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Yilma M, Houhong Xu R, Saxena V, Muzzin M, Tucker LY, Lee J, Mehta N, Mukhtar N. Survival Outcomes Among Patients With Hepatocellular Carcinoma in a Large Integrated US Health System. JAMA Netw Open 2024; 7:e2435066. [PMID: 39316399 PMCID: PMC11423175 DOI: 10.1001/jamanetworkopen.2024.35066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/25/2024] Open
Abstract
Importance Hepatocellular carcinoma (HCC) is the leading oncologic cause of death among patients with cirrhosis, but large studies examining mortality trends are lacking. Objective To evaluate survival among patients with HCC in one of the largest integrated health care systems in the US. Design, Setting, and Participants This retrospective cohort study included 3441 adult patients who received a diagnosis of HCC between January 1, 2006, and December 31, 2019, with end of follow-up on December 31, 2020. The study period was further categorized as era 1, defined as 2006 to 2012, and era 2, defined as 2013 to 2019. Statistical analysis was conducted from January 2021 to June 2024. Exposures Patient demographic characteristics and disease factors. Main Outcomes and Measures All-cause and HCC-specific mortality were used as primary end points, and survival probabilities were estimated using the Kaplan-Meier method. Cox proportional hazards regression analyses were adjusted for age at diagnosis, sex, race and ethnicity, cause of disease, Barcelona Clinic Liver Cancer (BCLC) stage, alpha-fetoprotein level, and treatment type. Results Of 3441 patients with HCC, 2581 (75.0%) were men, and the median age was 65 years (IQR, 58-73 years). A total of 1195 patients (34.7%) received curative treatment, 1374 (39.9%) received noncurative treatment, and 872 (25.3%) received no treatment. During the study period, 2500 patients (72.7%) experienced all-cause mortality, and 1809 (52.6%) had HCC-specific mortality. In multivariable analysis, being 70 years of age or older (adjusted hazard ratio [AHR], 1.39; 95% CI, 1.22-1.59), male sex (AHR, 1.20; 95% CI, 1.07-1.35), BCLC stage C or D (AHR, 2.40; 95% CI, 2.15-2.67), increasing alpha-fetoprotein level (vs <20 ng/mL; 20-99 ng/mL: AHR, 1.20; 95% CI, 1.04-1.38; ≥1000 ng/mL: AHR, 2.84; 95% CI, 2.45-3.25), noncurative treatment (AHR, 2.51; 95% CI, 2.16-2.90), and no treatment (AHR, 3.15; 95% CI, 2.64-3.76) were associated with higher all-cause mortality, while Asian or Other Pacific Islander race and ethnicity (vs non-Hispanic White; AHR, 0.76; 95% CI, 0.65-0.88) was associated with lower all-cause mortality. Survival improved in diagnosis era 2 (2013-2019; n = 2007) compared with diagnosis era 1 (2006-2012; n = 1434). Conclusions and Relevance This large, racially and ethnically diverse cohort study of patients with HCC found improving survival over time, especially among individuals with early-stage HCC receiving potentially curative treatments. This study highlights the importance of surveillance for detection of HCC at early stages, particularly among groups at risk for poorer outcomes.
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Affiliation(s)
- Mignote Yilma
- General Surgery, University of California, San Francisco
- National Clinician Scholars Program, San Francisco, California
| | | | - Varun Saxena
- Department of Gastroenterology, Kaiser Permanente South San Francisco Medical Center, San Francisco, California
- Department of Medicine, University of California, San Francisco
| | - Monica Muzzin
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco
| | - Lue-Yen Tucker
- Division of Research, Kaiser Permanente, Oakland, California
| | - Jeffrey Lee
- Division of Research, Kaiser Permanente, Oakland, California
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco
| | - Neil Mehta
- Department of Medicine, University of California, San Francisco
| | - Nizar Mukhtar
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco
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Agudile EP, Vega EA, Salirrosas O, Agudile UM, Chirban AM, Lathan C, Sorescu GP, Odisio BC, Panettieri E, Conrad C. Temporal trends of health disparity in the utilization of curative-intent treatments for hepatocellular carcinoma: are we making progress? J Gastrointest Surg 2024; 28:1392-1399. [PMID: 38754809 DOI: 10.1016/j.gassur.2024.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 04/17/2024] [Accepted: 05/11/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Liver-directed treatments - ablative therapy (AT), surgical resection (SR), liver transplantation (LT), and transarterial chemoembolization (TACE) - improve the overall survival of patients with early-stage hepatocellular carcinoma (HCC). Although racial and socioeconomic disparities affect access to liver-directed therapies, the temporal trends for the curative-intent treatment of HCC remain to be elucidated. METHODS This study performed chi-square, logistic regression, and temporal trends analyses on data from the Nationwide Inpatient Sample from 2011 to 2019. The outcome of interest was the rate of AT, SR, LT (curative-intent treatments), and TACE utilization, and the primary predictors were racial/ethnic group and socioeconomic status (SES; insurance status). RESULTS African American and Hispanic patients had lower odds of receiving AT (African American: odds ratio [OR], 0.78; P < .001; Hispanic: OR, 0.84; P = .005) and SR (African American: OR, 0.71; P < .001; Hispanics: OR, 0.64; P < .001) than White patients. Compared with White patients, the odds of LT was lower in African American patients (OR, 0.76; P < .001) but higher in Hispanic patients (OR, 1.25; P = .001). Low SES was associated with worse odds of AT (OR, 0.79; P = .001), SR (OR, 0.66; P < .001), and LT (OR, 0.84; P = .028) compared with high SES. Although curative-intent treatments showed significant upward temporal trends among White patients (10.6%-13.9%; P < .001) and Asian and Pacific Islander/other patients (14.4%-15.7%; P = .007), there were nonsignificant trends among African American patients (10.9%-10.1%; P = .825) or Hispanic patients (12.2%-13.7%; P = .056). CONCLUSION Our study demonstrated concerning disparities in the utilization of curative-intent treatment for HCC based on race/ethnicity and SES. Moreover, racial/ethnic disparities have widened rather than improved over time.
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Affiliation(s)
- Emeka P Agudile
- Department of Medicine, Steward Carney Hospital, Dorchester, Massachusetts, United States; Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States
| | - Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, United States
| | - Oscar Salirrosas
- Department of Surgery, St. Elizabeth's Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, United States
| | - Ukamaka M Agudile
- Department of Medicine, Steward Carney Hospital, Dorchester, Massachusetts, United States
| | - Ariana M Chirban
- Department of Surgery, St. Elizabeth's Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, United States; Department of Surgery, School of Medicine, University of California San Diego, La Jolla, California, United States
| | - Christopher Lathan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard School of Medicine, Boston, Massachusetts, United States
| | - George P Sorescu
- Department of Medicine, Lemuel Shattuck Hospital, Boston, Massachusetts, United States
| | - Bruno C Odisio
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Elena Panettieri
- Department of Surgery, St. Elizabeth's Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, United States; Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Claudius Conrad
- Division of Surgical Oncology, Carle Illinois College of Medicine, University of Illinois Urbana Champaign, Illinois, United States.
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Begum TF, Patil VS, Zhu L, Yeh MC, González E, Fraser MA, Lu W, Zhu S, Rubio-Torio N, Ma GX, Tan Y. Assessing Physicians' Recommendations for Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) Testing Among Minority Populations in Greater Philadelphia and New York City. J Community Health 2024; 49:588-597. [PMID: 38286964 DOI: 10.1007/s10900-023-01316-3] [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] [Accepted: 11/26/2023] [Indexed: 01/31/2024]
Abstract
Deaths from liver cancer are on the rise and disproportionately affect minority racial/ethnic groups. In this study, we examined associations between physicians' recommendations for hepatitis B virus (HBV) and hepatitis C virus (HCV) screening and sociodemographic and lifestyle factors among minority populations in the areas of Greater Philadelphia and New York City. Using Poisson regression with robust variance estimation, we evaluated potential associations for 576 Hispanic American (HA), African American (AA), and Asian Pacific American (APA) adults, using blood tests as an outcome measure, with adjustment for sociodemographic factors We found that APAs (34.2%) were most likely to have a physician recommend HBV and HCV screening tests (34.2% and 27.1%, respectively), while HAs were least likely to receive an HBV recommendation (15.0%) and AAs were least likely to receive an HCV recommendation (15.3%). HAs were significantly likely to have never received a blood test for either HBV or HCV (RR = 1.25, 95% CI: 1.05, 1.49). APAs were significantly more likely to receive a screening recommendation for HBV (RR = 1.10, 95%CI: 1.01, 1.20) and to have a blood test (RR = 1.57, 95% CI: 1.06, 2.33). Our findings show that, among HAs, AAs, and APAs, physician recommendations are strongly associated with patients undergoing blood tests for HBV and HCV and that minority populations should increasingly be recommended to screen for HBV and HCV, especially given their elevated risk.
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Affiliation(s)
- Thoin F Begum
- Center for Asian Health, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA.
| | - Vidya S Patil
- Center for Asian Health, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Lin Zhu
- Center for Asian Health, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
- Department of Urban Health and Population Science, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Ming-Chin Yeh
- Nutrition Program, Hunter College, City University of New York, New York, NY, USA
| | - Evelyn González
- Office of Community Outreach, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA, USA
| | | | - Wenyue Lu
- Center for Asian Health, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Steven Zhu
- Pennsylvania United Chinese Coalition, Philadelphia, PA, USA
| | | | - Grace X Ma
- Center for Asian Health, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
- Department of Urban Health and Population Science, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Yin Tan
- Center for Asian Health, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
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Mazur RD, Cron DC, Goldberg DS, Yeh H, Dageforde LA. Racial-ethnic differences in liver transplant waitlist outcomes in patients with hepatocellular carcinoma before and after recent changes to allocation policy. Clin Transplant 2024; 38:e15365. [PMID: 38804605 DOI: 10.1111/ctr.15365] [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: 09/12/2023] [Revised: 02/07/2024] [Accepted: 05/14/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND In May 2019, liver transplant (LT) allocation policy changed to limit MELD exception points for hepatocellular carcinoma (HCC) to median MELD at transplant minus three (MMaT-3). We evaluated this policy's impact on waitlist outcomes for HCC candidates, by race and ethnicity, hypothesizing that the introduction of the MMaT-3 reduced inequities in waitlist outcomes. METHODS Retrospective cohort study of the Scientific Registry for Transplant Recipients, including all adult LT candidates (N = 10 751) who received HCC exception points from May 17, 2017 to May 18, 2019 (pre-policy; N = 6627) to May 19, 2019 to March 1, 2021 (post-policy; N = 4124). We compared incidence of LT and waitlist removal for death or becoming too sick pre- and post-policy for non-Hispanic White, non-Hispanic Black, Hispanic/Latinx, and Asian patients using competing risk regression adjusted for candidate characteristics. RESULTS One-year cumulative incidence of LT decreased significantly pre-/post-policy among White (77.4% vs. 64.5%; p < .01) and Black (76.2% vs. 63.1%; p < .01) candidates only, while a 1-year incidence of death/non-LT waitlist removal decreased significantly only among Hispanics (13.4% vs. 7.5%; p < .01). After covariate adjustment, the effect of the policy change was a significantly decreased incidence of LT for White (SHR: .63 compared to pre-policy; p < .001), Black (SHR: .62; p < .001), and Asian (SHR: .68; p = .002), but no change for Hispanic patients. Only Hispanic patients had a significant decrease in death/waitlist removal after the policy change (SHR: .69; p = .04). Compared to White patients in the pre-policy era, Hispanic (SHR: .88, p < .007) and Asian candidates (SHR: .72; p < .001) had lower unadjusted incidence of LT. This disparity was mitigated in the post-policy era where Hispanic patients had higher likelihood of LT than Whites (SHR: 1.22; p = .002). For the outcome of death/non-LT waitlist removal, the only significant difference was a 42% lower incidence of waitlist removal for Asian compared to White patients in the post-policy era (SHR: .58; p = .03). CONCLUSION Among LT recipients with HCC, racial/ethnic subpopulations were differentially affected by the MMAT-3 policy, resulting in a post-policy reduction of some of the previous disparities.
