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Wu Y, Zhuo C, Lu Y, Luo Z, Lu L, Wang J, Tang Q, Phipps MM, Nahm WJ, Facciorusso A, Ge B. A machine learning clinic scoring system for hepatocellular carcinoma based on the Surveillance, Epidemiology, and End Results database. J Gastrointest Oncol 2024; 15:1082-1100. [PMID: 38989413 PMCID: PMC11231840 DOI: 10.21037/jgo-24-230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Accepted: 05/07/2024] [Indexed: 07/12/2024] Open
Abstract
Background Hepatocellular carcinoma (HCC) poses a global threat to life; however, numerical tools to predict the clinical prognosis of these patients remain scarce. The primary objective of this study is to establish a clinical scoring system for evaluating the overall survival (OS) rate and cancer-specific survival (CSS) rate in HCC patients. Methods From the Surveillance, Epidemiology, and End Results (SEER) Program, we identified 45,827 primary HCC patients. These cases were randomly allocated to a training cohort (22,914 patients) and a validation cohort (22,913 patients). Univariate and multivariate Cox regression analyses, coupled with Kaplan-Meier methods, were employed to evaluate prognosis-related clinical and demographic features. Factors demonstrating prognostic significance were used to construct the model. The model's stability and accuracy were assessed through C-index, receiver operating characteristic (ROC) curves, calibration curves, and clinical decision curve analysis (DCA), while comparisons were made with the American Joint Committee on Cancer (AJCC) staging. Ultimately, machine learning (ML) quantified the variables in the model to establish a clinical scoring system. Results Univariate and multivariate Cox regression analyses identified 11 demographic and clinical-pathological features as independent prognostic indicators for both CSS and OS using. Two models, each incorporating the 11 features, were developed, both of which demonstrated significant prognostic relevance. The C-index for predicting CSS and OS surpassed that of the AJCC staging system. The area under the curve (AUC) in time-dependent ROC consistently exceeded 0.74 in both the training and validation sets. Furthermore, internal and external calibration plots indicated that the model predictions aligned closely with observed outcomes. Additionally, DCA demonstrated the superiority of the model over the AJCC staging system, yielding greater clinical net benefit. Ultimately, the quantified clinical scoring system could efficiently discriminate between high and low-risk patients. Conclusions A ML clinical scoring system trained on a large-scale dataset exhibits good predictive and risk stratification performance in the cohorts. Such a clinical scoring system is readily integrable into clinical practice and will be valuable in enhancing the accuracy and efficiency of HCC management.
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Affiliation(s)
- Yueqing Wu
- Department of General Surgery, The Fifth Affiliated Hospital of Zunyi Medical University, Zhuhai, China
| | - Chenyi Zhuo
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, China
- Guangxi Clinical Medical Research Center for Hepatobiliary Diseases, Baise, China
- Key Laboratory of Research on Prevention and Control of High Incidence Disease in Western Guangxi, Baise, China
| | - Yuan Lu
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, China
- Guangxi Clinical Medical Research Center for Hepatobiliary Diseases, Baise, China
- Key Laboratory of Research on Prevention and Control of High Incidence Disease in Western Guangxi, Baise, China
| | - Zongjiang Luo
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, China
- Guangxi Clinical Medical Research Center for Hepatobiliary Diseases, Baise, China
- Key Laboratory of Research on Prevention and Control of High Incidence Disease in Western Guangxi, Baise, China
| | - Libai Lu
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, China
- Guangxi Clinical Medical Research Center for Hepatobiliary Diseases, Baise, China
- Key Laboratory of Research on Prevention and Control of High Incidence Disease in Western Guangxi, Baise, China
| | - Jianchu Wang
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, China
- Guangxi Clinical Medical Research Center for Hepatobiliary Diseases, Baise, China
- Key Laboratory of Research on Prevention and Control of High Incidence Disease in Western Guangxi, Baise, China
| | - Qianli Tang
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, China
- Guangxi Clinical Medical Research Center for Hepatobiliary Diseases, Baise, China
- Key Laboratory of Research on Prevention and Control of High Incidence Disease in Western Guangxi, Baise, China
| | - Meaghan M. Phipps
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - William J. Nahm
- New York University Grossman School of Medicine, New York, NY, USA
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Medical Sciences, University of Foggia, Foggia, Italy
| | - Bin Ge
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, China
- Guangxi Clinical Medical Research Center for Hepatobiliary Diseases, Baise, China
- Key Laboratory of Research on Prevention and Control of High Incidence Disease in Western Guangxi, Baise, China
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Singal AG, Narasimman M, Daher D, Yekkaluri S, Liu Y, Lee M, Cerda V, Khan A, Seif El Dahan K, Kramer J, Gopal P, Murphy C, Hernaez R. Effectiveness of mailed outreach and patient navigation to promote HCC screening process completion: a multicentre pragmatic randomised clinical trial. Gut 2024:gutjnl-2024-332508. [PMID: 38839269 DOI: 10.1136/gutjnl-2024-332508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 05/22/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is plagued by failures across the cancer care continuum, leading to frequent late-stage diagnoses and high mortality. We evaluated the effectiveness of mailed outreach invitations plus patient navigation to promote HCC screening process completion in patients with cirrhosis. METHODS Between April 2018 and September 2021, we conducted a multicentre pragmatic randomised clinical trial comparing mailed outreach plus patient navigation for HCC screening (n=1436) versus usual care with visit-based screening (n=1436) among patients with cirrhosis at three US health systems. Our primary outcome was screening process completion over a 36-month period, and our secondary outcome was the proportion of time covered (PTC) by screening. All patients were included in intention-to-screen analyses. RESULTS All 2872 participants (median age 61.3 years; 32.3% women) were included in intention-to-screen analyses. Screening process completion was observed in 6.6% (95% CI: 5.3% to 7.9%) of patients randomised to outreach and 3.3% (95% CI: 2.4% to 4.3%) of those randomised to usual care (OR 2.05, 95% CI: 1.44 to 2.92). The intervention increased HCC screening process completion across most subgroups including age, sex, race and ethnicity, Child-Turcotte-Pugh class and health system. PTC was also significantly higher in the outreach arm than usual care (mean 37.5% vs 28.2%; RR 1.33, 95% CI: 1.31 to 1.35). Despite screening underuse, most HCC in both arms were detected at an early stage. CONCLUSION Mailed outreach plus navigation significantly increased HCC screening process completion versus usual care in patients with cirrhosis, with a consistent effect across most examined subgroups. However, screening completion remained suboptimal in both arms, underscoring a need for more intensive interventions. TRIAL REGISTRATION NUMBER NCT02582918.
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Affiliation(s)
- Amit G Singal
- Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Manasa Narasimman
- Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Darine Daher
- Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Sruthi Yekkaluri
- Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Yan Liu
- Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, USA
| | - MinJae Lee
- Population and Data Sciences, UT Southwestern Medical, Dallas, Texas, USA
| | - Vanessa Cerda
- Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Aisha Khan
- Michael E. DeBakey Veterans Affairs Medical Center, Center for Innovations in Quality, Effectiveness and Safety and Baylor College of Medicine, Houston, Texas, USA
| | - Karim Seif El Dahan
- Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jennifer Kramer
- Michael E. DeBakey Veterans Affairs Medical Center, Center for Innovations in Quality, Effectiveness and Safety and Baylor College of Medicine, Houston, Texas, USA
| | - Purva Gopal
- Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Caitlin Murphy
- School of Public Health, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Ruben Hernaez
- Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, USA
- Gastroenterology and Hepatology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
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3
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Wong RJ, Jones PD, Niu B, Therapondos G, Thamer M, Kshirsagar O, Zhang Y, Pinheiro P, Kyalwazi B, Fass R, Khalili M, Singal AG. Clinician-Level Knowledge and Barriers to Hepatocellular Carcinoma Surveillance. JAMA Netw Open 2024; 7:e2411076. [PMID: 38743424 PMCID: PMC11094557 DOI: 10.1001/jamanetworkopen.2024.11076] [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: 12/22/2023] [Accepted: 03/12/2024] [Indexed: 05/16/2024] Open
Abstract
Importance Surveillance for hepatocellular carcinoma (HCC) in patients with cirrhosis is underused. Identifying potentially modifiable factors to address barriers in HCC surveillance is critical to improve patient outcomes. Objective To evaluate clinician-level factors contributing to underuse of HCC surveillance in patients with cirrhosis. Design, Setting, and Participants This survey study included primary care clinicians (PCCs) and gastroenterology and hepatology clinicians at 5 safety-net health systems in the US. Clinicians were surveyed from March 15 to September 15, 2023, to assess knowledge, attitudes, beliefs, perceived barriers, and COVID-19-related disruptions in HCC surveillance in patients with cirrhosis. Data were analyzed from October to November 2023. Main Outcome and Measures HCC surveillance knowledge was assessed with 6 questions querying the respondent's ability to correctly identify appropriate use of HCC surveillance. Attitudes, perceived barriers, and beliefs regarding HCC surveillance and perceived impact of the COVID-19 pandemic-related disruptions with HCC surveillance were assessed with a series of statements using a 4-point Likert scale and compared PCCs and gastroenterology and hepatology clinicians. Results Overall, 347 of 1362 clinicians responded to the survey (25.5% response rate), among whom 142 of 237 (59.9%) were PCCs, 48 of 237 (20.3%) gastroenterology and hepatology, 190 of 236 (80.5%) were doctors of medicine and doctors of osteopathic medicine, and 46 of 236 (19.5%) were advanced practice clinicians. On HCC knowledge assessment, 144 of 270 (53.3%) scored 5 or more of 6 questions correctly, 37 of 48 (77.1%) among gastroenterology and hepatology vs 65 of 142 (45.8%) among PCCs (P < .001). Those with higher HCC knowledge scores were less likely to report barriers to HCC surveillance. PCCs were more likely to report inadequate time to discuss HCC surveillance (37 of 139 [26.6%] vs 2 of 48 [4.2%]; P = .001), difficulty identifying patients with cirrhosis (82 of 141 [58.2%] vs 5 of 48 [10.4%]; P < .001), and were not up-to-date with HCC surveillance guidelines (87 of 139 [62.6%] vs 5 of 48 [10.4%]; P < .001) compared with gastroenterology and hepatology clinicians. While most acknowledged delays during the COVID-19 pandemic, 62 of 136 PCCs (45.6%) and 27 of 45 gastroenterology and hepatology clinicians (60.0%) reported that patients with cirrhosis could currently complete HCC surveillance without delays. Conclusions and Relevance In this survey study, important gaps in knowledge and perceived barriers to HCC surveillance were identified. Effective delivery of HCC education to PCCs and health system-level interventions must be pursued in parallel to address the complex barriers affecting suboptimal HCC surveillance in patients with cirrhosis.
