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Romatoski K, Chung S, Dia M, Papageorge MV, Woods AP, Cherukuri P, Canakis A, Gupta A, LeBedis C, Sachs TE, Mohanty A. The impact of social risk factors on the presentation, treatment and survival of patients with hepatocellular carcinoma at an urban, academic safety-net hospital. Am J Surg 2023; 226:278-283. [PMID: 37291013 DOI: 10.1016/j.amjsurg.2023.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/10/2023] [Accepted: 05/14/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND Vulnerable populations have worse hepatocellular carcinoma (HCC) outcomes. We sought to understand if this could be mitigated at a safety-net hospital. METHODS A retrospective chart review of HCC patients was conducted (2007-2018). Stage at presentation, intervention and systemic therapy were analyzed (Chi-square for categorical variables and Wilcoxon tests for continuous variables) and median survival calculated by Kaplan-Meier method. RESULTS 388 HCC patients were identified. Sociodemographic factors were similar for stage at presentation, except insurance status (diagnosis at earlier stages for commercial insurance and later stages for safety-net/no insurance). Higher education level and origin of mainland US increased intervention rates for all stages. Early-stage disease patients had no differences in receipt of intervention or therapy. Late-stage disease patients with higher education level had increased intervention rates. Median survival was not impacted by any sociodemographic factor. CONCLUSION Urban safety-net hospitals with a focus on vulnerable patient populations provide equitable outcomes and can serve as a model to address inequities in HCC management.
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Affiliation(s)
- Kelsey Romatoski
- Department of Surgery, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Sophie Chung
- Department of Surgery, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Manal Dia
- Department of Surgery, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Marianna V Papageorge
- Department of Surgery, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Alison P Woods
- Department of Surgery, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA; Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Priya Cherukuri
- Department of Gastroenterology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Andrew Canakis
- Department of Gastroenterology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Avneesh Gupta
- Department of Radiology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Christina LeBedis
- Department of Radiology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Teviah E Sachs
- Department of Surgery, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
| | - Arpan Mohanty
- Department of Gastroenterology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
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Rich NE, Carr C, Yopp AC, Marrero JA, Singal AG. Racial and Ethnic Disparities in Survival Among Patients With Hepatocellular Carcinoma in the United States: A Systematic Review and Meta-Analysis. Clin Gastroenterol Hepatol 2022; 20:e267-e288. [PMID: 33387668 PMCID: PMC8243558 DOI: 10.1016/j.cgh.2020.12.029] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 12/22/2020] [Accepted: 12/24/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Hepatocellular carcinoma (HCC) is the fastest rising cause of cancer-related death in the United States; however, HCC incidence and mortality are not equally distributed among racial and ethnic groups. Our aim was to characterize the direction and magnitude of racial and ethnic disparities in overall survival and early tumor detection among patients with HCC. METHODS We searched MEDLINE, EMBASE and Cochrane databases from inception through August 2020 for studies reporting HCC outcomes (early stage presentation and overall survival) by race and ethnicity. We calculated pooled hazard ratios (HRs) and odds ratios (ORs) for each racial and ethnic group (White, Black, Hispanic, Asian) using the DerSimonian and Laird method for a random-effects model. RESULTS We identified 35 articles comprising 563,097 patients (53.0% White, 17.3% Black, 18.4% Hispanic, 5.0% Asian). Compared with White patients, Black patients had worse survival (pooled HR 1.08; 95% CI, 1.05 - 1.12), whereas Hispanic (pooled HR 0.92; 95% CI, 0.87 - 0.97) and Asian (pooled HR 0.81; 95% CI, 0.73 - 0.88) patients had better survival. Among articles reporting tumor stage (n = 20), Black patients had lower odds of early stage HCC compared with White patients (OR, 0.66; 95% CI, 0.54 - 0.78). Conversely, there was no difference in odds of early HCC detection for Asian (OR, 1.01; 95% CI, 0.97 - 1.05) or Hispanic patients (OR, 0.87; 95% CI, 0.74 - 1.01) compared with White patients. The most common limitation of studies was risk of residual confounding from socioeconomic status and liver dysfunction. CONCLUSIONS There are significant racial and ethnic disparities in HCC prognosis in the United States, with Black patients having worse overall survival and Hispanic and Asian patients having better overall survival compared with White patients. Interventions are needed to reduce disparities in early HCC detection to improve HCC prognosis.