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Affiliation(s)
| | - David C Cron
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - David S Goldberg
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Heidi Yeh
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Transplantation, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Leigh Anne Dageforde
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Transplantation, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
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Bteich F, Desai K, Zhang C, Kaur A, Levy RA, Bioh L, Wang A, Sultana S, Kaubisch A, Kinkhabwala M, Bellemare S, Fidvi S, Kanmaniraja D, Berkenblit R, Moon JY, Adedimeji A, Tow CY, Saenger Y. Immunotherapy Efficacy in Advanced Hepatocellular Carcinoma in a Diverse and Underserved Population in the United States. J Hepatocell Carcinoma 2024; 11:257-269. [PMID: 38333221 PMCID: PMC10849901 DOI: 10.2147/jhc.s436804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/07/2023] [Indexed: 02/10/2024] Open
Abstract
Background Incidence of hepatocellular cancer (HCC) in the Bronx is 61% higher than the rest of New York State. Underserved populations are not well represented in clinical trials of immune checkpoint inhibitors (ICI). Methods Demographics were tabulated for 194 patients treated with ICI at the Montefiore-Einstein Comprehensive Cancer Center (MECCC) between 2017 and 2022. Categorical variables were analyzed by Chi-squared test, and survival was analyzed using Kaplan-Meier (KM) curves. Results MECCC patients were 40.7% Hispanic and 20.6% Black, compared with 3% and 2%, respectively, in the landmark IMbrave 150 study. Median overall survival (mOS) on ICI was 9.0 months, 25.0 months for the 100 (51.5%) favorable-prognosis Child Pugh A (CPA) patients included in HCC clinical trials. Disease control rate (DCR) was 58.5% among 123 evaluable patients per mRECIST 1.1. Baseline liver function, as defined by CP and the Model for End-Stage Liver Disease-Sodium (MELD-Na), correlated with survival (p < 0.001). Hepatitis C Virus (HCV) and alcoholism were over-represented relative to National Cancer Institute (NCI) data (56.2% vs 4.7% and 38.7% vs 8.2%, respectively). HCV treatment correlated with prolonged survival in infected patients (p = 0.0017). AFP decline correlated with response (p = 0.001). Hispanic patients lived longer when clinical variables were controlled for (mOS 52 vs 23 months; p = 0.011). Conclusion In an underserved HCC population, ICI yielded a DCR of 58.5% and low rates of severe toxicity. This work highlights ICI efficacy in minority groups, a need for earlier HCC diagnosis and for studies of genetic and environmental factors in Hispanics with HCC.
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Affiliation(s)
- Fernand Bteich
- Montefiore Einstein Comprehensive Cancer Center, Bronx, NY, USA
| | - Kush Desai
- Montefiore Einstein Comprehensive Cancer Center, Bronx, NY, USA
| | - Chenxin Zhang
- Montefiore Einstein Comprehensive Cancer Center, Bronx, NY, USA
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Anahat Kaur
- Department of Medicine, Division of Medical Oncology, Jacobi Medical Center, Bronx, NY, USA
| | - Rachel A Levy
- Montefiore Einstein Comprehensive Cancer Center, Bronx, NY, USA
| | - Lydia Bioh
- Montefiore Einstein Comprehensive Cancer Center, Bronx, NY, USA
| | - Aaron Wang
- Montefiore Einstein Comprehensive Cancer Center, Bronx, NY, USA
| | - Sharmin Sultana
- Montefiore Einstein Comprehensive Cancer Center, Bronx, NY, USA
| | | | - Milan Kinkhabwala
- Montefiore Einstein Comprehensive Cancer Center, Bronx, NY, USA
- Department of General Surgery, Division of Abdominal Transplantation, Montefiore Medical Center, Bronx, NY, USA
| | - Sarah Bellemare
- Montefiore Einstein Comprehensive Cancer Center, Bronx, NY, USA
- Department of General Surgery, Division of Abdominal Transplantation, Montefiore Medical Center, Bronx, NY, USA
| | - Shabnam Fidvi
- Department of Radiology, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Robert Berkenblit
- Department of Radiology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jee-Young Moon
- Montefiore Einstein Comprehensive Cancer Center, Bronx, NY, USA
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Adebola Adedimeji
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Clara Y Tow
- Department of Medicine, Division of Transplant Hepatology, Montefiore Medical Center, Bronx, NY, USA
| | - Yvonne Saenger
- Montefiore Einstein Comprehensive Cancer Center, Bronx, NY, USA
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6
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Feng JC, He Y, Polychronidis G, Xin J, You S, Xiong J. Incidence, Risk Factors, and Prognosis of Patients with Hepatocellular Carcinoma and Brain Metastases. Curr Med Sci 2024; 44:180-186. [PMID: 38393527 DOI: 10.1007/s11596-023-2809-3] [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: 08/22/2023] [Accepted: 10/11/2023] [Indexed: 02/25/2024]
Abstract
OBJECTIVE Brain metastases significantly impact the clinical course of patients with hepatocellular carcinoma (HCC). This study aimed to examine the age-related incidence, demographics, and survival of patients with HCC and brain metastases. METHODS Data of HCC patients from 2010 to 2015 in the Surveillance, Epidemiology, and End Results (SEER) Registry were screened for the presence of brain metastases. They were stratified by age and ethnicity. Multivariable logistic and Cox regression analyses were used to identify factors associated with brain metastases and those with overall survival (OS) and liver cancer-specific survival (CSS), respectively. RESULTS A total of 141 HCC patients presenting with brain metastases were identified, accounting for 0.35% of all HCC patients and 2.37% of patients with metastatic disease. Among all HCC patients, the incidence rate was the highest among patients aged 30-49 years old (0.47%). Ethnicity was not associated with the presence of brain metastases at the time of HCC diagnosis. However, African-American patients presented with a significantly lower disease-specific survival [median time: 1 month; interquartile range (IQR): 0-3.0 months)]. Initial lung or bone metastasis was independently associated with an increased risk of the presence of brain metastases [odds ratio (OR): 12.62, 95% confidence interval (CI): 8.40-18.97] but was not associated with a worse OS or CSS among those with brain metastases. CONCLUSION This study identified the age-related incidence and risk factors of brain metastases in HCC patients. These results may contribute to the consideration of brain screening among patients with initial metastatic HCC with lung or bone metastases, and influence the counseling of this patient population regarding their prognosis.
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Affiliation(s)
- Jin-Cheng Feng
- Department of Liver Transplantation, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Ying He
- Key Laboratory of Transplant Engineering and Immunology, Laboratory of Liver Transplantation, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Georgios Polychronidis
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Im Neuenheimer Feld 110, Heidelberg, 69120, Germany
| | - Jian Xin
- Department of Liver Transplantation, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Shen You
- Department of Hepatobiliary and Pancreatic Surgery, Fujian Provincial Hospital, Fuzhou, 350001, China.
| | - Jun Xiong
- Department of Liver Transplantation, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
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Malik MS, Subrize MW, Ou J, Curry MP, Parikh ND, Novack V, Weinstein JL, Ahmed M, Sarwar A. Association between Patient Experience Scores and Low Utilization of Hepatocellular Carcinoma Treatment in the United States: A Surveillance, Epidemiology, and End Results-Consumer Assessment of Healthcare Providers and Systems Analysis (SEER-CAHPS). J Vasc Interv Radiol 2024; 35:102-112.e5. [PMID: 37696431 DOI: 10.1016/j.jvir.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 08/30/2023] [Accepted: 09/02/2023] [Indexed: 09/13/2023] Open
Abstract
PURPOSE To study the experiences of patients with hepatocellular carcinoma (HCC) contributing to treatment discrepancy in the United States. MATERIALS AND METHODS Using Surveillance, Epidemiology, and End Results data from National Cancer Institute (NCI), Medicare (2002-2015) beneficiaries with HCC who completed a Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey were included. Six CAHPS items (3 global scores: global care rating [GCR], primary doctor rating [PDR], and specialist rating [SR]; 3 composite scores: getting needed care [GNC], getting care quickly [GCQ], and doctor communication [DC]) assessed patient experience. Covariates assessed between treated and nontreated groups included patient, disease, hospital, and CAHPS items. RESULTS Among 548 patients with HCC, 211 (39%) received treatment and 337 (61%) did not receive treatment. Forty-two percent (GCR), 29% (PDR), 30% (SR), 36% (GNC), 78% (GCQ), and 35% (DC) of patients reported less-than-excellent experiences on the respective CAHPS items. Chronic liver disease (CLD) was present in 52% and liver decompensation (LD) in 60%. A minority of the hospitals were NCI-designated cancer centers (47%), transplant centers (27%), and referral centers (9%). On univariable analysis, patients with at least a high school degree (odds ratio [OR], 1.9), admittance to a ≥400-bed hospital (OR, 2.7), CLD (OR, 3.0), or LD (OR, 1.7) were more likely to receive treatment, whereas older patients (≥75 years) (OR, 0.5) were less likely to receive treatment. On multivariable, patients with CLD (OR, 6.8) and an excellent experience in GNC with a specialist (OR, 10.6) were more likely to receive treatment. CONCLUSIONS HCC treatment discrepancy may be associated with patient-related factors, such as lack of specialist care (GNC), and disease-related factors, such as absence of underlying CLD.
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Affiliation(s)
- M Saad Malik
- Division of Interventional, Department of Radiology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts.
| | - Michael W Subrize
- Division of Interventional, Department of Radiology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts
| | - Jiangda Ou
- Division of Interventional, Department of Radiology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts
| | - Michael P Curry
- Division of Gastroenterology & Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts
| | - Neehar D Parikh
- Division of Gastroenterology & Hepatology, Department of Medicine, Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Victor Novack
- Center for Healthcare Delivery Sciences, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Department of Medicine, Clinical Research Center, Soroka University Medical Center, Beer-Sheva, Israel
| | - Jeffrey L Weinstein
- Division of Interventional, Department of Radiology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts
| | - Muneeb Ahmed
- Division of Interventional, Department of Radiology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts
| | - Ammar Sarwar
- Division of Interventional, Department of Radiology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts
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8
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Gholami S, Kleber KT, Perry LM, Abidalhassan M, McFadden NR, Bateni SB, Maguire FB, Stewart SL, Morris C, Chen M, Gaskill CE, Merkow RP, Keegan TH. Disparities in treatment and survival in early-stage hepatocellular carcinoma in California. J Surg Oncol 2023; 128:1302-1311. [PMID: 37610042 PMCID: PMC10841249 DOI: 10.1002/jso.27423] [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: 05/14/2023] [Revised: 07/31/2023] [Accepted: 08/04/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND AND OBJECTIVES Curative intent therapy is the standard of care for early-stage hepatocellular carcinoma (HCC). However, these therapies are under-utilized, with several treatment and survival disparities. We sought to demonstrate whether the type of facility and distance from treatment center (with transplant capabilities) contributed to disparities in curative-intent treatment and survival for early-stage HCC in California. METHODS We performed a retrospective analysis of the California Cancer Registry for patients diagnosed with stage I or II primary HCC between 2005 and 2017. Primary and secondary outcomes were receipt of treatment and overall survival, respectively. Multivariable logistic regression and Multivariable Cox proportional hazards regression were used to evaluate associations. RESULTS Of 19 059 patients with early-stage HCC, only 36% (6778) received curative-intent treatment. Compared to Non-Hispanic White patients, Hispanic patients were less likely, and Asian/Pacific Islander patients were more likely to receive curative-intent treatment. Our results showed that rural residence, public insurance, lower neighborhood SES, and care at non-National Cancer Institute-designated cancer center were associated with not receiving treatment and decreased survival. CONCLUSIONS Although multiple factors influence receipt of treatment for early-HCC, our findings suggest that early intervention programs should target travel barriers and access to specialist care to help improve oncologic outcomes.
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Affiliation(s)
- Sepideh Gholami
- Division of Surgical Oncology, Department of Surgery, Northwell Health, New Hyde Park, NY USA
| | - Kara T. Kleber
- Division of Surgical Oncology, Department of Surgery, University of California Davis Medical Center, Sacramento, CA, USA
| | - Lauren M. Perry
- Division of Surgical Oncology, Department of Surgery, University of California Davis Medical Center, Sacramento, CA, USA
| | - Mustafa Abidalhassan
- Division of Surgical Oncology, Department of Surgery, Northwell Health, New Hyde Park, NY USA
| | - Nikia R. McFadden
- Division of Surgical Oncology, Department of Surgery, University of California Davis Medical Center, Sacramento, CA, USA
| | - Sarah B. Bateni
- Division of Surgical Oncology, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Frances B. Maguire
- California Cancer Reporting and Epidemiologic Surveillance Program, University of California Davis Comprehensive Cancer Center, Sacramento, CA, USA
| | - Susan L. Stewart
- California Cancer Reporting and Epidemiologic Surveillance Program, University of California Davis Comprehensive Cancer Center, Sacramento, CA, USA
| | - Cyllene Morris
- California Cancer Reporting and Epidemiologic Surveillance Program, University of California Davis Comprehensive Cancer Center, Sacramento, CA, USA
| | - Moon Chen
- Division of Hematology and Oncology, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Cameron E. Gaskill
- Division of Surgical Oncology, Department of Surgery, University of California Davis Medical Center, Sacramento, CA, USA
| | - Ryan P. Merkow
- Division of Surgical Oncology, Department of Surgery, University of Chicago Medicine, Chicago, Illinois, USA
| | - Theresa H. Keegan
- Department of Public Health Sciences, University of California Davis, Sacramento, CA, USA
- Center for Oncology Hematology Outcomes Research and Training (COHORT) and Division of Hematology and Oncology, University of California Davis School of Medicine, Sacramento, CA, USA
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Gera K, Kahramangil D, Fenton GA, Martir D, Rodriguez DN, Ijaz Z, Lin RY, Rogers SC, Ramnaraign BH, George TJ, Hong YR, Hughes SJ, Nassour I, Sahin I. Prognosis and Treatment Outcomes of Bone Metastasis in Gallbladder Adenocarcinoma: A SEER-Based Study. Cancers (Basel) 2023; 15:5055. [PMID: 37894422 PMCID: PMC10605374 DOI: 10.3390/cancers15205055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 10/12/2023] [Accepted: 10/17/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Gallbladder carcinoma (GBC) is a rare, aggressive malignancy comprising 0.5% of gastrointestinal cancers. It has poor survival outcomes due to its insidious onset, lack of standardized screening, and limited therapies. Advanced-stage diagnosis with liver, lymph node, and peritoneal metastasis is common, while bone metastasis is rare. The knowledge on bone metastasis in GBC is limited to case reports and small series, and its clinical significance is largely unexplored. METHODS The study extracted the demographic and clinical variables of patients with metastatic (M1) gallbladder adenocarcinoma from the Surveillance, Epidemiology, and End Results (SEER) database between 2011 and 2020. Descriptive statistics were used to analyze the demographic characteristics. The multivariate Cox regression analysis was used to calculate the hazard ratio. The overall survival (OS) was assessed using the Kaplan-Meier method, and the log-rank test was utilized to compare the survival between the groups. RESULTS A total of 2724 patients were included in the study. A total of 69% of the patients were female, and the median age was 68 (range 24-90+). A total of 7.4% of the patients had bone metastasis on diagnosis. The multivariate Cox analysis identified bone metastasis as an independent mortality risk factor in metastatic GBC (HR 1.50, p < 0.001). The patients were divided into two age groups: a younger age group (18-74 years) and an older age group (75+ years). In the younger group, the median OS with and without bone metastasis was 3 and 5 months, respectively (p < 0.0001). In the older age group, there was no significant difference in the OS between the patients with and without bone metastasis (p = 0.35). In the younger group who were treated with chemotherapy, the patients with bone metastasis had a significantly worse OS (median OS 5 months vs. 8 months, p < 0.0001). In the untreated group, the patients with bone metastasis in the younger age group had a significantly worse OS (median OS 1 month vs. 2 months, p = 0.014). In the patients with bone metastasis, those who did not receive chemotherapy had a significantly worse OS than those who were treated with chemotherapy in both age groups (younger age group: median OS 1 month vs. 5 months, p < 0.0001 and older age group: median OS 1 month vs. 5 months, p = 0.041). CONCLUSIONS Our findings suggest that the presence of bone metastasis in gallbladder adenocarcinoma is an independent prognostic factor associated with unfavorable survival outcomes in the younger age group (18-74 years). However, in the older age group (75+ years), the presence of bone metastasis did not impact the survival. Treatment with chemotherapy was associated with extended survival in all patients. Thus, early detection and aggressive management of bone metastasis, including the consideration of chemotherapy, may be crucial in improving the OS and quality of life for individuals with gallbladder adenocarcinoma.