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Affiliation(s)
- Robert J. Wong
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine and Gastroenterology Section, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
| | - Patricia D. Jones
- Division of Digestive Health and Liver Diseases, University of Miami School of Medicine and Jackson Memorial Health System, Miami, Florida
| | - Bolin Niu
- Division of Gastroenterology and Hepatology, MetroHealth Hospital and Health System, Cleveland, Ohio
| | | | - Mae Thamer
- Medical Technology and Practice Patterns Institute, Bethesda, Maryland
| | - Onkar Kshirsagar
- Medical Technology and Practice Patterns Institute, Bethesda, Maryland
| | - Yi Zhang
- Medical Technology and Practice Patterns Institute, Bethesda, Maryland
| | - Paulo Pinheiro
- Division of Epidemiology and Population Health Sciences, University of Miami School of Medicine, Miami, Florida
| | - Beverly Kyalwazi
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Ronnie Fass
- Division of Gastroenterology and Hepatology, MetroHealth Hospital and Health System, Cleveland, Ohio
| | - Mandana Khalili
- Division of Gastroenterology and Hepatology, University of California San Francisco and Zuckerberg San Francisco General Hospital, San Francisco
| | - Amit G. Singal
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center and Parkland Health, Dallas
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Wagle NS, Park S, Washburn D, Ohsfeldt R, Kum HC, Singal AG. Racial and Ethnic Disparities in Hepatocellular Carcinoma Treatment Receipt in the United States: A Systematic Review and Meta-Analysis. Cancer Epidemiol Biomarkers Prev 2024; 33:463-470. [PMID: 38252039 PMCID: PMC10990826 DOI: 10.1158/1055-9965.epi-23-1236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 12/13/2023] [Accepted: 01/16/2024] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND Racial and ethnic disparities in hepatocellular carcinoma (HCC) prognosis exist, partly related to differential failures along the cancer care continuum. We characterized racial and ethnic disparities in treatment receipt among patients with HCC in the United States. METHODS We searched Medline, Embase, and CINAHL databases to identify studies published between January 2012 and March 2022 reporting HCC treatment receipt among adult patients with HCC, stratified by race or ethnicity. We calculated pooled odds ratios for HCC treatment using random effects models. RESULTS We identified 15 studies with 320,686 patients (65.8% White, 13.9% Black, 10.4% Asian, and 8.5% Hispanic). Overall, 33.2% of HCC patients underwent any treatment, and 22.7% underwent curative treatment. Compared with White patients, Black patients had lower odds of any treatment (OR 0.67, 95% CI 0.55-0.81) and curative treatment (OR 0.74, 95% CI 0.71-0.78). Similarly, Hispanic patients had lower pooled odds of curative treatment (OR 0.79, 95% CI 0.73-0.84). CONCLUSIONS There were significant racial and ethnic disparities in HCC treatment receipt, with Black patients having lower odds of receiving any and curative treatment while Hispanic patients having lower odds of curative treatment. IMPACT Racial and ethnic differences in treatment receipt serve as an intervention target to reduce disparities in HCC prognosis.
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Affiliation(s)
- Nikita Sandeep Wagle
- Population Informatics Lab, Texas A&M University, College Station, Texas
- Department of Health Policy and Management, School of Public Health, Texas A&M, Health Science Center, College Station, Texas
| | - Sulki Park
- Department of Health Policy and Management, School of Public Health, Texas A&M, Health Science Center, College Station, Texas
- Department of Industrial and Systems Engineering, Texas A&M University, College, Station, Texas
| | - David Washburn
- Population Informatics Lab, Texas A&M University, College Station, Texas
- Department of Health Policy and Management, School of Public Health, Texas A&M, Health Science Center, College Station, Texas
| | - Robert Ohsfeldt
- Population Informatics Lab, Texas A&M University, College Station, Texas
- Department of Health Policy and Management, School of Public Health, Texas A&M, Health Science Center, College Station, Texas
| | - Hye-Chung Kum
- Population Informatics Lab, Texas A&M University, College Station, Texas
- Department of Health Policy and Management, School of Public Health, Texas A&M, Health Science Center, College Station, Texas
- Department of Industrial and Systems Engineering, Texas A&M University, College, Station, Texas
| | - Amit G Singal
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas
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Beltrán Ponce S, Gokun Y, Douglass F, Dawson L, Miller E, Thomas CR, Pitter K, Conteh L, Diaz DA. Disparities in outcomes and access to therapy options in hepatocellular carcinoma. J Natl Cancer Inst 2024; 116:264-274. [PMID: 37831897 DOI: 10.1093/jnci/djad213] [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: 02/24/2023] [Revised: 08/10/2023] [Accepted: 09/28/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) disproportionately impacts racial and ethnic minorities and patients with lower socioeconomic status. These social determinants of health (SDH) lead to disparities in access to care and outcomes. We aim to understand the relationship between SDH and survival and locoregional treatment options in HCC. METHODS Using the National Cancer Database, we evaluated survival and access locoregional treatments including non-transplant surgery, liver transplant (LT), and liver-directed radiation therapy (LDRT) in patients with HCC diagnosed between 2004 and 2017. Variables including clinical stage, age, sex, race, income, rurality, year of diagnosis, facility type (FT), Charlson-Deyo score (CD), and insurance were evaluated. Cox proportional hazards multivariable regression and dominance analyses were used for analyses. RESULTS In total, 140 340 patients were included. Worse survival was seen with advanced stage, older age, Black race, rurality, public insurance, treatment at a nonacademic center, and lower income. The top predictors for survival included stage, age, and income. Completion of non-transplant surgery was best predicted by stage, FT, and insurance type, whereas LT was predicted by age, year of diagnosis, and CD score. LDRT utilization was most associated with year of diagnosis, FT, and CD score. CONCLUSION For patients with HCC, survival was predicted primarily by stage, age, and income. The primary sociodemographic factors associated with access to surgical treatments, in addition to FT, were insurance and income, highlighting the financial burdens of health care. Work is needed to address disparities in access to care, including improved insurance access, addressing financial inequities and financial toxicities of treatments, and equalizing care opportunities in community centers.
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Affiliation(s)
- Sara Beltrán Ponce
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Yevgeniya Gokun
- Secondary Data Core, Center for Biostatistics, The Ohio State University Wexner School of Medicine, Columbus, OH, USA
| | | | - Laura Dawson
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Eric Miller
- Department of Radiation Oncology, The Ohio State University Wexner School of Medicine, The James Cancer Center, Columbus, OH, USA
| | - Charles R Thomas
- Department of Radiation Oncology, Dartmouth Geisel School of Medicine, Hanover, NH, USA
| | - Kenneth Pitter
- Department of Radiation Oncology, The Ohio State University Wexner School of Medicine, The James Cancer Center, Columbus, OH, USA
| | - Lanla Conteh
- Division of Hepatology, Department of Gastroenterology, The Ohio State University Wexner School of Medicine, Columbus, OH, USA
| | - Dayssy A Diaz
- Department of Radiation Oncology, The Ohio State University Wexner School of Medicine, The James Cancer Center, Columbus, OH, 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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Kirkpatrick H, Buccheri RK, Sharifi C. Advance Care Planning Engagement Strategies for Primary Care Providers Seeing Diverse Patient Populations: A Scoping Review. J Hosp Palliat Nurs 2024; 26:E20-E29. [PMID: 38096444 DOI: 10.1097/njh.0000000000001002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
Diverse patients are less likely than Whites to have advance care planning. The primary purpose of this scoping review was to summarize recent evidence about advance care planning engagement interventions for primary care providers working with diverse patients. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses-extension for Scoping Reviews (PRISMA-ScR) Checklist was followed. Peer-reviewed articles published in English since 2000 reporting the results of studies testing intervention programs in primary care to improve advance care planning with adult, racially diverse populations were included. Searches were conducted in 5 online databases and yielded 72 articles. Gray literature yielded 23 articles. Two authors independently reviewed the abstracts of 72 articles determining that 9 articles met the aim of this review. These studies were analyzed by communication tools and other resources, population, intervention, primary outcomes, instruments, and primary findings and organized into 3 categories: ( a ) provider-focused interventions, ( b ) patient-focused interventions, and ( c ) multilevel interventions. Improvement in advance care planning outcomes can be achieved for racially diverse populations by implementing targeted advance care planning engagement interventions for both providers and patients. These interventions can be used in primary care to increase advance care planning for diverse patients. More research is needed that evaluates best practices for integrating advance care planning into primary care workflows.