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Affiliation(s)
- Nicole E Rich
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas; Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, Texas.
| | - Christian Carr
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Adam C Yopp
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas; Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, Texas
| | - Jorge A Marrero
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas; Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, Texas
| | - Amit G Singal
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas; Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, Texas
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Parsons HM, Chu Q, Karlitz JJ, Stevens JL, Harlan LC. Adoption of Sorafenib for the Treatment of Advanced-Stage Hepatocellular Carcinoma in Oncology Practices in the United States. Liver Cancer 2017; 6:216-226. [PMID: 29234628 PMCID: PMC5704716 DOI: 10.1159/000473862] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The adoption of sorafenib into oncology practice as a first-line systemic treatment for advanced hepatocellular carcinoma (HCC) is not well understood. We examined sorafenib use since Food and Drug Administration (FDA) approval in 2007 and associated survival for individuals diagnosed with advanced HCC, conducting a population-based evaluation of treatment patterns and outcomes for this newly approved drug in the US over time. METHODS We identified individuals diagnosed with Barcelona Clinic Liver Cancer Stage C from the 2007 and 2012 National Cancer Institute Patterns of Care study. We examined trends in use as well as patient and clinical factors associated with receiving sorafenib using multivariate logistic regression analysis. We then evaluated the association between sorafenib use and overall hazard of death using multivariate Cox proportional hazards regression. RESULTS Among 550 individuals diagnosed with advanced HCC, we found no significant increase in the proportion of patients treated with sorafenib from 2007 to 2012 (26.3 vs. 30.4%). After adjusting for patient and clinical characteristics, non-Hispanic Blacks (compared to non-Hispanic Whites) and those with a lower Child-Pugh score remained more likely to receive sorafenib. Individuals receiving systemic chemotherapy only, radiation therapy only, or no treatment at all experienced a higher risk of death than those treated with sorafenib, while those receiving a transplant experienced a lower risk of death. CONCLUSIONS Sorafenib has not been widely adopted into oncology practice since FDA approval for advanced HCC. Few factors apart from Child-Pugh score and race/ethnicity predict sorafenib use in clinical practice, although sorafenib treatment is associated with a lower risk of death.
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Affiliation(s)
- Helen M. Parsons
- Division of Health Policy and Management, University of Minnesota, Minneapolis, MN
| | - Quyen Chu
- LSU-Health Sciences Center-Shreveport, Shreveport, LA, USA
| | - Jordan J. Karlitz
- Division of Gastroenterology, Tulane University School of Medicine, New Orleans, LA, USA
| | | | - Linda C. Harlan
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA
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Alkhalili E, Greenbaum A, Luo L, Rodriguez R, Munoz OE, O'Neill J, Nir I, Morris KT. Racial disparities in treatment and survival of hepatocellular carcinoma in native Americans and Hispanics. Am J Surg 2016. [PMID: 28624027 DOI: 10.1016/j.amjsurg.2016.09.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND We investigated if there were any differences in disease presentation and survival between the 3 major ethnicities in New Mexico; non-Hispanic whites (NHW), native Americans (NA), and Hispanics (H). METHODS A retrospective analysis of patients with hepatocellular carcinoma treated at our institution between 2000 and 2014 was performed. Overall survival was analyzed using the Kaplan-Meier and Cox regression models. RESULTS We identified 326 patients; 106 (32.5%) NHW, 183 (56.1%) H, and 37 (11.4%) NA. No difference in disease stage, resectability, rate of offering surgery, or chemotherapy was found. Advanced cirrhosis was more common in H and NA than NHW (P = .01). NA had a higher incidence of nonviral hepatocellular carcinoma (P = .0009). NHW were more likely to receive transarterial chemoembolization/radiofrequency than NA or H (P = .04). Median survivals for NA, NHW, H were 24, 14, and 11 months, respectively, (P = .01). CONCLUSIONS Although there was no difference in disease stage or resectability, NA and H had more advanced cirrhosis and were less likely to undergo transarterial chemoembolization and/or radiofrequency than NHW. NA had the best survival, whereas H had the worst survival.