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Affiliation(s)
- Kriti Gera
- Department of Medicine, University of Florida College of Medicine, Gainesville, FL 32610, USA; (K.G.); (D.N.R.); (Z.I.); (R.Y.L.)
| | - Doga Kahramangil
- Division of Hematology and Oncology, Department of Medicine, University of Florida College of Medicine, Gainesville, FL 32610, USA; (D.K.); (S.C.R.); (B.H.R.); (T.J.G.)
- University of Florida Health Cancer Center, Gainesville, FL 32610, USA;
| | - Graeme A. Fenton
- University of Florida College of Medicine, Gainesville, FL 32610, USA;
| | - Daniela Martir
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL 32610, USA;
| | - Diana N. Rodriguez
- Department of Medicine, University of Florida College of Medicine, Gainesville, FL 32610, USA; (K.G.); (D.N.R.); (Z.I.); (R.Y.L.)
| | - Zohaib Ijaz
- Department of Medicine, University of Florida College of Medicine, Gainesville, FL 32610, USA; (K.G.); (D.N.R.); (Z.I.); (R.Y.L.)
| | - Rick Y. Lin
- Department of Medicine, University of Florida College of Medicine, Gainesville, FL 32610, USA; (K.G.); (D.N.R.); (Z.I.); (R.Y.L.)
| | - Sherise C. Rogers
- Division of Hematology and Oncology, Department of Medicine, University of Florida College of Medicine, Gainesville, FL 32610, USA; (D.K.); (S.C.R.); (B.H.R.); (T.J.G.)
- University of Florida Health Cancer Center, Gainesville, FL 32610, USA;
| | - Brian H. Ramnaraign
- Division of Hematology and Oncology, Department of Medicine, University of Florida College of Medicine, Gainesville, FL 32610, USA; (D.K.); (S.C.R.); (B.H.R.); (T.J.G.)
- University of Florida Health Cancer Center, Gainesville, FL 32610, USA;
| | - Thomas J. George
- Division of Hematology and Oncology, Department of Medicine, University of Florida College of Medicine, Gainesville, FL 32610, USA; (D.K.); (S.C.R.); (B.H.R.); (T.J.G.)
- University of Florida Health Cancer Center, Gainesville, FL 32610, USA;
| | - Young-Rock Hong
- University of Florida Health Cancer Center, Gainesville, FL 32610, USA;
- Department of Health Services Research, Management and Policy, University of Florida College of Medicine, Gainesville, FL 32610, USA
| | - Steven J. Hughes
- Division of Surgical Oncology, Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610, USA; (S.J.H.); (I.N.)
| | - Ibrahim Nassour
- Division of Surgical Oncology, Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610, USA; (S.J.H.); (I.N.)
| | - Ilyas Sahin
- Division of Hematology and Oncology, Department of Medicine, University of Florida College of Medicine, Gainesville, FL 32610, USA; (D.K.); (S.C.R.); (B.H.R.); (T.J.G.)
- University of Florida Health Cancer Center, Gainesville, FL 32610, USA;
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10
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Kilani Y, Kamal SAF, Vikash F, Vikash S, Aldiabat M, Alsakarneh S, Aljabiri Y, Sohail H, Kumar V, Numan L, Al Khalloufi K. Racial Disparities in Liver Transplantation for Hepatocellular Carcinoma in the United States: An Update. Dig Dis Sci 2023; 68:4050-4059. [PMID: 37584869 DOI: 10.1007/s10620-023-08084-z] [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: 06/27/2023] [Accepted: 08/07/2023] [Indexed: 08/17/2023]
Abstract
BACKGROUND Previous studies have demonstrated a disparity in liver transplantation (LT) for hepatocellular carcinoma (HCC) among races in the United States (U.S.). AIMS We aimed to update the literature on the odds, trends, and complications of LT in the treatment of hepatocellular carcinoma (HCC), among individuals of different racial backgrounds. METHODS This is a nationwide study of adult individuals admitted for LT with a primary diagnosis of HCC. Using weighted data from the National Inpatient Sample (NIS) database, we compared the odds of LT among different races from 2016 to 2020, using a multivariate regression analysis. We further assessed the trends and outcomes of LT among races. RESULTS A total of 112,110 adult were hospitalized with a primary diagnosis of HCC. 3020 underwent LT. When compared to Whites, the likelihood of undergoing LT for HCC was significantly reduced in Blacks (OR = 0.60, 95% CI = 0.46-0.78). Further, Blacks had increased mortality rates (7% in Blacks vs. 1% in Whites, p < 0.001), sepsis (11% in Blacks vs. 3% in Whites, p = 0.015), and acute kidney injury (AKI) (54% in Blacks vs. 31% in Whites, p < 0.001) following LT. CONCLUSIONS Individuals identifying as Blacks were less likely to undergo LT for HCC, and more likely to develop complications. Further initiatives are warranted to mitigate the existing disparities among racial groups.
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Affiliation(s)
- Yassine Kilani
- Department of Medicine, Lincoln Medical Center/Weill Cornell Medicine, New York, NY, USA.
| | | | - Fnu Vikash
- Department of Medicine, Jacobi Medical Center, New York, NY, USA
| | - Sindhu Vikash
- Department of Medicine, Jacobi Medical Center, New York, NY, USA
| | | | - Saqr Alsakarneh
- Department of Medicine, University of Missouri, Kansas City, MO, USA
| | - Yazan Aljabiri
- Department of Medicine, Lincoln Medical Center/Weill Cornell Medicine, New York, NY, USA
| | - Haris Sohail
- Department of Medicine, Lincoln Medical Center/Weill Cornell Medicine, New York, NY, USA
| | - Vikash Kumar
- Department of Medicine, Brooklyn Hospital Center, New York, NY, USA
| | - Laith Numan
- Department of Gastroenterology, Saint Louis University, Saint Louis, MO, USA
| | - Kawtar Al Khalloufi
- Department of Transplant Hepatology, University of South Florida, Tampa, FL, USA
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11
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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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12
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Kim NJ, Cravero A, VoPham T, Vutien P, Carr R, Issaka RB, Johnston J, McMahon B, Mera J, Ioannou GN. Addressing racial and ethnic disparities in US liver cancer care. Hepatol Commun 2023; 7:e00190. [PMID: 37347221 PMCID: PMC10289716 DOI: 10.1097/hc9.0000000000000190] [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: 10/31/2022] [Accepted: 05/09/2023] [Indexed: 06/23/2023] Open
Abstract
HCC, the most common form of primary liver cancer, is the fastest rising cause of cancer-related death in the United States. HCC disproportionately affects racial and ethnic minorities in the United States. A practical framework is needed to organize the complex patient, provider, health system, and societal factors that drive these racial and ethnic disparities. In this narrative review, we adapted and applied the National Institute on Minority Health and Health Disparities (NIMHD) Research Framework to the HCC care continuum, as a step toward better understanding and addressing existing HCC-related disparities. We first summarize the literature on HCC-related disparities by race and ethnicity organized by the framework's 5 domains (biological, behavioral, physical/built environment, sociocultural environment, and health care system) and 4 levels (individual, interpersonal, community, and societal) of influence. We then offer strategies to guide future research initiatives toward promotion of health equity in HCC care. Clinicians and researchers may help mitigate further inequities and better address racial and ethnic disparities in HCC care by prioritizing the following in HCC research: (1) increasing racial and ethnic minority representation, (2) collecting and reporting HCC-related data by racial and ethnic subgroups, (3) assessing the patient experience of HCC care by race and ethnicity, and (4) evaluating HCC-specific social determinants of health by race and ethnicity. These 4 priorities will help inform the development of future programs and interventions that are tailored to the unique experiences of each racial and ethnic group.
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Affiliation(s)
- Nicole J. Kim
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Anne Cravero
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Trang VoPham
- Epidemiology Program, Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington, USA
| | - Philip Vutien
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Rotonya Carr
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Rachel B. Issaka
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, Washington, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Janet Johnston
- Liver Disease and Hepatitis Program, Alaska Native Tribal Health Consortium, Anchorage, Alaska
| | - Brian McMahon
- Liver Disease and Hepatitis Program, Alaska Native Tribal Health Consortium, Anchorage, Alaska
| | - Jorge Mera
- Cherokee Nation Health Services, Tahlequah, Oklahoma
| | - George N. Ioannou
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, Washington, USA
- Division of Gastroenterology, Department of Medicine, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
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13
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Rasic G, de Geus SWL, Papageorge MV, Woods AP, Ng SC, McAneny D, Tseng JF, Sachs TE. Disparities in the Receipt of Recommended Curative Treatment for Patients with Early-Stage Hepatocellular Carcinoma. World J Surg 2023; 47:1780-1789. [PMID: 36918443 DOI: 10.1007/s00268-023-06969-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/25/2022] [Indexed: 03/16/2023]
Abstract
BACKGROUND In early-stage hepatocellular carcinoma (HCC), the receipt of recommended care is critical for long-term survival. Unfortunately, not all patients decide to undergo therapy. We sought to identify factors associated with the decision to decline recommended intervention among patients with early-stage HCC. METHODS The National Cancer Database was queried for patients diagnosed with clinical stages I and II HCC (2004-2017). Cohorts were created based on the receipt or decline of recommended interventions-hepatectomy, liver transplantation, and ablation. Multivariable logistic regression identified predictors for declining intervention, and propensity score analysis was used to calculate the respective odds. Survival analysis was performed using the Kaplan-Meier method. RESULTS Of 20,863 patients, 856 (4.1%) declined intervention. Patients who were documented as having declined intervention were more often Black (vs. other: OR, 1.3; 95% CI, 1.1-1.6; p = 0.0038), had Medicaid or no insurance (vs. Private, Medicare, or other government insurance): OR, 1.9; 95% CI, 1.6-2.3; p < 0.0001), lived in a low-income area (vs. other: OR, 1.4; 95% CI, 1.2-1.7; p < 0.0001), and received treatment at a non-academic center (vs. academic: OR, 2.1; 95% CI, 1.9-2.5; p < 0.0001). Patients who declined recommended interventions had worse survival compared to those who received treatment (22.9 vs. 59.2 months; p < 0.0001, respectively). CONCLUSIONS Racial and socioeconomic disparities persist in the decision to undergo recommended treatment. Underutilization of treatment acts as a barrier to addressing racial and socioeconomic disparities in early-stage HCC outcomes.
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Affiliation(s)
- Gordana Rasic
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Susanna W L de Geus
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Marianna V Papageorge
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Alison P Woods
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA.,Division of Surgical Oncology, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sing Chau Ng
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - David McAneny
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Jennifer F Tseng
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Teviah E Sachs
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA. .,Department of Surgical Oncology, Boston Medical Center, 820 Harrison Avenue, FGH Building-Suite 5007, Boston, MA, 02118, USA.