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Shaltiel T, Sarpel U, Branch AD. The adverse characteristics of hepatocellular carcinoma in the non-cirrhotic liver disproportionately disadvantage Black patients. Cancer Med 2024; 13:e6654. [PMID: 38230878 PMCID: PMC10905547 DOI: 10.1002/cam4.6654] [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: 04/17/2023] [Revised: 08/24/2023] [Accepted: 10/12/2023] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND Black patients have higher hepatocellular carcinoma (HCC)-related mortality than White patients and more often develop HCC in non-cirrhotic liver. HCC surveillance is primarily directed toward cirrhotic patients. We aimed to characterize HCC in non-cirrhotic patients and to identify factors associated with HCC beyond Milan criteria. METHODS Demographic, imaging, laboratory, and pathology data of HCC patients at our institution, 2003-2018, were reviewed, retrospectively. Race/ethnicity were self-reported. Cirrhosis was defined as a Fibrosis-4 score ≥3.25. RESULTS Compared to 1146 cirrhotic patients, 411 non-cirrhotic patients had larger tumors (median 4.7 cm vs. 3.1 cm, p < 0.01) and were less likely to be within Milan criteria (42.6% vs. 57.7%, p < 0.01). Among non-cirrhotic patients, Black patients had larger tumors (4.9 cm vs. 4.3 cm, p < 0.01) and a higher percentage of poorly differentiated tumors (39.4% vs. 23.1%, p = 0.02). Among cirrhotic patients, Black patients had larger tumors (3.3 cm vs. 3.0 cm, p = 0.03) and were less likely to be within Milan criteria (52.3% vs. 83.2%, p < 0.01). In multivariable analysis, lack of commercial insurance (OR 1.45 [CI 95% 1.19-1.83], p < 0.01), male sex (OR 1.34 [CI 95% 1.05-1.70], p < 0.01), absence of cirrhosis (OR 1.58 [CI 95% 1.27-1.98], p < 0.01) and Black race/ethnicity (OR 1.34 [CI 95% 1.09-1.66], p = 0.01) were associated with HCC beyond Milan criteria. Black patients had lower survival rates than other patients (p < 0.01). CONCLUSIONS Non-cirrhotic patients had more advanced HCC than cirrhotic patients. Black patients (with or without cirrhosis) had more advanced HCC than comparable non-Black patients and higher mortality rates. Improved access to healthcare (commercial insurance) may increase early diagnosis (within Milan criteria) and reduce disparities.
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Affiliation(s)
- Tali Shaltiel
- Division of Surgical Oncology, Department of SurgeryIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Umut Sarpel
- Division of Surgical Oncology, Department of SurgeryIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Andrea D. Branch
- Division of Liver Diseases, Department of MedicineIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
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Kam LY, Yeo YH, Ji F, Henry L, Cheung R, Nguyen MH. Treatment rates and factors associated with direct-acting antiviral therapy for insured patients with hepatitis C-related hepatocellular carcinoma - A real-world nationwide study. Aliment Pharmacol Ther 2024; 59:350-360. [PMID: 37937485 DOI: 10.1111/apt.17794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 10/03/2023] [Accepted: 10/23/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND Since the inception of the interferon-free direct-acting antiviral agents (DAAs) for hepatitis C virus (HCV) infection, guidelines as to who should receive this potentially curative treatment have evolved. Treatment with DAAs is now considered for all patients except for those considered moribund. AIM To determine the DAA treatment rate for patients with HCV-related hepatocellular carcinoma (HCC). METHODS This was a retrospective study from January 2015 to March 2021 of a national sample of privately insured patients with HCV-related HCC using Optum's Clinformatics® Data Mart (CDM) Database - a large, de-identified, adjudicated claims database. RESULTS We identified 3922 patients with HCV-related HCC: 922 (23.5%) received DAA. Compared to untreated patients, DAA-treated patients were younger (65.2 ± 7.5 vs. 66.4 ± 7.5 years, p < 0.001), more frequently saw a gastroenterology/infectious disease (GI/ID) physician (41.2% vs. 34.2%), and had decompensated cirrhosis (56% vs. 53%, p = 0.001). In multivariable analysis, younger age (HR: 0.98, 95% CI: 0.97-0.99, p < 0.001), GI/ID care (HR: 3.06, 95% CI: 2.13-4.51, p < 0.001), and having cirrhosis (compensated: HR: 1.60, 95% CI: 1.18-2.21, p = 0.003; decompensated: HR: 1.45, 95% CI: 1.07-1.98, p = 0.02) were associated with receiving DAA treatment, but not sex, race, or ethnicity. DAA-treated patients had significantly higher 5-year survival than untreated patients (47.2% vs. 35.2%, p < 0.001). Following adjustment for age, sex, race/ethnicity, Charlson Comorbidity Index, and HCC treatment, receiving DAA treatment was associated with lower mortality (aHR: 0.61, 95% CI: 0.53-0.69, p < 0.001). CONCLUSION DAA treatment remains underutilised in insured patients with HCV-related HCC; fewer than one in four patients received treatment. Seeing a specialist and having decompensated cirrhosis were predictors for DAA treatment; additional efforts are needed to increase awareness of HCV treatment.
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Affiliation(s)
- Leslie Y Kam
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, USA
| | - Yee Hui Yeo
- Karsh Division of Gastroenterology and Hepatology, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Fanpu Ji
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Linda Henry
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, USA
| | - Ramsey Cheung
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, USA
- Division of Gastroenterology and Hepatology, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Mindie H Nguyen
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, USA
- Department of Epidemiology and Population Health, Stanford University Medical Center, Palo Alto, California, USA
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10
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Abstract
Globally, hepatocellular carcinoma (HCC) is a major cause of cancer-related death and a leading cause of morbidity and mortality in patients with chronic liver disease and cirrhosis. The predominant cause of HCC is shifting from viral to nonviral causes, in parallel with the high global prevalence of nonalcoholic fatty liver disease and increasing alcohol consumption in many countries. There have been promising recent advances in the treatment of all stages of HCC; however, improvements in early detection, increased utilization of HCC surveillance, and equitable access to HCC therapies are needed to curb increases in HCC mortality.
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Affiliation(s)
- Nicole E Rich
- Division of Digestive and Liver Diseases, Department of Internal Medicine, Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, 5959 Harry Hines Boulevard, Professional Office Building 1, Suite 4.420G, Dallas, TX 75390-8887, USA.
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11
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Koo E, Singal AG. Hepatocellular Carcinoma Surveillance: Evidence-Based Tailored Approach. Surg Oncol Clin N Am 2024; 33:13-28. [PMID: 37945138 DOI: 10.1016/j.soc.2023.06.005] [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] [Indexed: 11/12/2023]
Abstract
Hepatocellular carcinoma (HCC) surveillance is recommended by professional society guidelines given a consistent association with reduced HCC-related mortality. HCC surveillance should be performed using semiannual abdominal ultrasound and alpha-fetoprotein, although this combination has suboptimal sensitivity and can miss more than one-third of HCC at an early stage. There are promising emerging blood-based and imaging-based strategies, including abbreviated MRI and biomarker panels; however, these require further validation before routine use in clinical practice. HCC surveillance is underused in clinical practice due to patient-related and provider-related barriers, highlighting a need for interventions to improve surveillance utilization in clinical practice.
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Affiliation(s)
- Eden Koo
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Amit G Singal
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA; Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, 5959 Harry Hines Boulevard, POB 1, Suite 420, Dallas, TX 75390-8887, USA.
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12
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Singal AG, Llovet JM, Yarchoan M, Mehta N, Heimbach JK, Dawson LA, Jou JH, Kulik LM, Agopian VG, Marrero JA, Mendiratta-Lala M, Brown DB, Rilling WS, Goyal L, Wei AC, Taddei TH. AASLD Practice Guidance on prevention, diagnosis, and treatment of hepatocellular carcinoma. Hepatology 2023; 78:1922-1965. [PMID: 37199193 PMCID: PMC10663390 DOI: 10.1097/hep.0000000000000466] [Citation(s) in RCA: 222] [Impact Index Per Article: 222.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 05/01/2023] [Indexed: 05/19/2023]
Affiliation(s)
- Amit G. Singal
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Josep M. Llovet
- Liver Cancer Program, Division of Liver Diseases, Tisch Cancer Institute, Mount Sinai School of Medicine, New York, New York, USA
- Translational Research in Hepatic Oncology, Liver Unit, August Pi i Sunyer Biomedical Research Institute, Hospital Clinic, University of Barcelona, Catalonia, Spain
- Institució Catalana de Recerca i Estudis Avançats, Barcelona, Catalonia, Spain
| | - Mark Yarchoan
- Department of Medical Oncology, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland, USA
| | - Neil Mehta
- University of California, San Francisco, San Francisco, California, USA
| | | | - Laura A. Dawson
- Radiation Medicine Program/University Health Network, Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Janice H. Jou
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, Oregon, USA
| | - Laura M. Kulik
- Northwestern Medical Faculty Foundation, Chicago, Illinois, USA
| | - Vatche G. Agopian
- The Dumont–University of California, Los Angeles, Transplant Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Jorge A. Marrero
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mishal Mendiratta-Lala
- Department of Radiology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Daniel B. Brown
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - William S. Rilling
- Division of Interventional Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Lipika Goyal
- Department of Medicine, Stanford School of Medicine, Palo Alto, California, USA
| | - Alice C. Wei
- Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - Tamar H. Taddei
- Department of Medicine (Digestive Diseases), Yale School of Medicine, New Haven, CT, USA
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
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13
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Singal AG, Kanwal F, Llovet JM. Global trends in hepatocellular carcinoma epidemiology: implications for screening, prevention and therapy. Nat Rev Clin Oncol 2023; 20:864-884. [PMID: 37884736 DOI: 10.1038/s41571-023-00825-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2023] [Indexed: 10/28/2023]
Abstract
Hepatocellular carcinoma (HCC) mortality rates are increasing globally, and particularly in the Western world. Cirrhosis remains the predominant risk factor for HCC. However, epidemiological shifts in the incidence of HCC from patients with virus-related liver disease to those with non-viral aetiologies, including alcohol-associated and metabolic dysfunction-associated steatotic liver disease, have important implications for prevention, surveillance and treatment. Hepatitis B vaccination and antiviral therapy for hepatitis B and C are effective for primary prevention of virus-related HCCs, but chemoprevention strategies for non-viral liver disease remain an unmet need. Emerging data suggest associations between aspirin, statins, metformin and coffee and reduced HCC incidence, although none has been proved to be causally related. Secondary prevention of HCC via semi-annual surveillance is associated with improvements in early detection and thus reduced mortality; however, current tools, including abdominal ultrasonography, have suboptimal sensitivity for the detection of early stage HCC, particularly in patients with obesity and/or non-viral liver disease. Promising blood-based or imaging-based surveillance strategies are emerging, although these approaches require further validation before adoption in clinical practice. In the interim, efforts should be focused on maximizing use of the existing surveillance tools given their prevalent underuse globally. Remarkable advances have been made in the treatment of HCC, including expanded eligibility for surgical therapies, improved patient selection for locoregional treatments and increased systemic treatment options, including immune-checkpoint inhibitors. In this Review, we discuss trends in the epidemiology of HCC and their implications for screening, prevention and therapy.