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Affiliation(s)
- Eyas Alkhalili
- Department of Surgery, School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Alissa Greenbaum
- Department of Surgery, School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Li Luo
- Department of Surgery, School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Rodrigo Rodriguez
- Department of Surgery, School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Oscar Estrada Munoz
- Department of Surgery, School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Jacqueline O'Neill
- Department of Surgery, School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Itzhak Nir
- Department of Surgery, School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Katherine T Morris
- Department of Surgery, School of Medicine, University of New Mexico, Albuquerque, NM, USA.
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Rajbhandari R, Simon RE, Chung RT, Ananthakrishnan AN. Racial Disparities in Inhospital Outcomes for Hepatocellular Carcinoma in the United States. Mayo Clin Proc 2016; 91:1173-82. [PMID: 27497857 DOI: 10.1016/j.mayocp.2016.06.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 06/02/2016] [Accepted: 06/03/2016] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To study racial disparities in therapeutic interventions and hospitalization outcomes for hepatocellular cancer (HCC) in the United States. PATIENTS AND METHODS Using the 2011 Nationwide Inpatient Sample (comprising hospitalizations between January 1 and December 31, 2011), we identified patients with HCC-related admissions using previously validated International Classification of Diseases, Ninth Revision, Clinical Modification codes. Among these, we also identified those that were procedure-related (associated with liver transplantation, hepatic resection, radiofrequency ablation, or transarterial chemoembolization). Multivariate regression was performed to identify the contribution of race to therapeutic interventions and outcomes. RESULTS A total of 22,933 HCC-related hospitalizations were included, of which 10,285 were procedure related (45%). Blacks had a smaller proportion (35%) of procedure-related HCC hospitalizations than did whites (46%) (odds ratio [OR], 0.65; 95% CI, 0.49-0.86). Specifically, blacks had lower odds of liver transplantation (OR, 0.43; 95% CI, 0.26-0.71), hepatic resection (OR, 0.57; 95% CI, 0.33-0.98), and ablation (OR, 0.46; 95% CI, 0.29-0.74) (P=.002) than did whites. Overall, 10.9% of HCC-related admissions resulted in death in blacks as compared with 6.4% in whites (OR, 1.58; 95% CI, 1.12-2.24). CONCLUSION Among patients admitted for HCC-related hospitalizations, blacks were less likely to receive liver transplantation, hepatic resection, and ablation than whites and had higher inhospital mortality. Identifying racial disparities in health care is a necessary first step to appropriately address and eliminate them.
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Affiliation(s)
- Ruma Rajbhandari
- Gastroenterology Division, Massachusetts General Hospital, Boston, MA; Department of Medicine, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | | | - Raymond T Chung
- Gastroenterology Division, Massachusetts General Hospital, Boston, MA; Department of Medicine, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA.
| | - Ashwin N Ananthakrishnan
- Gastroenterology Division, Massachusetts General Hospital, Boston, MA; Department of Medicine, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
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Lam P, Obirieze A, Ortega G, Nwokeabia I, Onyewu S, Purnell S, Samimi M, Weeks C, Lee E, Shokrani B, Frederick W, Callender C, Wilson L. Characterization of Hepatitis B and C Among Liver Transplant Recipients With Hepatocellular Carcinoma: An Analysis of the Nationwide Inpatient Sample Database. Transplant Proc 2016; 48:123-7. [DOI: 10.1016/j.transproceed.2015.12.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 12/07/2015] [Indexed: 02/07/2023]
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Palanisamy AP, Dowden JE, Al Manasra AR, Rohan VS, Bratton CF, McGillicuddy JW, Baliga PK, Chavin KD, Taber DJ. Racial disparity outcomes in patients undergoing hepatectomy: is baseline kidney function a potential explanation? Prog Transplant 2015; 25:257-62. [PMID: 26308786 DOI: 10.7182/pit2015765] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background-Reasons underlying disparities in outcomes in liver resections between patients who are African American and patients who are not are poorly understood. Methods-An observational longitudinal cohort study was performed. Clinical data were collected from medical records of 166 patients (59 African American, 107 not) undergoing partial hepatectomy between 2004 and 2012. Univariate and multivariate analyses were performed. Results-African Americans patients undergoing partial hepatectomy were more likely to be female, heavier, have hemangiomas or adenomas, and have hepatic steatosis on explant. Intraoperatively, African Americans had longer surgical times, higher estimated blood loss, and greater use of blood products. Major postoperative complications were significantly more common in African Americans. Multivariable modeling demonstrated that race, history of hepatitis C, and estimated blood loss were the only variables that were independently associated with a major complication; however, baseline serum creatinine level was the only variable that significantly modified the effect of race on complications. Conclusions-African Americans with normal serum creatinine levels had a similar rate of complication to patients who were not African American, but as the baseline serum level of creatinine increased, the odds ratio for a complication developing increased dramatically in the African American patients, suggesting that the disparities seen are predominantly driven by a subset of African American patients who have preexisting renal insufficiency.