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14
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Chikovsky L, Kutuk T, Rubens M, Balda AN, Appel H, Chuong MD, Kaiser A, Hall MD, Contreras J, Mehta MP, Kotecha R. Racial disparities in clinical presentation, surgical procedures, and hospital outcomes among patients with hepatocellular carcinoma in the United States. Cancer Epidemiol 2023; 82:102317. [PMID: 36566577 DOI: 10.1016/j.canep.2022.102317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 12/13/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is one of the leading causes of cancer-related deaths in the United States (US), with substantial disparities observed in cancer incidence and survival among racial groups. This study provides analyses on race and ethnicity disparities for patients with HCC. METHODS This is a cross-sectional analysis of data from the National Inpatient Sample (NIS) between 2011 and 2016, utilizing the STROBE guidelines. Multivariate logistic regression analyses were used to examine the risk-adjusted associations between race and pre-treatment clinical presentation, surgical procedure allocation, and post-treatment hospital outcomes. All clinical parameters were identified using ICD-9-CM and ICD-10-CM diagnosis and procedure codes. RESULTS 83,876 weighted HCC hospitalizations were reported during the study period. Patient demographics were divided according to NIS racial/ethnic categorization, which includes Caucasian (57.3%), African American (16.9%), Hispanic (15.7%), Asian or Pacific Islanders (9.3%), and Native American (0.8%). Association between greater odds of hospitalization and Elixhauser Comorbidity Index > 4 was significantly higher among Native Americans (aOR=1.79; 95% CI: 1.23-2.73), African Americans (aOR=1.24; 95% CI: 1.12-1.38), and Hispanics (aOR=1.11; 95% CI, 1.01-1.24). Risk-adjusted association between race and receipt of surgical procedures demonstrated that the odds of having surgery was significantly lower for African Americans (aOR=0.64; 95% CI: 0.55-0.73) and Hispanics (aOR=0.70; 95% CI: 0.59-0.82), while significantly higher for Asians/Pacific Islanders (aOR=1.36; 95% CI: 1.28-1.63). Post-operative complications were significantly lower for African Americans (aOR=0.68; 95% CI: 0.55-0.86) while the odds of in-hospital mortality were significantly higher for African Americans (aOR=1.28; 95% CI: 1.11-1.49) and Asians/Pacific Islanders (aOR=1.26; 95% CI: 1.13-1.62). CONCLUSIONS After controlling for potential confounders, there were significant racial disparities in pre-treatment presentations, surgical procedure allocations, and post-treatment outcomes among patients with HCC. Further studies are needed to determine the underlying factors for these disparities to develop targeted interventions to reduce these disparities of care.
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Affiliation(s)
- Liza Chikovsky
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Tugce Kutuk
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Muni Rubens
- Office of Clinical Research, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA.
| | - Amber N Balda
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Haley Appel
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Michael D Chuong
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199 USA
| | - Adeel Kaiser
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199 USA
| | - Matthew D Hall
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199 USA
| | - Jessika Contreras
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199 USA
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199 USA
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199 USA; Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199 USA.
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15
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Weaver B, Lidofsky S, Scriver G, Lester-Coll N. Insurance Status Correlates with Access to Procedural Therapy for Patients with Early-Stage Hepatocellular Carcinoma: A Retrospective Cohort Study of the National Cancer Database. J Vasc Interv Radiol 2022; 34:824-831.e1. [PMID: 36596321 DOI: 10.1016/j.jvir.2022.12.476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 12/15/2022] [Accepted: 12/26/2022] [Indexed: 01/01/2023] Open
Abstract
PURPOSE To compare access to specific procedural therapies across insurance types for patients with American Joint Commission on Cancer (AJCC) Stage I or II hepatocellular carcinoma (HCC). MATERIALS AND METHODS Using the National Cancer Database, patients diagnosed with Stage I or II HCC between 2004 and 2019 were identified. Parametric and nonparametric testing was used to compare the rates of procedural modalities and time to therapy across insurance types. Univariate and multivariate logistic regression analyses were used to identify the likelihood of receiving specific procedural therapy based on insurance status. RESULTS In total, 105,703 patients with AJCC Stage I or II HCC were identified. The rates of ablative therapy were similar across insurance types (18.1% total, 17.2% private insurance, 15.3% uninsured, 18.1% Medicaid, and 18.8% Medicare). In the logistic regression analysis, patients with private insurance were more likely to receive a transplant or undergo resection or procedural therapy of any kind. Patients with Medicare insurance were more likely to undergo ablation (odds ratio, 1.11; 95% confidence interval, 1.07-1.15; P < .001) than those with private insurance. CONCLUSIONS Patients with private insurance were more likely to receive most forms of procedural therapy for early-stage HCC, with the notable exception of ablative therapy, which patients with Medicare were slightly more likely to receive.
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Affiliation(s)
- Benjamin Weaver
- Larner College of Medicine at the University of Vermont, University of Vermont, Burlington, Vermont.
| | - Steven Lidofsky
- Larner College of Medicine at the University of Vermont, University of Vermont, Burlington, Vermont; University of Vermont Medical Center, Burlington, Vermont
| | - Geoffrey Scriver
- Larner College of Medicine at the University of Vermont, University of Vermont, Burlington, Vermont; University of Vermont Medical Center, Burlington, Vermont
| | - Nataniel Lester-Coll
- Larner College of Medicine at the University of Vermont, University of Vermont, Burlington, Vermont; University of Vermont Medical Center, Burlington, Vermont
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16
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Herren OM, Gillman AS, Marshall VJ, Das R. Understanding the Changing Landscape of Health Disparities in Chronic Liver Diseases and Liver Cancer. GASTRO HEP ADVANCES 2022; 2:505-520. [PMID: 37347072 PMCID: PMC10281758 DOI: 10.1016/j.gastha.2022.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/23/2023]
Abstract
Liver disease and liver cancer disparities in the U.S. are reflective of complex multiple determinants of health. This review describes the disproportionate burden of liver disease and liver cancer among racial, ethnic, sexual, and gender minority, rural, low socioeconomic status (SES) populations, and place-based contexts. The contributions of traditional and lifestyle-related risk factors (e.g., alcohol consumption, evitable toxin exposure, nutrition quality) and comorbid conditions (e.g., viral hepatitis, obesity, type II diabetes) to disparities is also explored. Biopsychosocial mechanisms defining the physiological consequences of inequities underlying these health disparities, including inflammation, allostatic load, genetics, epigenetics, and social epigenomics are described. Guided by the National Institute on Minority Health and Health Disparities (NIMHD) framework, integrative research of unexplored social and biological mechanisms of health disparities, appropriate methods and measures for early screening, diagnosis, assessment, and strategies for timely treatment and maintaining multidisciplinary care should be actively pursued. We review emerging research on adverse social determinants of liver health, such as structural racism, discrimination, stigma, SES, rising care-related costs, food insecurity, healthcare access, health literacy, and environmental exposures to pollutants. Limited research on protective factors of liver health is also described. Research from effective, multilevel, community-based interventions indicate a need for further intervention efforts that target both risk and protective factors to address health disparities. Policy-level impacts are also needed to reduce disparities. These insights are important, as the social contexts and inequities that influence determinants of liver disease/cancer have been worsened by the coronavirus disease-2019 pandemic and are forecasted to amplify disparities.
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Affiliation(s)
- Olga M. Herren
- Extramural Scientific Programs, Division of Integrative Biological and Behavioral Sciences
| | - Arielle S. Gillman
- Extramural Scientific Programs, Division of Integrative Biological and Behavioral Sciences
| | - Vanessa J. Marshall
- Office of the Director National Institute on Minority Health and Health Disparities (NIMHD), Bethesda, MD
| | - Rina Das
- Extramural Scientific Programs, Division of Integrative Biological and Behavioral Sciences
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Sempokuya T, Warner J, Azawi M, Nogimura A, Wong LL. Current status of disparity in liver disease. World J Hepatol 2022; 14:1940-1952. [PMID: 36483604 PMCID: PMC9724102 DOI: 10.4254/wjh.v14.i11.1940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 11/09/2022] [Accepted: 11/16/2022] [Indexed: 11/24/2022] Open
Abstract
Disparities have emerged as an important issue in many aspects of healthcare in developed countries and may be based on race, ethnicity, sex, geographical location, and socioeconomic status. For liver disease specifically, these potential disparities can affect access to care and outcome in viral hepatitis, chronic liver disease, and hepatocellular carcinoma. Shortages in hepatologists and medical providers versed in liver disease may amplify these disparities by compromising early detection of liver disease, surveillance for hepatocellular carcinoma, and prompt referral to subspecialists and transplant centers. In the United States, continued efforts have been made to address some of these disparities with better education of healthcare providers, use of telehealth to enhance access to specialists, reminders in electronic medical records, and modifying organ allocation systems for liver transplantation. This review will detail the current status of disparities in liver disease and describe current efforts to minimize these disparities.
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Affiliation(s)
- Tomoki Sempokuya
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE 68198, United States
| | - Josh Warner
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE 68198, United States
| | - Muaataz Azawi
- Division of Gastroenterology and Hepatology, Sanford Center for Digestive Health, Sioux Falls 57105, SD, Uruguay
| | - Akane Nogimura
- Department of Public Health, Nagoya City University Graduate School of Medical Sciences, Nagoya 467-8601, Aichi, Japan
- Division of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya 467-8601, Aichi, Japan
| | - Linda L Wong
- Department of Surgery, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HI 96813, United States
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Vidal AC, Moylan CA, Wilder J, Grant DJ, Murphy SK, Hoyo C. Racial disparities in liver cancer: Evidence for a role of environmental contaminants and the epigenome. Front Oncol 2022; 12:959852. [PMID: 36072796 PMCID: PMC9441658 DOI: 10.3389/fonc.2022.959852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 07/21/2022] [Indexed: 01/09/2023] Open
Abstract
Liver cancer incidence has tripled since the early 1980s, making this disease one of the fastest rising types of cancer and the third leading cause of cancer-related deaths worldwide. In the US, incidence varies by geographic location and race, with the highest incidence in the southwestern and southeastern states and among racial minorities such as Hispanic and Black individuals. Prognosis is also poorer among these populations. The observed ethnic disparities do not fully reflect differences in the prevalence of risk factors, e.g., for cirrhosis that may progress to liver cancer or from genetic predisposition. Likely substantial contributors to risk are environmental factors, including chemical and non-chemical stressors; yet, the paucity of mechanistic insights impedes prevention efforts. Here, we review the current literature and evaluate challenges to reducing liver cancer disparities. We also discuss the hypothesis that epigenetic mediators may provide biomarkers for early detection to support interventions that reduce disparities.
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Affiliation(s)
- Adriana C. Vidal
- Department of Biological Sciences, Center for Human Health and the Environment, North Carolina State University, Raleigh, NC, United States
| | - Cynthia A. Moylan
- Department of Medicine, Division of Gastroenterology and Hepatology, School of Medicine, Duke University, Durham, NC, United States
| | - Julius Wilder
- Department of Medicine, Division of Gastroenterology and Hepatology, School of Medicine, Duke University, Durham, NC, United States
| | - Delores J. Grant
- Department of Biomedical and Biological Sciences, Julius L. Chambers Biomedical Biotechnology Research Institute, North Carolina Central University, Durham, NC, United States
| | - Susan K. Murphy
- Department of Obstetrics and Gynecology, Division of Research, School of Medicine, Duke University, Durham, NC, United States
| | - Cathrine Hoyo
- Department of Biological Sciences, Center for Human Health and the Environment, North Carolina State University, Raleigh, NC, United States
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19
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Reynolds J, Hashimi S, Nguyen N, Infield J, Weir A, Khattak A. The Effect of Race on Outcomes in Veterans With Hepatocellular Carcinoma at a Single Center. Fed Pract 2022; 39:S64-S67a. [PMID: 36426109 PMCID: PMC9662307 DOI: 10.12788/fp.0304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Black patients have a higher incidence and mortality associated with hepatocellular carcinoma (HCC) compared with that of White patients in many retrospective analyses. This study sought to determine whether veterans treated for HCC at the Memphis Veterans Affairs Medical Center (VAMC) in Tennessee showed similar disparities in terms of stage at diagnosis, type of therapy received, and overall survival (OS). METHODS A retrospective review evaluated 132 White and 95 Black patients treated for HCC between 2009 and 2021. We evaluated the impact on OS of age, sex, comorbidities, tumor stage, α-fetoprotein level, method of diagnosis, first-line treatment, systemic treatment, and surgical options offered. Kaplan-Meier analysis was used to investigate differences in OS and cumulative hazard ratio for death. Cox regression multivariate analysis evaluated discrepancies among investigated variables. RESULTS The study found no significant difference in OS between Black and White veterans with HCC. Significant differences were found in who received surgical treatment and systemic therapy. More White veterans received any form of treatment compared with Black veterans (P < .001), and White veterans were more likely to undergo surgical resection and transplant (P = .052). There was no significant difference between age or stage at diagnosis, receipt of systemic therapy, alcohol, tobacco or drug use, HIV coinfection, or cirrhosis. CONCLUSIONS Black veterans with HCC at the Memphis VAMC were less likely to receive any form of treatment, surgical resection, or transplant compared with White veterans, but this did not have a statistically significant effect on OS.