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Affiliation(s)
- Amit G Singal
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA.
| | - Fasiha Kanwal
- Section of Gastroenterology and Hepatology and Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- VA Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, TX, USA
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Josep M Llovet
- Mount Sinai Liver Cancer Program, Division of Liver Diseases, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Translational Research in Hepatic Oncology, Liver Unit, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clinic, University of Barcelona, Barcelona, Spain
- Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain
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14
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Alvarez CS, Ruhl J, Flynn G, Graubard BI, McGlynn KA. Trends in hepatocellular carcinoma stage by racial/ethnic group in the United States, 1992-2019. JHEP Rep 2023; 5:100868. [PMID: 37799980 PMCID: PMC10550401 DOI: 10.1016/j.jhepr.2023.100868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/11/2023] [Accepted: 07/12/2023] [Indexed: 10/07/2023] Open
Abstract
Background & Aims Although incidence rates of hepatocellular carcinoma (HCC) began to decline in the United States in the past decade, disparities in rates among racial/ethnic groups have persisted. Whether disparities in stage at diagnosis have remained over time, however, is unclear. Methods National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) program has created a new staging-over-time variable that facilitates the examination of trends in HCC stage. Thus, the proportions of HCCs diagnosed by stage between 1992 and 2019 were examined among non-Hispanic White, non-Hispanic Black (NHB), Hispanic, Asian/Pacific Islander, and American Indian/Alaska Native (AI/AN) individuals. HCC incidence between 1992 and 2019 was also analysed using Joinpoint regression. Results Between 1992 and 2019, the proportion of stage 1 HCCs increased and the proportion of stage 4 HCCs decreased among non-Hispanic White, NHB, Hispanic, and Asian/Pacific Islander individuals. Among AI/AN persons, the proportion of stage 1 tumours remained stable, and the proportion of stage 4 tumours declined. In the most recent time period, NHB individuals had the lowest proportions of stage 1 HCCs (32%) and the highest proportion of stage 4 HCCs (20%) of any group. Joinpoint analysis found that HCC incidence began to decline by 2013 among all groups except AI/AN individuals, the only group that had an increase in incidence. Conclusions Despite generally favourable trends in HCC stage and incidence rates, disparities remain. NHB persons continue to have less favourable stages at diagnosis, and incidence rates continue to increase among AI/AN persons. Impact and implications HCC incidence rates among most United States racial/ethnic groups began to decline in recent years, but whether stage at diagnosis also improved was unclear. As a result, a new SEER stage variable was used to examine stage trends by race/ethnicity. Although the finding of generally favourable trends in stage as well as incidence is encouraging, continuity disparities in both stage and incidence require serious attention.
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Affiliation(s)
- Christian S. Alvarez
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | - Jennifer Ruhl
- Division of Cancer Control and Population Sciences, NCI, Rockville, MD, USA
| | | | - Barry I. Graubard
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | - Katherine A. McGlynn
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
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15
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Liu M, Lai M, Li D, Zhang R, Wang L, Peng W, Yang J, He W, Sheng Y, Xiao S, Nan A, Zeng X. Nucleus-localized circSLC39A5 suppresses hepatocellular carcinoma development by binding to STAT1 to regulate TDG transcription. Cancer Sci 2023; 114:3884-3899. [PMID: 37549641 PMCID: PMC10551608 DOI: 10.1111/cas.15906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 06/16/2023] [Accepted: 06/26/2023] [Indexed: 08/09/2023] Open
Abstract
Accumulating evidence indicates that circular RNAs (circRNAs) are inextricably linked to cancer development. However, the function and mechanism of nucleus-localized circRNAs in hepatocellular carcinoma (HCC) still require investigation. Here, qRT-PCR and receiver-operating characteristic curve were used to detect the expression and diagnostic potential of circSLC39A5 for HCC. The biological function of circSLC39A5 in HCC was investigated in vitro and in vivo. Nucleoplasmic separation assay, fluorescence in situ hybridization, RNA pulldown, RNA immunoprecipitation, the HDOCK Server, the NucleicNet Webserver, crosslinking-immunoprecipitation, MG132 treatment, and chromatin immunoprecipitation were utilized to explore the potential molecular mechanism of circSLC39A5 in HCC. The results showed that circSLC39A5 was downregulated in both HCC tissues and plasma and was associated with satellite nodules and lymph node metastasis/vascular invasion. CircSLC39A5 was stably expressed in plasma samples under different storage conditions, showing good diagnostic potential for HCC (AUC = 0.915). CircSLC39A5 inhibited proliferation, migration, and invasion, facilitated the apoptosis of HCC cells, and was associated with low expression of Ki67 and CD34. Remarkably, circSLC39A5 is mainly localized in the nucleus and binds to the transcription factor signal transducer and activator of transcription 1 (STAT1), affecting its stabilization and expression. STAT1 binds to the promoter of thymine DNA glycosylase (TDG). Overexpression of circSLC39A5 elevates TDG expression and reverses the increase of proliferating cell nuclear antigen (PCNA) expression and the overactive cell proliferation caused by TDG silencing. Our findings uncovered a novel plasma circRNA, circSLC39A5, which may be a potential circulating diagnostic marker for HCC, and the mechanism by which nucleus-localized circSLC39A5 exerts a transcriptional regulatory role in HCC by affecting STAT1/TDG/PCNA provides new insights into the mechanism of circRNAs.
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Affiliation(s)
- Meiliang Liu
- Department of Epidemiology and Health Statistics, School of Public HealthGuangxi Medical UniversityNanningChina
- Guangxi Colleges and Universities Key Laboratory of Prevention and Control of Highly Prevalent DiseasesGuangxi Medical UniversityNanningChina
| | - Mingshuang Lai
- Department of Epidemiology and Health Statistics, School of Public HealthGuangxi Medical UniversityNanningChina
- Guangxi Colleges and Universities Key Laboratory of Prevention and Control of Highly Prevalent DiseasesGuangxi Medical UniversityNanningChina
| | - Deyuan Li
- Department of Epidemiology and Health Statistics, School of Public HealthGuangxi Medical UniversityNanningChina
- Guangxi Colleges and Universities Key Laboratory of Prevention and Control of Highly Prevalent DiseasesGuangxi Medical UniversityNanningChina
| | - Ruirui Zhang
- Guangxi Colleges and Universities Key Laboratory of Prevention and Control of Highly Prevalent DiseasesGuangxi Medical UniversityNanningChina
- Department of Toxicology, School of Public HealthGuangxi Medical UniversityNanningChina
| | - Lijun Wang
- Department of Epidemiology and Health Statistics, School of Public HealthGuangxi Medical UniversityNanningChina
- Guangxi Colleges and Universities Key Laboratory of Prevention and Control of Highly Prevalent DiseasesGuangxi Medical UniversityNanningChina
| | - Wenyi Peng
- Guangxi Colleges and Universities Key Laboratory of Prevention and Control of Highly Prevalent DiseasesGuangxi Medical UniversityNanningChina
- Department of Toxicology, School of Public HealthGuangxi Medical UniversityNanningChina
| | - Jialei Yang
- Department of Epidemiology and Health Statistics, School of Public HealthGuangxi Medical UniversityNanningChina
- Guangxi Colleges and Universities Key Laboratory of Prevention and Control of Highly Prevalent DiseasesGuangxi Medical UniversityNanningChina
| | - Wanting He
- Department of Epidemiology and Health Statistics, School of Public HealthGuangxi Medical UniversityNanningChina
- Guangxi Colleges and Universities Key Laboratory of Prevention and Control of Highly Prevalent DiseasesGuangxi Medical UniversityNanningChina
| | - Yonghong Sheng
- Department of Epidemiology and Health Statistics, School of Public HealthGuangxi Medical UniversityNanningChina
- Guangxi Colleges and Universities Key Laboratory of Prevention and Control of Highly Prevalent DiseasesGuangxi Medical UniversityNanningChina
| | - Suyang Xiao
- Department of Epidemiology and Health Statistics, School of Public HealthGuangxi Medical UniversityNanningChina
- Guangxi Colleges and Universities Key Laboratory of Prevention and Control of Highly Prevalent DiseasesGuangxi Medical UniversityNanningChina
| | - Aruo Nan
- Guangxi Colleges and Universities Key Laboratory of Prevention and Control of Highly Prevalent DiseasesGuangxi Medical UniversityNanningChina
- Department of Toxicology, School of Public HealthGuangxi Medical UniversityNanningChina
| | - Xiaoyun Zeng
- Department of Epidemiology and Health Statistics, School of Public HealthGuangxi Medical UniversityNanningChina
- Guangxi Colleges and Universities Key Laboratory of Prevention and Control of Highly Prevalent DiseasesGuangxi Medical UniversityNanningChina
- Key Laboratory of Early Prevention and Treatment for Regional High Frequency Tumor (Guangxi Medical University), Ministry of EducationNanningChina
- Guangxi Key Laboratory of Early Prevention and Treatment for Regional High Frequency TumorNanningChina
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16
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Huang DC, Yu RL, Alqahtani S, Tamim H, Saberi B, Bonder A. Racial, ethnic, and socioeconomic disparities impact post-liver transplant survival in patients with hepatocellular carcinoma. Ann Hepatol 2023; 28:101127. [PMID: 37286167 DOI: 10.1016/j.aohep.2023.101127] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 05/16/2023] [Accepted: 05/24/2023] [Indexed: 06/09/2023]
Abstract
INTRODUCTION AND OBJECTIVES Liver transplantation can be a curative treatment for patients with hepatocellular carcinoma (HCC); however, the morbidity and mortality associated with HCC varies by socioeconomic status and race and ethnicity. Policies like Share 35 were implemented to ensure equitable access to organ transplants; however, their impacts are unclear. We aimed to characterize differences in post-liver transplant (LT) survival among patients with HCC, when considering race and ethnicity, income, and insurance type, and understand if these associations were impacted by Share 35. MATERIALS AND METHODS We conducted a retrospective cohort study of 30,610 adult LT recipients with HCC. Data were obtained from the UNOS database. Survival analysis was carried out using Kaplan-Meier curves, and multivariate Cox regression analysis was used to calculate hazard ratios. RESULTS Men (HR: 0.90 (95% CI: 0.85-0.95)), private insurance (HR: 0.91 (95% CI: 0.87-0.92)), and income (HR: 0.87 (95% CI: 0.83-0.92)) corresponded with higher post-LT survival, when adjusted for over 20 demographic and clinical characteristics (Table 2). African American or Black individuals were associated with lower post-LT survival (HR: 1.20 (95% CI: 1.12-1.28)), whereas. Asian (HR: 0.79 (95% CI: 0.71-0.88)) or Hispanic (HR: 0.86 (95% CI: 0.81-0.92)) individuals were associated with higher survival as compared with White individuals (Table 2). Many of these patterns held in the pre-Share 35 and Share 35 periods. CONCLUSIONS Racial, ethnic, and socioeconomic disparities at time of transplant, such as private insurance and income, influence post-LT survival in patients with HCC. These patterns persist despite the passage of equitable access policies, such as Share 35.
