improved access-to-care in already vulnerable populations.
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Affiliation(s)
- Joshua P Kronenfeld
- Division of Surgical Oncology, Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Emily L Ryon
- Division of Surgical Oncology, Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - David Goldberg
- Division of Digestive Health and Liver Disease, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Rachel M Lee
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Adam Yopp
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Annie Wang
- Division of Surgical Oncology, Department of Surgery, NYU Langone Health, New York, NY, USA
| | - Ann Y Lee
- Division of Surgical Oncology, Department of Surgery, NYU Langone Health, New York, NY, USA
| | - Sommer Luu
- Division of Surgical Oncology, Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Cary Hsu
- Division of Surgical Oncology, Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Eric Silberfein
- Division of Surgical Oncology, Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Maria C Russell
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Alan S Livingstone
- Division of Surgical Oncology, Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Nipun B Merchant
- Division of Surgical Oncology, Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Neha Goel
- Division of Surgical Oncology, Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA.
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Cheng E, Hung P, Wang SY. Geographic Variations of Potentially Curative Treatments for Hepatocellular Carcinoma in the United States: A SEER-Medicare Study. J Natl Compr Canc Netw 2020; 18:729-736. [DOI: 10.6004/jnccn.2020.7529] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 01/06/2020] [Indexed: 11/17/2022]
Abstract
Background: Transplantation, surgical resection, radiofrequency ablation, and percutaneous ethanol injection are generally considered potentially curative treatments for patients with hepatocellular carcinoma (HCC). With the increasing incidence of HCC, it is critical to investigate geographic variations in curative treatments and their associations with survival among patients. Methods: A total of 6,782 patients with HCC during 2004 to 2011 were identified in the SEER-Medicare linked database and placed in quartiles based on the proportions undergoing potentially curative treatments per hospital referral region (HRR). Hierarchical Cox proportional hazards models were used to examine the association between regional potentially curative treatment patterns and survival across quartiles. Results: An average of 16.9% of patients with HCC underwent potentially curative treatments during 2004 to 2011, varying substantially from 0% to 34.5% across HRRs. Compared with patients residing in the lowest-quartile regions, those in the highest-quartile regions were more likely to be of other races (vs white or black), be infected with hepatitis B virus, and have more comorbidities. The 5-year survival was 4.7% in the lowest-quartile regions and 11.4% in the highest-quartile regions (P<.001). After controlling for confounders, patients in the highest-quartile regions had a lower risk of mortality (adjusted hazard ratio, 0.78; 95% CI, 0.72–0.85). Conclusions: Patients with HCC who resided in HRRs with higher proportions of potentially curative treatments had better survival. Given its proven survival benefits, prompt clinical and policy actions are needed to reduce variations in treatment utilization.
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Affiliation(s)
- En Cheng
- 1Department of Chronic Disease Epidemiology, School of Public Health, Yale University, New Haven, Connecticut
| | - Peiyin Hung
- 2Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, and
- 3Rural and Minority Health Research Center, Columbia, South Carolina; and
| | - Shi-Yi Wang
- 1Department of Chronic Disease Epidemiology, School of Public Health, Yale University, New Haven, Connecticut
- 4Cancer Outcomes, Public Policy, and Effectiveness Research Center, Yale Cancer Center, New Haven, Connecticut
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Thylur RP, Roy SK, Shrivastava A, LaVeist TA, Shankar S, Srivastava RK. Assessment of risk factors, and racial and ethnic differences in hepatocellular carcinoma. JGH OPEN 2020; 4:351-359. [PMID: 32514436 PMCID: PMC7273694 DOI: 10.1002/jgh3.12336] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 03/05/2020] [Accepted: 03/24/2020] [Indexed: 12/24/2022]
Abstract
Despite improved screening and surveillance guidelines, significant race/ethnicity‐specific disparities in hepatocellular carcinoma (HCC) continue to exist and disproportionately affect minority and disadvantaged populations. This trend indicates that social determinants, genetic, and environmental factors are driving the epidemic at the population level. Race and geography had independent associations with risk of mortality among patients with HCC. The present review discusses the risk factors and issues related to disparities in HCC. The underlying etiologies for these disparities are complex and multifactorial. Some of the risk factors for developing HCC include hepatitis B (HBV) and hepatitis C (HCV) viral infection, nonalcoholic fatty liver disease, nonalcoholic steatohepatitis, smoking and alcohol consumption. In addition, population genetics; socioeconomic and health care access; treatment and prevention differences; and genetic, behavioral, and biological influences can contribute to HCC. Acculturation of ethnic minorities, insurance status, and access to health care may further contribute to the observed disparities in HCC. By increasing awareness, better modalities for screening and surveillance, improving access to health care, and adapting targeted preventive and therapeutic interventions, disparities in HCC outcomes can be reduced or eliminated.