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Affiliation(s)
| | - Sarah Hashimi
- The University of Tennessee Health Science Center, Memphis
| | - Ngan Nguyen
- The University of Tennessee Health Science Center, Memphis
| | - Jordan Infield
- The University of Tennessee Health Science Center, Memphis
- Duke University Health System, Durham, North Carolina
| | - Alva Weir
- The University of Tennessee Health Science Center, Memphis
- Memphis Veterans Affairs Medical Center, Tennessee
| | - Amna Khattak
- The University of Tennessee Health Science Center, Memphis
- Memphis Veterans Affairs Medical Center, Tennessee
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20
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Are MELD and MELDNa Still Reliable Tools to Predict Mortality on the Liver Transplant Waiting List? Transplantation 2022; 106:2122-2136. [PMID: 35594480 DOI: 10.1097/tp.0000000000004163] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Liver transplantation is the only curative treatment for end-stage liver disease. Unfortunately, the scarcity of donor organs and the increasing pool of potential recipients limit access to this life-saving procedure. Allocation should account for medical and ethical factors, ensuring equal access to transplantation regardless of recipient's gender, race, religion, or income. Based on their short-term prognosis prediction, model for end-stage liver disease (MELD) and MELD sodium (MELDNa) have been widely used to prioritize patients on the waiting list for liver transplantation resulting in a significant decrease in waiting list mortality/removal. Recent concern has been raised regarding the prognostic accuracy of MELD and MELDNa due, in part, to changes in recipients' profile such as body mass index, comorbidities, and general condition, including nutritional status and cause of liver disease, among others. This review aims to provide a comprehensive view of the current state of MELD and MELDNa advantages and limitations and promising alternatives. Finally, it will explore future options to increase the donor pool and improve donor-recipient matching.
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21
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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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22
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Goyes D, Nsubuga JP, Medina-Morales E, Barba R, Patwardhan V, Saberi B, Fricker Z, Bonder A. Race/Ethnicity Is Not Independently Associated with Risk of Adverse Waitlist Removal among Patients with HCC Exception Points. J Clin Med 2021; 10:jcm10245826. [PMID: 34945122 PMCID: PMC8704844 DOI: 10.3390/jcm10245826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 12/01/2021] [Accepted: 12/08/2021] [Indexed: 11/16/2022] Open
Abstract
(1) Background: Since 2015, exception points have been awarded to appropriate candidates after six months of waitlist time to allow more equitable access to liver transplants regardless of hepatocellular carcinoma status. However, it remains unknown whether racial disparities in outcomes among waitlisted patients remain after the introduction of a 6-month waiting period for exception points. (2) Methods: Using the United Network for Organ Sharing database, we identified 2311 patients diagnosed with hepatocellular carcinoma listed for liver transplant who received exception points from 2015 to 2019. The outcome of interest was waitlist survival defined as the composite outcome of death or removal for clinical deterioration. Competing risk analysis was used to identify factors associated with death or removal for clinical deterioration. The final model adjusted for age, sex, race/ethnicity, blood type, diabetes, obesity, laboratory MELD score, tumor size, AFP, locoregional therapies, UNOS region, and college education. (3) Results: No difference was found in the risk of adverse waitlist removal among ethnic/racial groups.
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Affiliation(s)
- Daniela Goyes
- Department of Medicine, Loyola Medicine—MacNeal Hospital, Berwyn, IL 60402, USA;
| | - John Paul Nsubuga
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA;
| | - Esli Medina-Morales
- Division of Gastroenterology, Hepatology and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA; (E.M.-M.); (R.B.); (V.P.); (B.S.); (Z.F.)
| | - Romelia Barba
- Division of Gastroenterology, Hepatology and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA; (E.M.-M.); (R.B.); (V.P.); (B.S.); (Z.F.)
| | - Vilas Patwardhan
- Division of Gastroenterology, Hepatology and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA; (E.M.-M.); (R.B.); (V.P.); (B.S.); (Z.F.)
| | - Behnam Saberi
- Division of Gastroenterology, Hepatology and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA; (E.M.-M.); (R.B.); (V.P.); (B.S.); (Z.F.)
| | - Zachary Fricker
- Division of Gastroenterology, Hepatology and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA; (E.M.-M.); (R.B.); (V.P.); (B.S.); (Z.F.)
| | - Alan Bonder
- Division of Gastroenterology, Hepatology and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA; (E.M.-M.); (R.B.); (V.P.); (B.S.); (Z.F.)
- Correspondence:
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Mullangi S, Keesari PR, Zaher A, Pulakurthi YS, Adusei Poku F, Rajeev A, Vidiyala PL, Guntupalli AL, Desai M, Ohemeng-Dapaah J, Asare Y, Patel AA, Lekkala M. Epidemiology and Outcomes of Hospitalizations Due to Hepatocellular Carcinoma. Cureus 2021; 13:e20089. [PMID: 35003948 PMCID: PMC8723719 DOI: 10.7759/cureus.20089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 12/01/2021] [Indexed: 11/19/2022] Open
Abstract
Background Hepatocellular Carcinoma (HCC) is a severe complication of cirrhosis and the incidence of HCC has been increasing in the United States (US). We aim to describe the trends, characteristics, and outcomes of hospitalizations due to HCC across the last decade. Methods We derived a study cohort from the Nationwide Inpatient Sample (NIS) for the years 2008-2017. Adult hospitalizations due to HCC were identified using the International Classification of Diseases (9th/10th Editions) Clinical Modification diagnosis codes (ICD-9-CM/ICD-10-CM). Comorbidities were also identified by ICD-9/10-CM codes and Elixhauser Comorbidity Software (Agency for Healthcare Research and Quality, Rockville, Maryland, US). Our primary outcomes were in-hospital mortality and discharge to the facility. We then utilized the Cochran-Armitage trend test and multivariable survey logistic regression models to analyze the trends, outcomes, and predictors. Results A total of 155,436 adult hospitalizations occurred due to HCC from 2008-2017. The number of hospitalizations with HCC decreased from 16,754 in 2008 to 14,715 in 2017. Additionally, trends of in-hospital mortality declined over the study period but discharge to facilities remained stable. Furthermore, in multivariable regression analysis, predictors of increased mortality in HCC patients were advanced age (OR 1.1; 95%CI 1.0-1.2; p< 0.0001), African American (OR 1.3; 95%CI 1.1-1.4;p< 0.001), Rural/ non-teaching hospitals (OR 2.7; 95%CI 2.4-3.3; p< 0.001), uninsured (OR 1.9; CI 1.6-2.2; p< 0.0001) and complications like septicemia and pneumonia as well as comorbidities such as hypertension, diabetes mellitus, and renal failure. We observed similar trends in discharge to facilities. Conclusions In this nationally representative study, we observed a decrease in hospitalizations of patients with HCC along with in-hospital mortality; however, discharge to facilities remained stable over the last decade. We also identified multiple predictors significantly associated with increased mortality, some of which are potentially modifiable and can be points of interest for future studies.
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Affiliation(s)
| | - Praneeth R Keesari
- Internal Medicine, Kamineni Academy of Medical Sciences and Research Center, Hyderabad, IND
| | - Anas Zaher
- Internal Medicine, University of Debrecen, Debrecen, HUN
| | | | | | - Arathi Rajeev
- Internal Medicine, Government Medical College Kozhikode, Kozhikode, IND
| | | | | | - Maheshkumar Desai
- Internal Medicine, Hamilton Medical Center, Medical College of Georgia/Augusta University, Dalton, USA
| | | | - Yaw Asare
- Epidemiology and Public Health, School of Public Health, University of Ghana, Accra, GHA
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24
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Khamis ZI, Pang X, Cui Z, Sang QXA, Zhang J. Cytochrome P450-2D6: A novel biomarker in liver cancer health disparity. PLoS One 2021; 16:e0257072. [PMID: 34597305 PMCID: PMC8486079 DOI: 10.1371/journal.pone.0257072] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 08/24/2021] [Indexed: 12/13/2022] Open
Abstract
Liver cancer morbidity and mortality rates differ among ethnic groups. In the United States, the burden of liver cancer in Asian Americans (AS) is higher compared to Caucasian Americans (CA). Research on liver cancer health disparities has mainly focused on environmental and socioeconomic factors yet has ignored the genotypic differences among various racial/ethnic groups. This lack of molecular level understanding has hindered the development of personalized medical approaches for liver cancer treatment. To understand the genetic heterogeneity of liver cancer between AS and CA, we performed a systematic analysis of RNA-seq data of AS and CA patients from The Cancer Genome Atlas (TCGA). We used four differential gene expression analysis packages; DESeq2, limma, edgeR, and Superdelta2, to identify the differentially expressed genes. Our analysis identified cytochrome P450-2D6 enzyme (CYP2D6) as the gene with the greatest differential expression with higher levels in AS compared to CA. To scrutinize the underlying mechanism of CYP2D6, Ingenuity Pathway Analysis (IPA) and Cytoscape were conducted and found hepatocyte nuclear factor-4α (HNF4A) and interleukin-6 (IL6) in direct association with CYP2D6. IL6 is downregulated in AS compared to CA, while HNF4A is not significantly different. Herein, we report that CYP2D6 may serve as a putative biomarker in liver cancer health disparities. Its negative association with IL6 proclaims an intricate relationship between CYP2D6 and inflammation in the ethnic differences seen in AS and CA liver cancer patients. The goal of the present study was to understand how genetic factors may contribute to the interethnic variability of liver cancer prevalence and outcomes in AS and CA patients. Identifying ethnic-specific genes may help ameliorate detection, diagnosis, surveillance, and treatments of liver cancer, as well as reduce disease-related incidence and mortality rates in the vulnerable population.
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Affiliation(s)
- Zahraa I. Khamis
- Department of Chemistry & Biochemistry, Florida State University, Tallahassee, Florida, United States of America
- Laboratory of Cancer Biology and Molecular Immunology, Department of Biochemistry, Faculty of Sciences-I, Lebanese University, Beirut, Lebanon
- * E-mail: (JZ); (ZIK)
| | - Xiaodong Pang
- Insilicom LLC, Tallahassee, Florida, United States of America
| | - Zihan Cui
- Department of Statistics, Florida State University, Tallahassee, Florida, United States of America
| | - Qing-Xiang Amy Sang
- Department of Chemistry & Biochemistry, Florida State University, Tallahassee, Florida, United States of America
- Institute of Molecular Biophysics, Florida State University, Tallahassee, Florida, United States of America
| | - Jinfeng Zhang
- Department of Statistics, Florida State University, Tallahassee, Florida, United States of America
- * E-mail: (JZ); (ZIK)
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25
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Malespin M, May EJ, Nephew LD, Paul S, McCary A, Kilaru S, Mukhtar NA, Hassan MA, Brady CW. AASLD Deepens Commitment to Diversity, Equity, and Inclusion. Hepatology 2021; 74:2216-2225. [PMID: 34028073 DOI: 10.1002/hep.31918] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 04/07/2021] [Accepted: 04/23/2021] [Indexed: 01/24/2023]
Affiliation(s)
| | | | - Lauren D Nephew
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN
| | - Sonali Paul
- Section of Gastroenterology Center for Liver Diseases, University of Chicago Medicine, Chicago, IL
| | - Alexis McCary
- Department of Gastroenterology, Mid-Atlantic Permanente Medical Group, Upper Marlboro, MD
| | - Saikiran Kilaru
- Division of Gastroenterology and Hepatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY
| | - Nizar A Mukhtar
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA
| | - Mohamed A Hassan
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, MN
| | - Carla W Brady
- Department of Medicine, Division of Gastroenterology, Duke University, Durham, NC
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26
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Moten AS, Fagenson AM, Pitt HA, Lau KN. Recent Improvements in Racial Disparity in the Treatment of Hepatocellular Carcinoma: How Times Have Changed. J Gastrointest Surg 2021; 25:2535-2544. [PMID: 33547582 DOI: 10.1007/s11605-021-04912-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 01/10/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Race has been shown to impact receipt of and outcomes following hepatobiliary surgery. We sought to determine if racial disparities in the management of hepatocellular carcinoma persist. METHODS Information on patients with hepatocellular carcinoma diagnosed between 2012 and 2016 was obtained from the Surveillance, Epidemiology, and End Results database. The sample was stratified by race/ethnicity, and associations between tumor characteristics, treatment, and survival were assessed. RESULTS Of 33,672 patients, the mean age was 65 years, and 77% were male. By race, 17,150 (51%) were white, 4755 (14%) black, 6850 (20%) Hispanic, and 4917 (15%) Asian. When assessing the likelihood of treatment versus no treatment for tumors less than 5 cm, no difference was observed between whites and blacks in any year, but Hispanics were less likely than whites to receive treatment in most years. Asians were more likely to receive treatment every year. When assessing the likelihood of transplant versus surgical resection, blacks were less likely than whites to undergo transplant in all years except 2016. Hispanics were equally likely, while Asians were less likely to undergo transplant in all years. For years 2012 to 2016 collectively, Asians had better 5-year survival rates than other races after undergoing ablation and resection. No difference in the risk of death was observed among blacks, whites, or Hispanics after undergoing ablation, resection, or transplant. CONCLUSION Racial disparities for blacks and Hispanics have improved. Although Asians were less likely to undergo transplant, they had better survival after undergoing resection or ablation.