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Affiliation(s)
- Dora C Huang
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Rosa L Yu
- Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Saleh Alqahtani
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, United States; College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Hani Tamim
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Behnam Saberi
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Alan Bonder
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States.
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17
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El-Serag HB, Ward JW, Asrani SK, Singal AG, Rich N, Thrift AP, Deshpande S, Turner BJ, Kaseb AO, Harrison AC, Fortune BE, Kanwal F. Prevention of Hepatocellular Carcinoma (HCC). White Paper of the Texas Collaborative Center for Hepatocellular Cancer (TeCH) Multi-stakeholder Conference. Clin Gastroenterol Hepatol 2023; 21:2183-2192. [PMID: 37086825 PMCID: PMC10524305 DOI: 10.1016/j.cgh.2023.03.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/17/2023] [Accepted: 03/17/2023] [Indexed: 04/24/2023]
Abstract
BACKGROUND & AIMS Texas has the highest age-adjusted incidence rate of hepatocellular carcinoma (HCC) in the United States. The Cancer Prevention and Research Institute of Texas has funded the Texas Collaborative Center for Hepatocellular Cancer (TeCH) to facilitate HCC research, education, and advocacy activities with the overall goal of reducing HCC mortality in Texas through coordination, collaboration, and advocacy. METHODS On September 17, 2022, TeCH co-sponsored a multi-stakeholder conference on HCC with the Baker Institute Center for Health and Biosciences. This conference was attended by HCC researchers, policy makers, payers, members from pharmaceutical industry and patient advocacy groups in and outside of Texas. This report summarizes the results of the conference. RESULTS The goal of this meeting was to identify different strategies for preventing HCC and evaluate their readiness for implementation. CONCLUSIONS We call for a statewide (1) viral hepatitis elimination program; (2) program to increase nonalcoholic steatohepatitis and obesity awareness; (3) research program to develop health care models that integrate alcohol associated liver disease treatment and treatment for alcohol use disorder; and (4) demonstration projects to evaluate the effectiveness of identifying and linking patient with advanced fibrosis and cirrhosis to clinical care.
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Affiliation(s)
| | - John W Ward
- The Coalition for Global Hepatitis Elimination, The Task Force for Global Health, Decatur, Georgia
| | | | - Amit G Singal
- Department of Medicine, University of Texas Southwestern Medical Center Dallas, Texas
| | - Nicole Rich
- Department of Medicine, University of Texas Southwestern Medical Center Dallas, Texas
| | - Aaron P Thrift
- Section of Epidemiology and Population Sciences, Department of Medicine, Baylor College of Medicine, Houston, Texas; Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas
| | | | - Barbara J Turner
- Department of Medicine, Keck School of Medicine of USC, Los Angeles, California
| | - Ahmed O Kaseb
- Department of Gastrointestinal Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ariel C Harrison
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Brett E Fortune
- Department of Medicine, Montefiore Medical Center, Bronx, New York
| | - Fasiha Kanwal
- Department of Medicine, Baylor College of Medicine, Houston, Texas
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18
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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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19
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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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Wagle NS, Park S, Washburn D, Ohsfeldt RL, Rich NE, Singal AG, Kum HC. Racial, Ethnic, and Socioeconomic Disparities in Treatment Delay Among Patients With Hepatocellular Carcinoma in the United States. Clin Gastroenterol Hepatol 2023; 21:1281-1292.e10. [PMID: 35933076 PMCID: PMC9898458 DOI: 10.1016/j.cgh.2022.07.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 06/25/2022] [Accepted: 07/23/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Failures have been reported across the cancer care continuum in patients with hepatocellular carcinoma (HCC); however, the impact of treatment delays on outcomes has not been well-characterized. We described the prevalence of treatment delays in a racially and ethnically diverse cohort of patients and its association with overall survival. METHODS Using the Surveillance, Epidemiology, and End Results-Medicare database, we identified patients diagnosed with HCC between 2001 and 2015. We performed multivariable logistic regression analysis to identify factors associated with treatment delay (ie, receipt of HCC-directed therapy >3 months after diagnosis). Cox proportional hazards regression analysis with a 5-month landmark was used to characterize the association between treatment delay and overall survival, accounting for immortal time bias. RESULTS Of 8450 patients with treatment within 12 months of HCC diagnosis, 1205 (14.3%) experienced treatment delays. The proportion with treatment delays ranged from 6.8% of patients undergoing surgical resection to 21.6% of those undergoing liver transplantation. In multivariable analysis, Black patients (odds ratio, 1.96; 95% confidence interval [CI], 1.21-3.15) and those living in high poverty neighborhoods (odds ratio, 1.55; 95% CI, 1.25-1.92) were more likely to experience treatment delays than white patients and those living in low poverty neighborhoods, respectively. Treatment delay was independently associated with worse survival (hazard ratio 1.15, 95% CI, 1.05-1.25). CONCLUSIONS Nearly 1 in 7 patients with HCC experience treatment delays, with higher odds in Black patients and those living in high poverty neighborhoods. Treatment delays are associated with worse survival, highlighting a need for interventions to improve time-to-treatment.
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Affiliation(s)
- Nikita Sandeep Wagle
- Population Informatics Lab, Texas A&M University, College Station, Texas; Department of Health Policy & Management, School of Public Health, Texas A&M Health Science Center, College Station, Texas
| | - Sulki Park
- Population Informatics Lab, Texas A&M University, College Station, Texas; Department of Industrial & Systems Engineering, Texas A&M University, College Station, Texas
| | - David Washburn
- Population Informatics Lab, Texas A&M University, College Station, Texas; Department of Health Policy & Management, School of Public Health, Texas A&M Health Science Center, College Station, Texas
| | - Robert L Ohsfeldt
- Population Informatics Lab, Texas A&M University, College Station, Texas; Department of Health Policy & Management, School of Public Health, Texas A&M Health Science Center, College Station, Texas
| | - Nicole E Rich
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas
| | - Amit G Singal
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas.
| | - Hye-Chung Kum
- Population Informatics Lab, Texas A&M University, College Station, Texas; Department of Health Policy & Management, School of Public Health, Texas A&M Health Science Center, College Station, Texas; Department of Industrial & Systems Engineering, Texas A&M University, College Station, Texas
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21
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Kardashian A, Serper M, Terrault N, Nephew LD. Health disparities in chronic liver disease. Hepatology 2023; 77:1382-1403. [PMID: 35993341 PMCID: PMC10026975 DOI: 10.1002/hep.32743] [Citation(s) in RCA: 46] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/14/2022] [Accepted: 06/16/2022] [Indexed: 12/14/2022]
Abstract
The syndemic of hazardous alcohol consumption, opioid use, and obesity has led to important changes in liver disease epidemiology that have exacerbated health disparities. Health disparities occur when plausibly avoidable health differences are experienced by socially disadvantaged populations. Highlighting health disparities, their sources, and consequences in chronic liver disease is fundamental to improving liver health outcomes. There have been large increases in alcohol use disorder in women, racial and ethnic minorities, and those experiencing poverty in the context of poor access to alcohol treatment, leading to increasing rates of alcohol-associated liver diseases. Rising rates of NAFLD and associated fibrosis have been observed in Hispanic persons, women aged > 50, and individuals experiencing food insecurity. Access to viral hepatitis screening and linkage to treatment are suboptimal for racial and ethnic minorities and individuals who are uninsured or underinsured, resulting in greater liver-related mortality and later-stage diagnoses of HCC. Data from more diverse cohorts on autoimmune and cholestatic liver diseases are lacking, supporting the need to study the contemporary epidemiology of these disorders in greater detail. Herein, we review the existing literature on racial and ethnic, gender, and socioeconomic disparities in chronic liver diseases using a social determinants of health framework to better understand how social and structural factors cause health disparities and affect chronic liver disease outcomes. We also propose potential solutions to eliminate disparities, outlining health-policy, health-system, community, and individual solutions to promote equity and improve health outcomes.
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Affiliation(s)
- Ani Kardashian
- Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles, California, USA
| | - Marina Serper
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Norah Terrault
- Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles, California, USA
| | - Lauren D. Nephew
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Indiana University Simon Comprehensive Cancer Center, Indianapolis, Indiana, USA
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Wang L, Peng JL, Wu JZ. Nomogram to predict the prognosis of patients with AFP-negative hepatocellular carcinoma undergoing chemotherapy: A SEER based study. Medicine (Baltimore) 2023; 102:e33319. [PMID: 37000113 PMCID: PMC10063275 DOI: 10.1097/md.0000000000033319] [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: 10/05/2022] [Revised: 01/27/2023] [Accepted: 02/27/2023] [Indexed: 04/01/2023] Open
Abstract
This study aimed to formulate reliable nomograms for predicting the outcomes of α-fetoprotein (AFP)-negative hepatocellular carcinoma (HCC) patients after chemotherapy. HCC patients with normal AFP expression who received chemotherapy were screened and evaluated from the surveillance, epidemiology, and end results database. The prognostic factors for predicting outcomes of HCC patients undergoing chemotherapy were chosen by analyzing the results of Cox analyses. Then, a nomogram integrating the prognostic factors was established. The discrimination ability of the nomogram was evaluated with computation of area under the curve (AUC) and calibration curve. A total of 2424 patients with AFP-negative HCC undergoing chemotherapy were identified. The median overall survival (OS) for HCC patients undergoing chemotherapy was 33 months. Age, race, pathologic grade, N stage, M stage, surgery, and lung metastases were significantly linked to OS. These relevant factors were incorporated into the nomogram. AUC values of the prognostic nomogram for 3- and 5-year OS were 0.696 and 0.706 in the training groups, which were superior to those of the tumor node metastasis (TNM) stage (0.641 and 0.671) in training groups. The calibration curves indicated a high consistency between the predicted probability of nomograms and the actual observation. The validation groups produced AUC values of 0.674 and 0.736 for 3- and 5-year OS, which were superior to those of the TNM stage (0.601 and 0.637) in validation groups. The results revealed significantly unfavorable OS in the high-risk group (P < .001). Nomograms to accurately predict the OS for AFP-negative HCC patients after chemotherapy were established and exhibited a more accurate predication than the conventional TNM staging system.