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Hepatitis C in African Americans. Am J Gastroenterol 2014; 109:1576-84; quiz 1575, 1585. [PMID: 25178700 DOI: 10.1038/ajg.2014.243] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Accepted: 07/01/2014] [Indexed: 12/11/2022]
Abstract
The care of hepatitis C virus (HCV) in African Americans represents an opportunity to address a major health disparity in medicine. In all facets of HCV infection, African Americans are inexplicably affected, including in the prevalence of the virus, which is higher among them compared with most of the racial and ethnic groups. Ironically, although fibrosis rates may be slow, hepatocellular carcinoma and mortality rates appear to be higher among African Americans. Sustained viral response (SVR) rates have historically significantly trailed behind Caucasians. The reasons for this gap in SVR are related to both viral and host factors. Moreover, low enrollment rates in clinical trials hamper the study of the efficacy of anti-viral therapy. Nevertheless, the gap in SVR between African Americans and Caucasians may be narrowing with the use of direct-acting agents. Gastroenterologists, hepatologists, primary care physicians, and other health-care providers need to address modifiable risk factors that affect the natural history, as well as treatment outcomes, for HCV among African Americans. Efforts need to be made to improve awareness among health-care providers to address the differences in screening and referral patterns for African Americans.
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Tan D, Yopp A, Beg MS, Gopal P, Singal AG. Meta-analysis: underutilisation and disparities of treatment among patients with hepatocellular carcinoma in the United States. Aliment Pharmacol Ther 2013; 38:703-12. [PMID: 23957569 PMCID: PMC3777750 DOI: 10.1111/apt.12450] [Citation(s) in RCA: 92] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Revised: 06/18/2013] [Accepted: 07/21/2013] [Indexed: 12/23/2022]
Abstract
BACKGROUND Despite wide availability of treatment options for hepatocellular carcinoma (HCC), several studies have suggested underutilisation in clinical practice. AIMS To quantify utilisation rates for HCC treatment among patients with HCC in the United States, and to summarise patterns of association between utilisation rates and patient socio-demographic characteristics. METHODS We performed a systematic literature review using the Medline database from January 1989 to March 2013. Two investigators independently extracted data on patient populations, study methods and results using standardised forms. Pooled treatment rates for any treatment and curative treatment, with 95% confidence intervals, were calculated. Prespecified subgroup analysis was performed to identify patient-level correlates of treatment utilisation. RESULTS We identified 24 studies that met inclusion criteria. The pooled rates of any treatment and curative treatment were 52.8% (95% CI 52.2-53.4%) and 21.8% (95% CI 21.4-22.1%) respectively. Among patients diagnosed at an early stage, the pooled curative treatment rate was 59.0% (95% CI 58.1-59.9%). Elderly, non-Caucasians and patients of low socioeconomic status had lower treatment rates than their counterparts. CONCLUSIONS Rates of HCC treatment in the United States, including curative treatment rates among patients detected at an early stage, are disappointingly low. Future efforts should focus on identifying appropriate intervention targets to increase treatment rates and reduce socio-demographic disparities.
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Affiliation(s)
- D Tan
- School of Public Health, UNT Health Science Center, Fort Worth, TX, USA
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