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Affiliation(s)
- Ambria S Moten
- Department of Surgery, Temple University Hospital, 3401 N Broad St, Philadelphia, PA, 19140, USA
| | - Alexander M Fagenson
- Department of Surgery, Temple University Hospital, 3401 N Broad St, Philadelphia, PA, 19140, USA
| | - Henry A Pitt
- Department of Surgery, Rutgers-Robert Wood Johnson Medical School, 125 Paterson Street, New Brunswick, NJ, 08901, USA
| | - Kwan N Lau
- Department of Surgery, Temple University Hospital, 3401 N Broad St, Philadelphia, PA, 19140, USA.
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27
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Rosenblatt R, Wahid N, Halazun KJ, Kaplan A, Jesudian A, Lucero C, Lee J, Dove L, Fox A, Verna E, Samstein B, Fortune BE, Brown RS. Black Patients Have Unequal Access to Listing for Liver Transplantation in the United States. Hepatology 2021; 74:1523-1532. [PMID: 33779992 DOI: 10.1002/hep.31837] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 01/27/2021] [Accepted: 03/17/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIMS The Model for End-Stage Liver Disease score may have eliminated racial disparities on the waitlist for liver transplantation (LT), but disparities prior to waitlist placement have not been adequately quantified. We aimed to analyze differences in patients who are listed for LT, undergo transplantation, and die from end-stage liver disease (ESLD), stratified by state and race/ethnicity. APPROACH AND RESULTS We analyzed two databases retrospectively, the Center for Disease Control Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) and the United Network for Organ Sharing (UNOS) databases, from 2014 to 2018. We included patients aged 25-64 years who had a primary cause of death of ESLD and were listed for transplant in the CDC WONDER or UNOS database. Our primary outcome was the ratio of listing for LT to death from ESLD-listing to death ratio (LDR). Our secondary outcome was the transplant to listing and transplant to death ratios. Chi-squared and multivariable linear regression evaluated for differences between races/ethnicities. There were 135,367 patients who died of ESLD, 54,734 patients who were listed for transplant, and 26,571 who underwent transplant. Patients were mostly male and White. The national LDR was 0.40, significantly lowest in Black patients (0.30), P < 0.001. The national transplant to listing ratio was 0.48, highest in Black patients (0.53), P < 0.01. The national transplant to death ratio was 0.20, lowest in Black patients (0.16), P < 0.001. States that had an above-mean LDR had a lower transplant to listing ratio but a higher transplant to death ratio. Multivariable analysis confirmed that Black race is significantly associated with a lower LDR and transplant to death ratio. CONCLUSIONS Black patients face a disparity in access to LT due to low listing rates for transplant relative to deaths from ESLD.
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Affiliation(s)
- Russell Rosenblatt
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY.,Center for Liver Disease and Transplantation, New York, NY
| | - Nabeel Wahid
- New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY
| | - Karim J Halazun
- Center for Liver Disease and Transplantation, New York, NY.,Liver Transplant and HPB Surgery, Weill Cornell Medical College, New York, NY
| | - Alyson Kaplan
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY
| | - Arun Jesudian
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY.,Center for Liver Disease and Transplantation, New York, NY
| | - Catherine Lucero
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY.,Center for Liver Disease and Transplantation, New York, NY
| | - Jihui Lee
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY
| | - Lorna Dove
- Center for Liver Disease and Transplantation, New York, NY.,Division of Digestive and Liver Disease, Columbia University Irving Medical Center, New York, NY
| | - Alyson Fox
- Center for Liver Disease and Transplantation, New York, NY.,Division of Digestive and Liver Disease, Columbia University Irving Medical Center, New York, NY
| | - Elizabeth Verna
- Center for Liver Disease and Transplantation, New York, NY.,Division of Digestive and Liver Disease, Columbia University Irving Medical Center, New York, NY
| | - Benjamin Samstein
- Center for Liver Disease and Transplantation, New York, NY.,Liver Transplant and HPB Surgery, Weill Cornell Medical College, New York, NY
| | - Brett E Fortune
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY.,Center for Liver Disease and Transplantation, New York, NY
| | - Robert S Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY.,Center for Liver Disease and Transplantation, New York, NY
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Clinical Presentation of Hepatocellular Carcinoma in African Americans vs. Caucasians: A Retrospective Analysis. PATHOPHYSIOLOGY 2021; 28:387-399. [PMID: 35366282 PMCID: PMC8830457 DOI: 10.3390/pathophysiology28030026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 08/10/2021] [Accepted: 08/19/2021] [Indexed: 12/27/2022] Open
Abstract
Hepatocellular carcinoma (HCC) remains an important form of cancer-related morbidity and mortality in the U.S. and worldwide. Previous U.S.-based studies on survival suggest ethnic disparities in HCC patients, but the complex interplay of multiple factors that contribute are still incompletely understood. Here we considered the influences of risk factors contributing towards HCC survival, including ethnic background, over ten years at a premier academic medical center with a majority (57.20%) African American (AA) population. Retrospective HCC data were collected from 2008–2018 at LSUHSC-Shreveport, an urban tertiary medical center. Data included demographics, comorbidities, liver disease characteristics, and tumor parameters. Statistical analysis was performed using Chi Square and one-way ANOVA. Results: 229 HCC patients were identified (male 78.6%). The mean HCC age at diagnosis was 61 years (SD = 7.3). Compared to non-Hispanic Caucasians (42.7%), AA patients (57.2% of total) were older at presentation, had more frequent diabetes/dyslipidemia/NAFLD (45 (34.3%) compared with 19 (19.3%) in non-Hispanic Caucasians, p = 0.02), and had a larger HCC burden at diagnosis. We conclude that compared to white patients, despite having similar BMI and MELD scores and rates of portal vein thrombosis, AA patients with HCC in our cohort were older at presentation, had a significantly increased incidence of modifiable metabolic risk factors including diabetes, higher AFP values, increased incidence of gallstones, and larger sized HCCs, and were more likely to be outside Milan criteria. These findings have important prognostic and diagnostic implications for developing a more targeted HCC surveillance program.
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Nephew LD, Serper M. Racial, Gender, and Socioeconomic Disparities in Liver Transplantation. Liver Transpl 2021; 27:900-912. [PMID: 33492795 DOI: 10.1002/lt.25996] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 11/30/2020] [Accepted: 01/13/2021] [Indexed: 12/11/2022]
Abstract
Liver transplantation (LT) is a life-saving therapy; therefore, equitable distribution of this scarce resource is of paramount importance. We searched contemporary literature on racial, gender, and socioeconomic disparities across the LT care cascade in referral, waitlist practices, allocation, and post-LT care. We subsequently identified gaps in the literature and future research priorities. Studies found that racial and ethnic minorities (Black and Hispanic patients) have lower rates of LT referral, more advanced liver disease and hepatocellular carcinoma at diagnosis, and are less likely to undergo living donor LT (LDLT). Gender-based disparities were observed in waitlist mortality and LT allocation. Women have lower LT rates after waitlisting, with size mismatch accounting for much of the disparity. Medicaid insurance has been associated with higher rates of chronic liver disease and poor waitlist outcomes. After LT, some studies found lower overall survival among Black compared with White recipients. Studies have also shown lower literacy and limited educational attainment were associated with increased posttransplant complications and lower use of digital technology. However, there are notable gaps in the literature on disparities in LT. Detailed population-based estimates of the advanced liver disease burden and LT referral and evaluation practices, including for LDLT, are lacking. Similarly, little is known about LT disparities worldwide. Evidence-based strategies to improve access to care and reduce disparities have not been comprehensively identified. Prospective registries and alternative "real-world" databases can provide more detailed information on disease burden and clinical practices. Modeling and simulation studies can identify ways to reduce gender disparities attributed to size or inaccurate estimation of renal function. Mixed-methods studies and clinical trials should be conducted to reduce care disparities across the transplant continuum.
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Affiliation(s)
- Lauren D Nephew
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Marina Serper
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Shaltiel T, Zheng S, Siderides C, Gleeson EM, Carr J, Pletcher ER, Cohen NA, Golas BJ, Magge DR, Labow DM, Branch AD, Sarpel U. Hepatitis C-positive Black patients develop hepatocellular carcinoma at earlier stages of liver disease and present with a more aggressive phenotype. Cancer 2021; 127:1395-1406. [PMID: 33629759 PMCID: PMC8084866 DOI: 10.1002/cncr.33377] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 08/28/2020] [Accepted: 09/07/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND In the United States, mortality after a diagnosis of hepatocellular carcinoma (HCC) is higher in patients who are Black than in patients of other racial groups. The objective of this study was to clarify factors contributing to this disparity by analyzing liver and tumor characteristics in patients with HCC who have a history of hepatitis C virus (HCV) infection. METHODS Records of patients with HCV and HCC at the authors' institution from 2003 to 2018 were retrospectively reviewed. Race and ethnicity were self-identified. Imaging, laboratory, and pathologic features were compared between Black and non-Black cohorts. RESULTS Among 1195 individuals with HCC, 390 identified as Black. At the time of HCC diagnosis, Black patients had better liver function, as measured by Child-Pugh score, Model of End-Stage Liver Disease score, histology of nontumor tissue, and fibrosis-4 (FIB-4) score (all P < .05). FIB-4 scores were <3.25 in 31% of Black patients. In addition, Black patients had less early stage HCC (20.2% vs 32.3%; P < .05), larger tumors (median [interquartile range]: 3.5 cm [2.2-6.2 cm] vs 3.1 cm [2.1-5.1 cm]; P < .01), more multiple tumors (median, [interquartile range]: 1 tumor [1-3 tumors] vs 1 tumor [1-2 tumors]; P = .03), more poorly differentiated tumors (30.3% vs 20.5%; P < .05), and more microvascular invasion (67.2% vs 56.5%; P < .05). CONCLUSIONS Black patients with HCV exposure develop HCC at earlier stages of liver disease than members of other racial groups. Nearly one-third would not qualify for HCC screening using the common FIB-4 cirrhosis threshold. Practice guidelines that stress HCC surveillance for cirrhotic patients with HCV may need to be revised to be more inclusive for Black patients. In addition, tumors in Black patients carry worse prognostic features, and molecular studies are needed to characterize their biologic properties.
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Affiliation(s)
- Tali Shaltiel
- Department of Surgery, Division of Surgical Oncology, New York, NY
| | - Serena Zheng
- Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | - Jacquelyn Carr
- Department of Surgery, Division of Surgical Oncology, New York, NY
| | - Eric R. Pletcher
- Department of Surgery, Division of Surgical Oncology, New York, NY
| | - Noah A. Cohen
- Department of Surgery, Division of Surgical Oncology, New York, NY
| | | | - Deepa R. Magge
- Department of Surgery, Division of Surgical Oncology, New York, NY
| | - Daniel M. Labow
- Department of Surgery, Division of Surgical Oncology, New York, NY
| | - Andrea D. Branch
- Department of Medicine, Division of Liver Diseases, New York, NY
| | - Umut Sarpel
- Department of Surgery, Division of Surgical Oncology, New York, NY
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31
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Zhou K, Pickering TA, Gainey CS, Cockburn M, Stern MC, Liu L, Unger JB, El-Khoueiry AB, Terrault NA. Presentation, Management, and Outcomes Across the Rural-Urban Continuum for Hepatocellular Carcinoma. JNCI Cancer Spectr 2021; 5:pkaa100. [PMID: 33442663 PMCID: PMC7791625 DOI: 10.1093/jncics/pkaa100] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 09/30/2020] [Indexed: 12/15/2022] Open
Abstract
Background Hepatocellular carcinoma is 1 of few cancers with rising incidence and mortality in the United States. Little is known about disease presentation and outcomes across the rural-urban continuum. Methods Using the population-based Surveillance, Epidemiology, and End Results registry, we identified adults with incident hepatocellular carcinoma between 2000 and 2016. Urban, suburban, and rural residence at time of cancer diagnosis were categorized by the Census Bureau’s percent of the population living in nonurban areas. We examined association between place of residence and overall survival. Secondary outcomes were late tumor stage and receipt of therapy. Results Of 83 368 incident cases of hepatocellular carcinoma, 75.8%, 20.4%, and 3.8% lived in urban, suburban, and rural communities, respectively. Median survival was 7 months (interquartile range = 2-24). All stage and stage-specific survival differed by place of residence, except for distant stage. In adjusted models, rural and suburban residents had a respective 1.09-fold (95% confidence interval [CI] = 1.04 to 1.14; P < .001) and 1.08-fold (95% CI = 1.05 to 1.10; P < .001) increased hazard of overall mortality as compared with urban residents. Furthermore, rural and suburban residents had 18% (odds ratio [OR] = 1.18, 95% CI = 1.10 to 1.27; P < .001) and 5% (OR = 1.05, 95% CI = 1.02 to 1.09; P = .003) higher odds of diagnosis at late stage and were 12% (OR = 0.88, 95% CI = 0.80 to 0.94; P < .001) and 8% (OR = 0.92, 95% CI = 0.88 to 0.95; P < .001) less likely to receive treatment, respectively, compared with urban residents. Conclusions Residence in a suburban and rural community at time of diagnosis was independently associated with worse indicators across the cancer continuum for liver cancer. Further research is needed to elucidate the primary drivers of these rural-urban disparities.