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Affiliation(s)
- Lei Wang
- Department of Rehabilitation Medicine, Hunan Provincial People’s Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, People’s Republic of China
| | - Jin-Lin Peng
- Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, People’s Republic of China
| | - Ji-Zhou Wu
- The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
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23
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Zhan G, Peng H, Zhou L, Jin L, Xie X, He Y, Wang X, Du Z, Cao P. A web-based nomogram model for predicting the overall survival of hepatocellular carcinoma patients with external beam radiation therapy: A population study based on SEER database and a Chinese cohort. Front Endocrinol (Lausanne) 2023; 14:1070396. [PMID: 36798659 PMCID: PMC9927006 DOI: 10.3389/fendo.2023.1070396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 01/18/2023] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND External beam radiation therapy (EBRT) for hepatocellular carcinoma (HCC) is rarely used in clinical practice. This study aims to develop and validate a prognostic nomogram model to predict overall survival (OS) in HCC patients treated with EBRT. METHOD We extracted eligible data of HCC patients between 2004 and 2015 from the Surveillance, Epidemiology, and End Results (SEER) database. Those patients were randomly divided into a training cohort (n=1004) and an internal validation cohort (n=429), and an external validation cohort composed of a Chinese cohort (n=95). A nomogram was established based on the independent prognostic variables identified from univariate and multivariate Cox regression analyses. The effective performance of the nomogram was evaluated using the concordance index (C-index), receiver operating characteristic curve (ROC), and calibration curves. The clinical practicability was evaluated using decision curve analysis (DCA). RESULTS T stage, N stage, M stage, AFP, tumor size, surgery, and chemotherapy were independent prognostic risk factors that were all included in the nomogram to predict OS in HCC patients with EBRT. In the training cohort, internal validation cohort, and external validation cohort, the C-index of the prediction model was 0.728 (95% confidence interval (CI): 0.716-0.740), 0.725 (95% CI:0.701-0.750), and 0.696 (95% CI:0.629-0.763), respectively. The 6-, 12-,18- and 24- month areas under the curves (AUC) of ROC in the training cohort were 0.835 、0.823 、0.810, and 0.801, respectively; and 0.821 、0.809 、0.813 and 0.804 in the internal validation cohort, respectively; and 0.749 、0.754 、0.791 and 0.798 in the external validation cohort, respectively. The calibration curves indicated that the predicted value of the prediction model performed well. The DCA curves showed better clinical practicability. In addition, based on the nomogram, we established a web-based nomogram to predict the OS of these patients visually. CONCLUSION Based on the SEER database and an independent external cohort from China, we established and validated a nomogram to predict OS in HCC patients treated with EBRT. In addition, for the first time, a web-based nomogram model can help clinicians judge the prognoses of these patients and make better clinical decisions.
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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: 0] [Impact Index Per Article: 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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25
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Ahn JC, Lauzon M, Luu M, Noureddin M, Ayoub W, Kuo A, Sundaram V, Kosari K, Nissen N, Gong J, Hendifar A, Roberts LR, Abou-Alfa GK, Singal AG, Yang JD. Racial and ethnic disparities in early treatment with immunotherapy for advanced HCC in the United States. Hepatology 2022; 76:1649-1659. [PMID: 35429171 DOI: 10.1002/hep.32527] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 03/29/2022] [Accepted: 04/04/2022] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND AIMS Immunotherapy has emerged as an effective treatment for patients with advanced-stage HCC. We aimed to investigate the efficacy of immunotherapy for advanced HCC in a nationwide cohort and racial and ethnic disparities in access to immunotherapy. APPROACH AND RESULTS We used the US National Cancer Database to identify patients with tumor-node-metastasis stage 3 or 4 HCC between 2017 and 2018. We performed multivariable Cox regression to identify factors associated with overall survival (OS) and logistic regression to identify factors associated with receipt of immunotherapy. Of the 3,990 patients treated for advanced HCC, 3,248 (81.4%) patients received chemotherapy and 742 (18.6%) patients received immunotherapy as a first-line treatment. Immunotherapy was associated with improved OS compared with chemotherapy (adjusted HR: 0.76, 95% CI: 0.65-0.88) after adjusting for covariates. There were racial and ethnic disparities in access to immunotherapy, with Hispanic (adjusted OR [aOR]: 0.63, 95% CI: 0.46-0.83) and Black patients (aOR: 0.71, 95% CI: 0.54-0.89) less likely to receive immunotherapy compared with White patients. There was a significant interaction between race-ethnicity and facility type, with higher disparity observed in nonacademic centers (interaction p = 0.004). CONCLUSIONS Immunotherapy was associated with improved OS compared with chemotherapy in advanced HCC. There are significant disparities in early access to immunotherapy, likely due to differential access to clinical trials and experimental therapies. A comprehensive approach to monitoring and eliminating racial-ethnic disparities in the management of advanced HCC is urgently needed.
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Affiliation(s)
- Joseph C Ahn
- Division of Gastroenterology and HepatologyMayo ClinicRochesterMinnesotaUSA
| | - Marie Lauzon
- 22494Biostatistics and Bioinformatics Research CenterCedars-Sinai Medical CenterLos AngelesCaliforniaUSA
| | - Michael Luu
- 22494Biostatistics and Bioinformatics Research CenterCedars-Sinai Medical CenterLos AngelesCaliforniaUSA
| | - Mazen Noureddin
- 22494Comprehensive Transplant CenterCedars-Sinai Medical CenterLos AngelesCaliforniaUSA.,22494Karsh Division of Gastroenterology and HepatologyCedars-Sinai Medical CenterLos AngelesCaliforniaUSA
| | - Walid Ayoub
- 22494Comprehensive Transplant CenterCedars-Sinai Medical CenterLos AngelesCaliforniaUSA.,22494Karsh Division of Gastroenterology and HepatologyCedars-Sinai Medical CenterLos AngelesCaliforniaUSA
| | - Alexander Kuo
- 22494Comprehensive Transplant CenterCedars-Sinai Medical CenterLos AngelesCaliforniaUSA.,22494Karsh Division of Gastroenterology and HepatologyCedars-Sinai Medical CenterLos AngelesCaliforniaUSA
| | - Vinay Sundaram
- 22494Comprehensive Transplant CenterCedars-Sinai Medical CenterLos AngelesCaliforniaUSA.,22494Karsh Division of Gastroenterology and HepatologyCedars-Sinai Medical CenterLos AngelesCaliforniaUSA
| | - Kambiz Kosari
- 22494Comprehensive Transplant CenterCedars-Sinai Medical CenterLos AngelesCaliforniaUSA.,22494Samuel Oschin Comprehensive Cancer InstituteCedars-Sinai Medical CenterLos AngelesCaliforniaUSA.,22494Department of SurgeryCedars-Sinai Medical CenterLos AngelesCaliforniaUSA
| | - Nicholas Nissen
- 22494Comprehensive Transplant CenterCedars-Sinai Medical CenterLos AngelesCaliforniaUSA.,22494Samuel Oschin Comprehensive Cancer InstituteCedars-Sinai Medical CenterLos AngelesCaliforniaUSA.,22494Department of SurgeryCedars-Sinai Medical CenterLos AngelesCaliforniaUSA
| | - Jun Gong
- 22494Samuel Oschin Comprehensive Cancer InstituteCedars-Sinai Medical CenterLos AngelesCaliforniaUSA
| | - Andrew Hendifar
- 22494Samuel Oschin Comprehensive Cancer InstituteCedars-Sinai Medical CenterLos AngelesCaliforniaUSA
| | - Lewis R Roberts
- Division of Gastroenterology and HepatologyMayo ClinicRochesterMinnesotaUSA
| | - Ghassan K Abou-Alfa
- Department of MedicineMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA.,Department of MedicineWeill Medical College at Cornell UniversityNew YorkNew YorkUSA
| | - Amit G Singal
- Harold C. Simmons Comprehensive Cancer CenterUT Southwestern Medical CenterDallasTexasUSA.,Division of Digestive and Liver DiseasesUT Southwestern Medical CenterDallasTexasUSA
| | - Ju Dong Yang
- 22494Comprehensive Transplant CenterCedars-Sinai Medical CenterLos AngelesCaliforniaUSA.,22494Karsh Division of Gastroenterology and HepatologyCedars-Sinai Medical CenterLos AngelesCaliforniaUSA.,22494Samuel Oschin Comprehensive Cancer InstituteCedars-Sinai Medical CenterLos AngelesCaliforniaUSA
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26
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Wong RJ, Jayasekera C, Jones P, Kanwal F, Singal AG, Ahmed A, Taglienti R, Younossi Z, Kulik L, Mehta N. An Open-Access, Interactive Decision-Support Tool to Facilitate Guideline-Driven Care for Hepatocellular Carcinoma. Gastroenterology Res 2022; 15:297-307. [PMID: 36660470 PMCID: PMC9822660 DOI: 10.14740/gr1573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/07/2022] [Indexed: 12/23/2022] Open
Abstract
Hepatocellular carcinoma (HCC) is increasing in incidence and is a leading cause of cancer-related mortality worldwide. Adherence to HCC surveillance guidelines and appropriate treatment triage of liver lesions may improve receipt of curative-intent treatment and improved survival. Late-stage HCC diagnosis reflects sub-optimal implementation of effective HCC surveillance, whereas inappropriate treatment triage or linkage to care accounts for the non-receipt of curative-intent in close to half of early-stage HCC in the USA. A free, open-access decision-support tool for liver lesions that incorporates current guideline recommendations in a user-friendly interface could improve appropriate and timely triage of patients to appropriate care. This review provides a summary of gaps and disparities in linkage to HCC care and introduces a free, internet-based, interactive decision-support tool for managing liver lesions. This tool has been developed by the HCC Steering Committee of the Chronic Liver Disease Foundation and is targeted toward clinicians across specialties who may encounter liver lesions during routine care or as part of dedicated HCC surveillance.