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Affiliation(s)
- Ramesh P Thylur
- Stanley S. Scott Cancer Center Louisiana State University Health-New Orleans School of Medicine New Orleans Louisiana USA
| | - Sanjit K Roy
- Stanley S. Scott Cancer Center Louisiana State University Health-New Orleans School of Medicine New Orleans Louisiana USA
| | | | - Thomas A LaVeist
- Department of Health Policy and Management Tulane University School of Public Health and Tropical Medicine New Orleans Louisiana USA
| | - Sharmila Shankar
- Stanley S. Scott Cancer Center Louisiana State University Health-New Orleans School of Medicine New Orleans Louisiana USA.,Department of Genetics Louisiana State University Health Sciences Center-New Orleans New Orleans Louisiana USA
| | - Rakesh K Srivastava
- Stanley S. Scott Cancer Center Louisiana State University Health-New Orleans School of Medicine New Orleans Louisiana USA.,Department of Genetics Louisiana State University Health Sciences Center-New Orleans New Orleans Louisiana USA
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Adler Jaffe S, Myers O, Meisner ALW, Wiggins CL, Hill DA, McDougall JA. Relationship between Insurance Type at Diagnosis and Hepatocellular Carcinoma Survival. Cancer Epidemiol Biomarkers Prev 2020; 29:300-307. [PMID: 31796525 PMCID: PMC7992905 DOI: 10.1158/1055-9965.epi-19-0902] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 10/01/2019] [Accepted: 11/26/2019] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND For individuals with hepatocellular carcinoma (HCC), type of insurance may be an important prognostic factor because of its impact on access to care. This study investigates the relationship between insurance type at diagnosis and stage-specific survival. METHODS This retrospective cohort analysis used data from 18 Surveillance, Epidemiology, and End Results Program cancer registries. Individuals ages 20 to 64 years, diagnosed with primary HCC between 2010 and 2015, with either private, Medicaid, or no insurance were eligible for cohort inclusion. Adjusted Cox proportional-hazards regression models were used to generate HRs and 95% confidence intervals (CI) for associations between insurance type at diagnosis and overall survival. All models were stratified by stage at diagnosis. RESULTS This analysis included 14,655 cases. Compared with privately insured individuals with the same stage of disease, those with Medicaid had a 43% (HR = 1.43; 95% CI, 1.13-1.32), 22% (HR = 1.22; 95% CI, 1.13-1.32), and 7% higher risk of death for localized, regional, and distant stage, respectively. Uninsured individuals had an 88% (HR = 1.88; 95% CI, 1.65-2.14), 59% (HR = 1.59; 95% CI, 1.41-1.80), and 35% (HR = 1.35; 95% CI, 1.18-1.55) higher risk of death for localized, regional, and distant stage, respectively, compared with privately insured individuals. CONCLUSIONS Disparities in survival exist by the type of insurance that individuals with HCC have at the time of diagnosis. IMPACT These findings support the need for additional research on access to and quality of cancer care for Medicaid and uninsured patients.
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Affiliation(s)
| | - Orrin Myers
- Department of Family and Community Medicine, University of New Mexico, Albuquerque, New Mexico
| | - Angela L W Meisner
- University of New Mexico Comprehensive Cancer Center, Albuquerque, New Mexico
- New Mexico Tumor Registry, Albuquerque, New Mexico
| | - Charles L Wiggins
- University of New Mexico Comprehensive Cancer Center, Albuquerque, New Mexico
- New Mexico Tumor Registry, Albuquerque, New Mexico
- Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico
| | - Deirdre A Hill
- Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico
| | - Jean A McDougall
- University of New Mexico Comprehensive Cancer Center, Albuquerque, New Mexico
- Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico
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Sridhar S, Sharma I, Sankpal UT, Ghabach B, Narra K, Neerukonda L, Basha R. Targeted Molecular Therapeutic Options for Hepatocellular Carcinoma. Crit Rev Oncog 2020; 25:47-55. [PMID: 32865910 PMCID: PMC11079775 DOI: 10.1615/critrevoncog.2020034985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Liver cancer is the 6th leading cause of cancer related deaths in the US even though it ranks 14th in incidence. More men are diagnosed with liver cancer than women, and the number of projected deaths among men (20,020) is almost double that among women (10,140) in the US. Infections like hepatitis and metabolic conditions like obesity are believed to be major risk factors for the onset of liver cancer. Hepatocellular carcinoma (HCC), the most common type of liver cancer, accounts for 75% of all cases. Chemotherapy has not been effective in treating HCC. Targeted therapies are being used in advanced HCC patients due to a better survival and less side effects when compared to traditional chemotherapy. Therapeutic agents targeting the regulators of growth factor signaling pathways and the mediators of downstream signaling-for example, inhibitors of the tyrosine kinase receptor-are used as targeted molecular therapies. Kinase inhibitors that modulate growth signals, such as sorafenib and lenvatinib, are commonly employed in targeted molecular therapy for HCC patients. This review covers these agents, highlighting modes of action and providing details on clinical trials.
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Affiliation(s)
- Swathi Sridhar
- Texas College of Osteopathic Medicine, University of North Texas Health Science Center at Fort Worth, Fort Worth, Texas
| | - Ishna Sharma
- Texas College of Osteopathic Medicine, University of North Texas Health Science Center at Fort Worth, Fort Worth, Texas
| | - Umesh T. Sankpal
- Texas College of Osteopathic Medicine, University of North Texas Health Science Center at Fort Worth, Fort Worth, Texas
| | | | | | | | - Riyaz Basha
- Texas College of Osteopathic Medicine, University of North Texas Health Science Center at Fort Worth, Fort Worth, Texas
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Potential Problems of Using Same Race Category for Native Hawaiians, Pacific Islanders, and Asians. Am J Prev Med 2019; 57:290. [PMID: 31326014 DOI: 10.1016/j.amepre.2019.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 03/04/2019] [Accepted: 03/05/2019] [Indexed: 11/21/2022]
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Shikany JM, Schoenberger YMM, Konety BR, Vickers SM. African American Men's Health: Research, Practice, and Policy. Am J Prev Med 2018; 55:S1-S4. [PMID: 30670194 DOI: 10.1016/j.amepre.2018.07.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 07/06/2018] [Accepted: 07/25/2018] [Indexed: 12/15/2022]
Affiliation(s)
- James M Shikany
- Division of Preventive Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama.
| | - Yu-Mei M Schoenberger
- Division of Preventive Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Badrinath R Konety
- Department of Urology, Medical School, University of Minnesota, Minneapolis, Minnesota
| | - Selwyn M Vickers
- Department of Surgery, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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