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Affiliation(s)
- Kali Zhou
- Department of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Trevor A Pickering
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA, USA
| | - Christina S Gainey
- Department of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Myles Cockburn
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA, USA.,Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Mariana C Stern
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA, USA.,Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Lihua Liu
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA, USA.,Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Jennifer B Unger
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA, USA.,Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Anthony B El-Khoueiry
- Department of Medicine, University of Southern California, Los Angeles, CA, USA.,Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Norah A Terrault
- Department of Medicine, University of Southern California, Los Angeles, CA, USA
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Ajayi F, Jan J, Singal AG, Rich NE. Racial and Sex Disparities in Hepatocellular Carcinoma in the USA. CURRENT HEPATOLOGY REPORTS 2020; 19:462-469. [PMID: 33828937 PMCID: PMC8020839 DOI: 10.1007/s11901-020-00554-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/23/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW In this review, we aim to provide a summary of the current literature on race and gender disparities in hepatocellular carcinoma (HCC) incidence, stage at diagnosis, treatment and prognosis in the United States. RECENT FINDINGS HCC incidence rates are rising in the U.S. in all racial/ethnic groups except for Asian/Pacific Islanders, with disproportionate rises and the highest rates among Hispanics compared to Blacks and non-Hispanic whites. There are striking sex disparities in HCC incidence and mortality; however, with the shifting epidemiology of HCC risk factors in the U.S, there is recent evidence that HCC is trending towards less male predominance, particularly among younger birth cohorts. Despite significant advances in HCC treatment over the past decade, disparities in HCC surveillance and treatment receipt persist among racial and ethnic minorities and the socioeconomically disadvantaged. Black patients continue to experience worse survival outcomes than non-Black patients with HCC. SUMMARY There are significant racial and gender disparities in HCC incidence, treatment, and mortality in the U.S. Though these disparities are well-documented, data are still limited on the specific determinants driving disparities in HCC. To achieve health equity for all patients with HCC, we must advance beyond simply reporting on disparities and begin implementing targeted interventions to eliminate disparities.
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Affiliation(s)
- Faith Ajayi
- Division of Digestive and Liver Diseases, Department of Internal Medicine
| | - Jenny Jan
- Division of Digestive and Liver Diseases, Department of Internal Medicine
| | - Amit G. Singal
- Division of Digestive and Liver Diseases, Department of Internal Medicine
- Harold C. Simmons Comprehensive Cancer Center
- Department of Population and Data Sciences, UT Southwestern Medical Center
| | - Nicole E. Rich
- Division of Digestive and Liver Diseases, Department of Internal Medicine
- Harold C. Simmons Comprehensive Cancer Center
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Sempokuya T, Wien EA, Pattison RJ, Ma J, Wong LL. Factors associated with 5-year survival of combined hepatocellular and cholangiocarcinoma. World J Hepatol 2020; 12:1020-1030. [PMID: 33312426 PMCID: PMC7701962 DOI: 10.4254/wjh.v12.i11.1020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 07/25/2020] [Accepted: 10/12/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Combined hepatocellular and cholangiocarcinoma (HCC/CC) is a rare primary hepatic malignancy which carries a poor prognosis due to its aggressive nature. Few centers have enough cases to draw definitive conclusions and there is limited understanding of prognosis. Given the rarity of HCC/CC, an analysis of large national cancer database was needed to obtain larger number of HCC/CC cases.
AIM To identify associated factors for 5-year survival of HCC/CC.
METHODS We conducted a retrospective study of The Surveillance, Epidemiology, and End Results (SEER) database obtained from SEER*Stat 8.3.6 software. Previously defined histology code 8180 for the International Classification of Disease for Oncology, 3rd edition was used to identify HCC/CC cases from 2004 to 2015. We collected demographics, American Joint Committee on Cancer (AJCC) stage, treatment, tumor size, and survival data. These data were converted to categorical variables. The Shapiro-Wilk normality test was used to assess normal distribution. Mann-Whitney U test was used to compare continuous variables without normal distribution, and t-test was used to compare continuous variables with a normal distribution. The Kaplan-Meier survival curve analyzed 5-year survival. Univariate and multivariate logistic regression model was used to analyze factors associated with 5-year survival. Multivariate Cox proportional hazard regression was done on 5-year survival. We defined P < 0.05 was statistically significant.
RESULTS We identified 497 patients with the following characteristics: Mean age 62.4 years (SD: 11.3), 149 (30.0%) were female, racial distribution was: 276 (55.5%) white, 53 (10.7%) black, 84 (16.9%) Asian and Pacific Islander (API), 77 (15.5%) Hispanic, and 7 (1.4%) others or unknown. Stage I/II disease occurred in 41.5% and tumor size < 50 mm was seen in 35.6% of patients. Twenty-four (4.8%) received locoregional therapy (LRT), 119 (23.9%) underwent resection, and 50 (10.1%) underwent liver transplantation. The overall median survival was 6 mo [Interquartile range (IQR): 1-22]. After multivariate logistic regression, tumor size < 50 mm [Odds ratios (OR): 2.415, P = 0.05], resection (OR: 12.849, P < 0.01), and transplant (OR: 27.129, P < 0.01) showed significance for 5-year survival. Age > 60, sex, race, AJCC stages, metastasis, and LRT were not significant. However, API vs white showed significant OR of 2.793 (CI: 1.120-6.967). Cox proportional hazard regression showed AJCC stages, tumor size < 50 mm, LRT, resection, and transplant showed significant hazard ratio.
CONCLUSION HCC/CC patients with tumor size < 50 mm, resection, and transplant were associated with an increase in 5-year survival. API showed advantageous OR and hazard ratios over white, black.
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Affiliation(s)
- Tomoki Sempokuya
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE 68198, United States
| | - Eric A Wien
- Department of Medicine, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HI 96813, United States
| | - Robert J Pattison
- Department of Medicine, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HI 96813, United States
| | - Jihyun Ma
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE 68198, United States
| | - Linda L Wong
- Department of Surgery, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HI 96817, United States
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Pomenti S, Gandle C, Abu Sbeih H, Phipps M, Livanos A, Guo A, Yeh J, Burney H, Liu H, Dakhoul L, Kettler C, Gawrieh S, deLemos A, Scanga A, Chalasani N, Miller E, Wattacheril J. Hepatocellular Carcinoma in Hispanic Patients: Trends and Outcomes in a Large United States Cohort. Hepatol Commun 2020; 4:1708-1716. [PMID: 33163839 PMCID: PMC7603535 DOI: 10.1002/hep4.1575] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 06/05/2020] [Accepted: 07/06/2020] [Indexed: 12/23/2022] Open
Abstract
Hepatocellular carcinoma (HCC) has a strong racial and ethnic association, with Hispanic patients having a higher incidence and mortality. However, there are limited data regarding clinical features and outcomes. This study includes Hispanic and non‐Hispanic White patients with HCC diagnosed between January 2000 and June 2014 from five United States academic medical centers. The chi‐square test for categorical variables and analysis of variance for continuous variables were used for statistical analysis, with two‐tailed P < 0.05 considered statistically significant. Of 5,327 patients, 4,217 met inclusion criteria, of whom 12.3% were Hispanic patients. Compared to their non‐Hispanic White counterparts, Hispanic patients were older at age of diagnosis (mean ± SD, 64.2 ± 10.9 vs. 61.9 ± 10.5 years; P < 0.0001), with higher body mass index (29.6 ± 6.5 vs. 28.8 ± 5.9 kg/m2; P = 0.01), and were more likely to have diabetes and hypertension. Hispanic patients had significantly more nonalcoholic fatty liver disease and alcohol‐related liver disease (both P < 0.0001). Hispanic patients presented with larger tumors, more advanced stage disease, and increased rates of macrovascular invasion and extrahepatic spread. HCCs in Hispanic patients were less likely to be within Milan criteria (26% vs. 38%; P < 0.0001) and were less likely to be treated with resection (9% vs. 13%; P = 0.03) or transplantation (8% vs. 19%; P < 0.0001). Hispanic patients had a median overall survival of 1.4 years (95% confidence interval [CI], 1.22‐1.56), which was similar to that of non‐Hispanic White patients (1.3 years; 95% CI, 1.26‐1.41; P = 0.07). Conclusion: Hispanic patients with HCC were more likely to have metabolic risk factors for chronic liver disease, including obesity. Despite diagnosis at more advanced stages with less curative intervention than non‐Hispanic White patients, median overall survival was similar between groups.
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Affiliation(s)
- Sydney Pomenti
- Department of Medicine Columbia University Irving Medical Center New York NY USA
| | - Cassandra Gandle
- Department of Medicine Baylor College of Medicine Houston TX USA
| | - Hamzah Abu Sbeih
- Department of Gastroenterology Hepatology, and Nutrition MD Anderson Cancer Center Houston TX USA
| | - Meaghan Phipps
- Department of Medicine Division of Digestive and Liver Diseases Center for Liver Disease and Transplantation Columbia University Irving Medical Center- New York Presbyterian Hospital New York NY USA
| | - Alexandra Livanos
- Department of Medicine Columbia University Irving Medical Center New York NY USA
| | - Averill Guo
- Department of Medicine Columbia University Irving Medical Center New York NY USA
| | - Jonathan Yeh
- Department of Medicine Division of Digestive and Liver Diseases Center for Liver Disease and Transplantation Columbia University Irving Medical Center- New York Presbyterian Hospital New York NY USA
| | - Heather Burney
- Department of Biostatistics Indiana University School of Medicine Indianapolis IN USA
| | - Hao Liu
- Department of Biostatistics Indiana University School of Medicine Indianapolis IN USA
| | - Lara Dakhoul
- Department of Medicine Division of Gastroenterology and Hepatology Indiana University School of Medicine Indianapolis IN USA
| | - Carla Kettler
- Department of Biostatistics Indiana University School of Medicine Indianapolis IN USA
| | - Samer Gawrieh
- Department of Medicine Division of Gastroenterology and Hepatology Indiana University School of Medicine Indianapolis IN USA
| | - Andrew deLemos
- Department of Medicine Division of Hepatology Atrium Health Charlotte NC USA
| | - Andrew Scanga
- Gastroenterology, Hepatology and Nutrition Vanderbilt University Medical Center Nashville TN USA
| | - Naga Chalasani
- Department of Medicine Division of Gastroenterology and Hepatology Indiana University School of Medicine Indianapolis IN USA
| | - Ethan Miller
- Department of Gastroenterology Hepatology, and Nutrition MD Anderson Cancer Center Houston TX USA
| | - Julia Wattacheril
- Department of Medicine Division of Digestive and Liver Diseases Center for Liver Disease and Transplantation Columbia University Irving Medical Center- New York Presbyterian Hospital New York NY USA
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Understanding Gaps in the Hepatocellular Carcinoma Cascade of Care: Opportunities to Improve Hepatocellular Carcinoma Outcomes. J Clin Gastroenterol 2020; 54:850-856. [PMID: 33030855 DOI: 10.1097/mcg.0000000000001422] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Hepatocellular carcinoma (HCC) is a leading cause of morbidity and mortality. Existing studies have highlighted significant disparities in HCC outcomes, particularly among vulnerable populations, including ethnic minorities, safety-net populations, underinsured patients, and those with low socioeconomic status and high risk behaviors. The majority of these studies have focused on HCC surveillance. Although HCC surveillance is one of the most important first steps in HCC monitoring and management, it is only one step in the complex HCC cascade of care that evolves from surveillance to diagnosis and tumor staging that leads to access to HCC therapies. In this current review, we explore the disparities that exist along this complex HCC cascade of care and further highlight potential interventions that have been implemented to improve HCC outcomes. These interventions focus on patient, provider, and system level factors and provide a potential framework for health systems to implement quality improvement initiatives to improve HCC monitoring and management.
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Lee RM, Gamboa AC, Turgeon MK, Yopp A, Ryon EL, Kronenfeld JP, Goel N, Wang A, Lee AY, Luu S, Hsu C, Silberfein E, Maithel SK, Russell MC. Dissecting disease, race, ethnicity, and socioeconomic factors for hepatocellular carcinoma: An analysis from the United States Safety Net Collaborative. Surg Oncol 2020; 35:120-125. [PMID: 32871546 DOI: 10.1016/j.suronc.2020.08.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/25/2020] [Accepted: 08/06/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Racial/ethnic and socioeconomic disparities are assumed to negatively affect treatment and outcomes for hepatocellular carcinoma (HCC). Our aim was to investigate the interaction of racial/ethnic and socioeconomic factors with stage of disease and type of treatment facility in receipt of treatment and overall survival (OS) of patients with HCC. METHODS All patients with primary HCC in the US Safety-Net Collaborative database (2012-2014) were included. Patients were categorized into "safety-net" or "tertiary referral center" based on where they received treatment. Socioeconomic factors were determined at the zip-code level and included median income and percent of adults who graduated from high-school. Primary outcomes were receipt of treatment and OS. RESULTS On MV Cox regression, neither race/ethnicity, median income, nor care provided at a SNH were associated with decreased OS (all p > 0.05). Independent predictors of decreased OS included lack of insurance (HR 1.34), less educational attainment (HR 1.59) higher MELD score (HR 1.07), higher stage at diagnosis (II:HR 1.34, III:HR 2.87, IV:HR 3.23), and not receiving treatment (HR 3.94) (all p < 0.05). Factors associated with not receiving treatment included history of alcohol abuse (OR 0.682), increasing MELD (OR 0.874), higher stage at diagnosis (III: OR 0.234, IV: OR 0.210) and care at a safety net facility (OR 0.424) There were no racial/ethnic or socioeconomic disparities in receipt of treatment. CONCLUSIONS There is no intrinsic or direct association of race/ethnicity, socioeconomic status, or being treated at select safety-net hospitals with worse outcomes. Poor liver function, no insurance, and advanced stage of presentation are the main determinants of not receiving treatment and decreased survival.