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Affiliation(s)
- Robert J. Wong
- Veterans Affairs Palo Alto Healthcare System, Stanford University School of Medicine, Palo Alto, CA, USA,Corresponding Author: Robert J. Wong, Veterans Affairs Palo Alto Healthcare System, Stanford University School of Medicine, Palo Alto, CA 94304, USA.
| | | | | | - Fasiha Kanwal
- Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA
| | - Amit G. Singal
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Aijaz Ahmed
- Stanford University School of Medicine, Stanford, CA, USA
| | | | | | | | - Neil Mehta
- University of California, San Francisco, CA, USA
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Jan J, Osho A, Murphy CC, Mazure CM, Singal AG, Rich NE. Gender, Age, Racial and Ethnic Disparities in Clinical Trial Enrollment for Primary Liver Cancer. Gastroenterology 2022; 163:14-20.e2. [PMID: 35288115 PMCID: PMC9232956 DOI: 10.1053/j.gastro.2022.03.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 03/05/2022] [Accepted: 03/07/2022] [Indexed: 02/06/2023]
Affiliation(s)
- Jenny Jan
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, Dallas TX
| | - Azeez Osho
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, Dallas TX
| | - Caitlin C. Murphy
- School of Public Health, University of Texas Health Science Center at Houston (UTHealth), Houston, TX
| | - Carolyn M. Mazure
- Department of Psychiatry; Women’s Health Research at Yale, Yale University School of Medicine, New Haven, CT
| | - Amit G. Singal
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, Dallas TX,Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas TX
| | - Nicole E. Rich
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, Dallas TX,Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas TX
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28
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Melendez-Torres J, Singal AG. Early detection of hepatocellular carcinoma: roadmap for improvement. Expert Rev Anticancer Ther 2022; 22:621-632. [PMID: 35514249 PMCID: PMC9845108 DOI: 10.1080/14737140.2022.2074404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Hepatocellular carcinoma (HCC) has a poor prognosis, related, in part, to frequent late-stage diagnosis. Improved implementation of effective HCC surveillance is critical to reduce HCC mortality. AREAS COVERED We performed a targeted literature review to identify intervention targets for improving HCC surveillance effectiveness, including enriched risk stratification tools, improved surveillance tools with higher accuracy for early HCC detection, and increasing surveillance adherence. EXPERT OPINION HCC surveillance has been demonstrated to be efficacious in several cohort studies but has lower surveillance effectiveness in clinical practice. HCC surveillance is currently recommended in all patients with cirrhosis, and improved risk stratification using clinical risk scores, genetic scores, and novel biomarkers are important to move from a 'one-size-fits-all' strategy to one more aligned with values of precision medicine. Current surveillance modalities, ultrasound, and AFP, miss over one-third of HCC at an early stage and are associated with potential surveillance harms, underscoring a need for alternative surveillance strategies with higher accuracy. MRI- and biomarker-based surveillance strategies have promising early data in phase II studies but require validation in phase III cohorts before routine use in practice. Finally, surveillance is underused in clinical practice, highlighting a need for intervention strategies to increase utilization.
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Wagle NS, Park S, Washburn D, Ohsfeldt RL, Rich NE, Singal AG, Kum H. Racial, Ethnic, and Socioeconomic Disparities in Curative Treatment Receipt and Survival in Hepatocellular Carcinoma. Hepatol Commun 2022; 6:1186-1197. [PMID: 34796703 PMCID: PMC9035560 DOI: 10.1002/hep4.1863] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 10/19/2021] [Accepted: 10/30/2021] [Indexed: 12/21/2022] Open
Abstract
Hepatocellular carcinoma (HCC) disproportionately affects racial, ethnic, and low socioeconomic status (SES) populations. However, the interaction between race, ethnicity, and neighborhood SES in HCC prognosis is not well explored. This study evaluates the interaction between race and ethnicity and neighborhood SES on curative treatment utilization and overall survival among patients with HCC in the United States. We conducted a retrospective cohort study of 13,874 patients aged ≥65 years diagnosed with HCC from 2001 through 2015 using the Surveillance, Epidemiology, and End Results Medicare-linked database. We performed multivariable logistic regression to examine the association between race, ethnicity, and curative treatment receipt across SES. We also evaluated the association between curative treatment receipt and overall survival using a Cox proportional hazards model. Among 13,874 patients, only 2,617 (18.9%) patients received curative treatment. Overall, Black patients had lower odds of receiving curative treatment than White patients (odds ratio [OR], 0.76; 95% confidence interval [CI], 0.64-0.91). When stratified by neighborhood SES, Black patients living in high-poverty neighborhoods had lower odds of curative treatment receipt (OR, 0.64; 95% CI, 0.49-0.84) and worse survival (hazard ratio, 1.13; 95% CI, 1.02-1.25). Conversely, Hispanic and Asian patients had similar curative treatment receipt compared to White patients across all socioeconomic levels. Conclusion: Disparities in curative treatment receipt and overall survival are pronounced between Black and White patients. Black-White disparities appear to be moderated by neighborhood SES and are particularly evident among those living in high-poverty neighborhoods.
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Affiliation(s)
- Nikita Sandeep Wagle
- Population Informatics LabTexas A&M School of Public HealthCollege StationTXUSA
- Department of Health Policy and ManagementTexas A&M School of Public HealthCollege StationTXUSA
| | - Sulki Park
- Population Informatics LabTexas A&M School of Public HealthCollege StationTXUSA
- Department of Industrial and Systems EngineeringTexas A&M UniversityCollege StationTXUSA
| | - David Washburn
- Population Informatics LabTexas A&M School of Public HealthCollege StationTXUSA
- Department of Health Policy and ManagementTexas A&M School of Public HealthCollege StationTXUSA
| | - Robert L. Ohsfeldt
- Population Informatics LabTexas A&M School of Public HealthCollege StationTXUSA
- Department of Health Policy and ManagementTexas A&M School of Public HealthCollege StationTXUSA
| | - Nicole E. Rich
- Division of Digestive and Liver DiseasesUniversity of Texas Southwestern Medical CenterDallasTXUSA
| | - Amit G. Singal
- Division of Digestive and Liver DiseasesUniversity of Texas Southwestern Medical CenterDallasTXUSA
| | - Hye‐Chung Kum
- Population Informatics LabTexas A&M School of Public HealthCollege StationTXUSA
- Department of Health Policy and ManagementTexas A&M School of Public HealthCollege StationTXUSA
- Department of Industrial and Systems EngineeringTexas A&M UniversityCollege StationTXUSA
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Paro A, Dalmacy D, Tslimigras DI, Cloyd J, Ejaz A, Pawlik TM. Association of County-Level Upward Economic Mobility with Stage at Diagnosis and Receipt of Curative-Intent Treatment among Patients with Hepatocellular Carcinoma. Ann Surg Oncol 2022; 29:5177-5185. [PMID: 35441305 DOI: 10.1245/s10434-022-11726-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 03/21/2022] [Indexed: 12/18/2022]
Abstract
BACKGROUND Upward economic mobility represents the ability of children to surpass their parents financially and improve their economic status. The extent to which it contributes to socioeconomic disparities in health outcomes remains largely unknown. METHODS Patients diagnosed with hepatocellular carcinoma (HCC) in 2004-2015 were identified from the SEER-Medicare linked database. Information on county-level upward economic mobility was obtained from the Opportunity Atlas, and its impact on early-stage diagnosis (tumor size ≤ 5 cm, no nodal involvement or distant metastases, no major vascular invasion or extrahepatic extension) and receipt of curative-intent treatment (resection, transplantation, or ablation) was examined. RESULTS Among 9190 Medicare beneficiaries diagnosed with HCC, the majority were White (64.9%, n = 5965). Overall, 44.7% (n = 4105) of patients were diagnosed with early-stage HCC and 29.7% (n = 2731) underwent curative-intent treatment. While higher upward economic mobility was not associated with HCC diagnosis at an early stage (OR 0.94, 95% CI 0.83-1.06), patients with early-stage HCC from areas of high upward economic mobility had increased odds of undergoing curative-intent treatment (OR 1.25, 95% CI 1.03-1.51). Upward economic mobility had no impact on the likelihood to undergo curative-intent treatment for early-stage HCC among White (OR 1.15, 95% CI 0.91-1.45), Black (OR 1.94, 95% CI 0.85-4.45) or Asian patients (OR 0.77, 95% CI 0.44-1.36). In contrast, non-White patients other than Blacks or Asians diagnosed with early-stage HCC had markedly higher odds of receiving curative-intent treatment if the individual resided in an area characterized by higher versus lower upward economic mobility (OR 2.58, 95% CI 1.50-4.46). CONCLUSIONS While community-level economic mobility was not associated with stage of diagnosis, it affected the likelihood of undergoing curative-intent treatment for early-stage HCC, especially among minority patients other than Black or Asian patients.
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Affiliation(s)
- Alessandro Paro
- Department of Surgery, James Cancer Hospital and Solove Research Institute, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Djhenne Dalmacy
- Department of Surgery, James Cancer Hospital and Solove Research Institute, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Diamantis I Tslimigras
- Department of Surgery, James Cancer Hospital and Solove Research Institute, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Jordan Cloyd
- Department of Surgery, James Cancer Hospital and Solove Research Institute, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, James Cancer Hospital and Solove Research Institute, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, James Cancer Hospital and Solove Research Institute, The Ohio State University, Wexner Medical Center, Columbus, OH, USA.
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31
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Wen C, Tang J, Luo H. Development and Validation of a Nomogram to Predict Cancer-Specific Survival for Middle-Aged Patients With Early-Stage Hepatocellular Carcinoma. Front Public Health 2022; 10:848716. [PMID: 35296046 PMCID: PMC8918547 DOI: 10.3389/fpubh.2022.848716] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 02/07/2022] [Indexed: 01/09/2023] Open
Abstract
Background Hepatocellular carcinoma is a common cause of death in middle-aged patients. We aimed to construct a new nomogram to predict cancer-specific survival (CSS) in middle-aged patients with hepatocellular carcinoma at an early stage. Method We collected clinicopathological information on early middle-aged patients with hepatocellular carcinoma from the SEER database. Univariate and multivariate Cox regression models were used to screen the independent risk factors for prognosis. These risk factors were used to construct predictions of CSS in patients with hepatocellular carcinoma. Consistency index (C- index), calibration curve, area under the receiver operating curve (AUC) were used. A decision analysis curve (DCA) was used to evaluate the clinical utility of the predictive model. Results A total of 6,286 patients with hepatocellular carcinoma in early middle age were enrolled. Univariate and multivariate Cox regression analysis showed that sex, marriage, race, histological tumor grade, T stage, surgery, chemotherapy, AFP, and tumor size were independent risk factors for prognosis. All independent risk factors were included in the nomogram to predict CSS at 1-, 3-, and 5-years in early middle age patients with hepatocellular carcinoma. In the training cohort and validation cohort, the C-index of the prediction model was 0.728 (95%CI: 0.716–0.740) and 0.733 (95%CI: 0.715–0.751), respectively. The calibration curve showed that the predicted value of the prediction model is highly consistent with the observed value. AUC also suggested that the model has good discrimination. DCA suggested that the nomogram had better predictive power than T staging. Conclusion We constructed a new nomogram to predict CSS in middle-aged patients with early-stage hepatocellular carcinoma. This prediction model has good accuracy and reliability, which can help patients and doctors to judge prognosis and make clinical decisions.
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Affiliation(s)
- Chong Wen
- General Surgery Center, The General Hospital of Western Theater, Chengdu, China
- College of Medicine, Southwest Jiaotong University, Chengdu, China
| | - Jie Tang
- Department of Biostatistics and Epidemiology, School of Public Health, Shenyang Medical College, Shenyang, China
| | - Hao Luo
- General Surgery Center, The General Hospital of Western Theater, Chengdu, China
- *Correspondence: Hao Luo
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32
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Alobuia WM, Meng T, Cisco RM, Lin DT, Suh I, Tamura MK, Trickey AW, Kebebew E, Seib CD. Racial disparities in the utilization of parathyroidectomy among patients with primary hyperparathyroidism: Evidence from a nationwide analysis of Medicare claims. Surgery 2022; 171:8-16. [PMID: 34229901 PMCID: PMC8688157 DOI: 10.1016/j.surg.2021.05.037] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/16/2021] [Accepted: 05/04/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Among patients with primary hyperparathyroidism, parathyroidectomy offers a chance of cure and mitigation of disease-related complications. The impact of race/ethnicity on referral and utilization of parathyroidectomy has not been fully explored. METHODS Population-based, retrospective cohort study using 100% Medicare claims from beneficiaries with primary hyperparathyroidism from 2006 to 2016. Associations of race/ethnicity with disease severity, surgeon evaluation, and subsequent parathyroidectomy were analyzed using adjusted multivariable logistic regression models. RESULTS Among 210,206 beneficiaries with primary hyperparathyroidism, 63,136 (30.0%) underwent parathyroidectomy within 1 year of diagnosis. Black patients were more likely than other races/ethnicities to have stage 3 chronic kidney disease (10.8%) but had lower prevalence of osteoporosis and nephrolithiasis compared to White patients, Black and Hispanic patients were more likely to have been hospitalized for primary hyperparathyroidism-associated conditions (White 4.8%, Black 8.1%, Hispanic 5.8%; P < .001). Patients who were White and met operative criteria were more likely to undergo parathyroidectomy than Black, Hispanic, or Asian patients (White 30.5%, Black 23.0%, Hispanic 21.4%, Asian 18.7%; P < .001). Black and Hispanic patients had lower adjusted odds of being evaluated by a surgeon (odds ratios 0.71 [95% confidence interval 0.69-0.74], 0.68 [95% confidence interval 0.61-0.74], respectively) and undergoing parathyroidectomy if evaluated by a surgeon (odds ratios 0.72 [95% confidence interval 0.68-0.77], 0.82 [95% confidence interval 0.67-0.99]). Asian race was associated with lower adjusted odds of being evaluated by a surgeon (odds ratio 0.64 [95% confidence interval 0.57-0.71]), but no difference in odds of parathyroidectomy. CONCLUSION Racial/ethnic disparities exist in the management of primary hyperparathyroidism among older adults. Determining the factors that account for this disparity require urgent attention to achieve parity in the management of primary hyperparathyroidism.
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Affiliation(s)
- Wilson M. Alobuia
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Tong Meng
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, Palo Alto, CA.,Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Robin M. Cisco
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Dana T. Lin
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Insoo Suh
- Division of Endocrine Surgery, NYU Langone Health, New York, NY
| | - Manjula Kurella Tamura
- Geriatric Research, Education and Clinical Center, Veterans Affairs Palo Alto, Palo Alto, CA.,Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA
| | - Amber W. Trickey
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Electron Kebebew
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Carolyn D. Seib
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA.,Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, Palo Alto, CA.,Division of General Surgery, Palo Alto Veterans Affairs Health Care System, Palo Alto, CA
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33
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Mospan AR, Morris HL, Fried MW. Real-world evidence in hepatocellular carcinoma. Liver Int 2021; 41 Suppl 1:61-67. [PMID: 34155788 DOI: 10.1111/liv.14864] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 02/28/2021] [Indexed: 12/19/2022]
Abstract
Real-world evidence includes all health-related information, such as electronic health records, insurance claims, pharmacy records and wearables that are obtained outside of clinical trials. These data can provide critical insights into the natural history of disease and evaluate the safety and effectiveness of treatment regimens used in clinical practice. Real-world data have been applied to varying degrees by global regulatory agencies to inform and expedite many phases of drug development and help refine the use of therapeutic regimens after marketing, especially in populations that are under-represented in registration trials. For the management of hepatocellular carcinoma, early detection provides the best chance for curative therapies, whose success has been evaluated in numerous cohorts. The availability of novel systemic therapies, including kinase inhibitors and immunotherapies, has provided new treatment options and improved survival in patients with advanced stage hepatocellular carcinoma. Real-world longitudinal observational studies can help understand the long-term safety and effectiveness of these agents.
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Affiliation(s)
| | | | - Michael W Fried
- Target RWE, Durham, NC, USA.,Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
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Lee YT, Wang JJ, Luu M, Noureddin M, Kosari K, Agopian VG, Rich NE, Lu SC, Tseng HR, Nissen NN, Singal AG, Yang JD. The Mortality and Overall Survival Trends of Primary Liver Cancer in the United States. J Natl Cancer Inst 2021; 113:1531-1541. [PMID: 34010422 DOI: 10.1093/jnci/djab079] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 03/05/2021] [Accepted: 04/09/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Recent trends of hepatocellular carcinoma (HCC) mortality and outcome remain unknown in the United States (US). We investigated the recent trends of primary liver cancer (excluding intrahepatic cholangiocarcinoma) mortality and HCC stage, treatment, and overall survival (OS) in the US. METHODS US Cancer Mortality database was analyzed to investigate the trend of primary liver cancer mortality. We analyzed the SEER 18 database to assess the temporal trend of tumor size, stage, treatment, and OS of HCC. Cox regression analysis investigated the association between HCC diagnosis year and OS. All statistical tests were 2-sided. RESULTS During 2000-2018, liver cancer mortality rates increased until 2013, plateaued during 2013-2016 (annual percent change [APC] = 0.1%/yr, 95% confidence interval [CI] = -2.1% to 2.4%; P=0.92), and started to decline during 2016-2018 (APC = -1.5%/yr, 95% CI= -3.2% to 0.2%; P=0.08). However, mortality continues to increase in American Indians/Alaska Natives, individuals aged 65 or older, and in 33 states. There was a 0.61% (95% CI = 0.53% to 0.69%; P<0.001) increase in localized stage HCC and 0.86 mm (95% CI= -1.10 to -0.62; P<0.001) decrease in median tumor size per year. One-year OS rate increased from 36.3% (95% CI = 34.3% to 38.3%) to 58.1% (95% CI = 56.9% to 59.4%) during 2000-2015, and five-year OS rate almost doubled from 11.7% (95% CI = 10.4% to 13.1%) to 21.3% (95% CI = 20.2% to 22.4%) during 2000-2011. Diagnosis year (per year) (adjusted hazard ratio = 0.96; 95% CI = 0.96 to 0.97) was independently associated with OS in multivariable analysis. CONCLUSIONS Primary liver cancer mortality rates have started to decline in the US with demographic and state-level variation. With an increasing detection of localized HCC, the OS of HCC has improved over the past decades.
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Affiliation(s)
- Yi-Te Lee
- California NanoSystems Institute, Crump Institute for Molecular Imaging.,Department of Molecular and Medical Pharmacology
| | - Jasmine J Wang
- Department of Molecular and Medical Pharmacology.,Samuel Oschin Comprehensive Cancer Institute
| | - Michael Luu
- Biostatistics and Bioinformatics Research Center
| | - Mazen Noureddin
- Karsh Division of Gastroenterology and Hepatology.,Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Kambiz Kosari
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Vatche G Agopian
- Department of Surgery.,Jonsson Comprehensive Cancer Center, University of California, Los Angeles, Los Angeles, CA, USA
| | - Nicole E Rich
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Shelly C Lu
- Samuel Oschin Comprehensive Cancer Institute.,Karsh Division of Gastroenterology and Hepatology
| | - Hsian-Rong Tseng
- California NanoSystems Institute, Crump Institute for Molecular Imaging.,Department of Molecular and Medical Pharmacology
| | - Nicholas N Nissen
- Samuel Oschin Comprehensive Cancer Institute.,Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Amit G Singal
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ju Dong Yang
- Samuel Oschin Comprehensive Cancer Institute.,Karsh Division of Gastroenterology and Hepatology.,Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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