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Affiliation(s)
- Rachel M Lee
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA, USA.
| | - Adriana C Gamboa
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA, USA
| | - Michael K Turgeon
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA, USA
| | - Adam Yopp
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Emily L Ryon
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Joshua P Kronenfeld
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Neha Goel
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Annie Wang
- Division of Surgical Oncology, Department of Surgery, NYU Langone Health, New York, NY, USA
| | - Ann Y Lee
- Division of Surgical Oncology, Department of Surgery, NYU Langone Health, New York, NY, USA
| | - Sommer Luu
- Division of Surgical Oncology, Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Cary Hsu
- Division of Surgical Oncology, Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Eric Silberfein
- Division of Surgical Oncology, Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Shishir K Maithel
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA, USA
| | - Maria C Russell
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA, USA
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Aly A, Ronnebaum S, Patel D, Doleh Y, Benavente F. Epidemiologic, humanistic and economic burden of hepatocellular carcinoma in the USA: a systematic literature review. Hepat Oncol 2020; 7:HEP27. [PMID: 32774837 PMCID: PMC7399607 DOI: 10.2217/hep-2020-0024] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 07/01/2020] [Indexed: 12/24/2022] Open
Abstract
AIM To describe the epidemiologic, humanistic and economic burdens of hepatocellular carcinoma (HCC) in the USA. MATERIALS & METHODS Studies describing the epidemiology and economic burden from national cohorts, any economic models, or any humanistic burden studies published 2008-2018 were systematically searched. RESULTS HCC incidence was 9.5 per 100,000 person-years in most recent data, but was ∼100-times higher among patients with hepatitis/cirrhosis. Approximately a third of patients were diagnosed with advanced disease. Patients with HCC experienced poor quality of life. Direct costs were substantial and varied based on underlying demographics, disease stage and treatment received. Between 25-77% of patients did not receive surgical, locoregional or systemic treatment. CONCLUSION Better treatments are needed to extend survival and improve quality of life for patients with HCC.
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Affiliation(s)
| | | | - Dipen Patel
- Pharmerit – an OPEN Health Company, Bethesda, MD 20814, USA
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Thylur RP, Roy SK, Shrivastava A, LaVeist TA, Shankar S, Srivastava RK. Assessment of risk factors, and racial and ethnic differences in hepatocellular carcinoma. JGH OPEN 2020; 4:351-359. [PMID: 32514436 PMCID: PMC7273694 DOI: 10.1002/jgh3.12336] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 03/05/2020] [Accepted: 03/24/2020] [Indexed: 12/24/2022]
Abstract
Despite improved screening and surveillance guidelines, significant race/ethnicity‐specific disparities in hepatocellular carcinoma (HCC) continue to exist and disproportionately affect minority and disadvantaged populations. This trend indicates that social determinants, genetic, and environmental factors are driving the epidemic at the population level. Race and geography had independent associations with risk of mortality among patients with HCC. The present review discusses the risk factors and issues related to disparities in HCC. The underlying etiologies for these disparities are complex and multifactorial. Some of the risk factors for developing HCC include hepatitis B (HBV) and hepatitis C (HCV) viral infection, nonalcoholic fatty liver disease, nonalcoholic steatohepatitis, smoking and alcohol consumption. In addition, population genetics; socioeconomic and health care access; treatment and prevention differences; and genetic, behavioral, and biological influences can contribute to HCC. Acculturation of ethnic minorities, insurance status, and access to health care may further contribute to the observed disparities in HCC. By increasing awareness, better modalities for screening and surveillance, improving access to health care, and adapting targeted preventive and therapeutic interventions, disparities in HCC outcomes can be reduced or eliminated.
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Affiliation(s)
- Ramesh P Thylur
- Stanley S. Scott Cancer Center Louisiana State University Health-New Orleans School of Medicine New Orleans Louisiana USA
| | - Sanjit K Roy
- Stanley S. Scott Cancer Center Louisiana State University Health-New Orleans School of Medicine New Orleans Louisiana USA
| | | | - Thomas A LaVeist
- Department of Health Policy and Management Tulane University School of Public Health and Tropical Medicine New Orleans Louisiana USA
| | - Sharmila Shankar
- Stanley S. Scott Cancer Center Louisiana State University Health-New Orleans School of Medicine New Orleans Louisiana USA.,Department of Genetics Louisiana State University Health Sciences Center-New Orleans New Orleans Louisiana USA
| | - Rakesh K Srivastava
- Stanley S. Scott Cancer Center Louisiana State University Health-New Orleans School of Medicine New Orleans Louisiana USA.,Department of Genetics Louisiana State University Health Sciences Center-New Orleans New Orleans Louisiana USA
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Dewdney B, Roberts A, Qiao L, George J, Hebbard L. A Sweet Connection? Fructose's Role in Hepatocellular Carcinoma. Biomolecules 2020; 10:E496. [PMID: 32218179 PMCID: PMC7226025 DOI: 10.3390/biom10040496] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 03/20/2020] [Accepted: 03/23/2020] [Indexed: 12/12/2022] Open
Abstract
Hepatocellular carcinoma is one of few cancer types that continues to grow in incidence and mortality worldwide. With the alarming increase in diabetes and obesity rates, the higher rates of hepatocellular carcinoma are a result of underlying non-alcoholic fatty liver disease. Many have attributed disease progression to an excess consumption of fructose sugar. Fructose has known toxic effects on the liver, including increased fatty acid production, increased oxidative stress, and insulin resistance. These effects have been linked to non-alcoholic fatty liver (NAFLD) disease and a progression to non-alcoholic steatohepatitis (NASH). While the literature suggests fructose may enhance liver cancer progression, the precise mechanisms in which fructose induces tumor formation remains largely unclear. In this review, we summarize the current understanding of fructose metabolism in liver disease and liver tumor development. Furthermore, we consider the latest knowledge of cancer cell metabolism and speculate on additional mechanisms of fructose metabolism in hepatocellular carcinoma.
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Affiliation(s)
- Brittany Dewdney
- Molecular and Cell Biology, and The Centre for Molecular Therapeutics, Australian Institute of Tropical Health and Medicine, James Cook University, Townsville QLD 4811, Australia; (B.D.); (A.R.)
| | - Alexandra Roberts
- Molecular and Cell Biology, and The Centre for Molecular Therapeutics, Australian Institute of Tropical Health and Medicine, James Cook University, Townsville QLD 4811, Australia; (B.D.); (A.R.)
| | - Liang Qiao
- Storr Liver Centre, Westmead Institute for Medical Research, Westmead Hospital and University of Sydney, Sydney NSW 2145, Australia; (L.Q.); (J.G.)
| | - Jacob George
- Storr Liver Centre, Westmead Institute for Medical Research, Westmead Hospital and University of Sydney, Sydney NSW 2145, Australia; (L.Q.); (J.G.)
| | - Lionel Hebbard
- Molecular and Cell Biology, and The Centre for Molecular Therapeutics, Australian Institute of Tropical Health and Medicine, James Cook University, Townsville QLD 4811, Australia; (B.D.); (A.R.)
- Storr Liver Centre, Westmead Institute for Medical Research, Westmead Hospital and University of Sydney, Sydney NSW 2145, Australia; (L.Q.); (J.G.)
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Disparities in Hepatocellular Carcinoma Surveillance: Dissecting the Roles of Patient, Provider, and Health System Factors. J Clin Gastroenterol 2020; 54:218-226. [PMID: 31913877 DOI: 10.1097/mcg.0000000000001313] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hepatocellular carcinoma (HCC) is a leading cause of cancer-related deaths worldwide and remains one of the most rapidly rising cancers among the US adults. While overall HCC survival is poor, early diagnosis via timely and consistent implementation of routine HCC surveillance among at-risk individuals leads to earlier tumor stage at diagnosis, which is directly correlated with improved options for potentially curative therapies, translating into improved overall survival. Despite this well-established understanding of the benefits of HCC surveillance, surveillance among cirrhosis patients remains suboptimal in a variety of practice settings. While the exact reasons underlying the unacceptably low rates of routine HCC surveillance are complex, it likely reflects multifactorial contributions at the patient, provider, and health care system levels. Furthermore, these multilevel challenges affect ethnic minorities disproportionately, which is particularly concerning given that ethnic minorities already experience existing barriers in timely access to consistent medical care, and these populations are disproportionately affected by HCC burden in the United States. In this review, we provide an updated evaluation of the existing literature on rates of HCC surveillance in the United States. We specifically highlight the existing literature on the impact of patient-specific, provider-specific, and health care system-specific factors in contributing to challenges in effective implementation of HCC surveillance.
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More Severe Deficits in Performance Status at Time of Liver Transplant is Associated With Significantly Higher Risk of Death Following Liver Transplantation. J Clin Gastroenterol 2019; 53:e392-e399. [PMID: 30762610 DOI: 10.1097/mcg.0000000000001187] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
GOAL To evaluate the impact of Karnofsky Performance Status score (KPSS) at the time of liver transplantation (LT) on post-LT survival. BACKGROUND While the Model for End-Stage Liver Disease (MELD) score is used to prioritize individuals for LT, it does not specifically incorporate functional status into patient assessment for LT. METHODS Using 2005 to 2016 United Network for Organ Sharing data, all adults (age 18 y and above) undergoing LT were identified. The association of KPSS at the time of LT (KPSS 1: functional status 80% to 100%, KPSS 2: 60% to 70%, KPSS 3: 40% to 50%, KPSS 4: 10% to 30%) with post-LT survival was evaluated using Kaplan-Meier methods and adjusted multivariate logistic regression models. RESULTS Among 66,397 LT recipients (68% male, 72% non-Hispanic white, 22% hepatocellular carcinoma, median age: 55 to 57), women were more likely to be KPSS 4 at the time of LT compared with men (27.95% vs. 22.79%; P<0.001) and African Americans (25.43% vs. 23.03%; P<0.001) and Hispanics (31.69% vs. 23.03%; P<0.001) were more likely to be KPSS 4 than non-Hispanic whites. Worse KPSS at LT correlated with higher post-LT mortality [compared with KPSS 1: Hazard Ratio (HR) for KPSS 2: 1.16, 95% confidence interval (CI): 1.10-1.22; HR for KPSS 3: 1.40; 95% CI: 1.32-1.49; HR for KPSS 4: 1.67; 95% CI: 1.55-1.79]. This increased mortality seen with worse KPSS was observed among all liver disease etiologies and in patients with and without hepatocellular carcinoma. CONCLUSIONS Worse functional status at the time of LT is strongly associated with higher risk of mortality following LT, emphasizing the importance of optimizing performance status in the preoperative period.
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Gutin L, Yao F, Dodge JL, Grab J, Mehta N. Comparison of Liver Transplant Wait-List Outcomes Among Patients With Hepatocellular Carcinoma With Public vs Private Medical Insurance. JAMA Netw Open 2019; 2:e1910326. [PMID: 31469395 PMCID: PMC6724163 DOI: 10.1001/jamanetworkopen.2019.10326] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE There are well-documented racial/ethnic and socioeconomic disparities in access to health care among patients with hepatocellular carcinoma (HCC); however, there are little data on the association of insurance type with liver transplant (LT) wait-list outcomes for patients with HCC. OBJECTIVE To examine LT wait-list outcomes for patients with HCC and public insurance compared with patients with private insurance. DESIGN, SETTING, AND PARTICIPANTS This single-center cohort study included 705 adult patients with HCC who had Model for End-Stage Liver Disease exceptions and were included on a waiting list for LT from January 1, 2010, to December 31, 2016. Patients with Kaiser Permanente medical insurance, other private medical insurance, or public medical insurance were included. Data analysis was conducted from May 2018 to October 2018. MAIN OUTCOMES AND MEASURES The main outcome was cumulative incidence of LT waiting list dropout within 2 years of waiting list enrollment (baseline). Secondary outcomes included competing-risks analysis to identify risk factors associated with wait-list outcomes. RESULTS Among 705 patients (median [interquartile range] age, 61 [57-65] years; 537 [76.2%] men) with HCC on an LT waiting list, 349 patients (49.5%) had Kaiser Permanente insurance, 157 patients (22.3%) had other private insurance, and 199 patients (28.2%) had public insurance. Median (interquartile range) follow-up was 13.2 (7.8-18.7) months. Tumor characteristics were similar among insurance types. The cumulative incidence of dropout owing to tumor progression or death within 2 years of baseline was 21.8% (95% CI, 17.2%-26.7%) among the Kaiser Permanente insurance group, 25.5% (95% CI, 18.6%-33.0%) among the other private insurance group, and 35.5% (95% CI, 28.3%-42.7%) among the public insurance group (P < .001). The cumulative incidence of LT within 2 years of baseline was 67.3% (95% CI, 61.2%-72.6%) among the Kaiser Permanente insurance group, 64.1% (95% CI, 55.2%-71.7%) among the other private insurance group, and 48.5% (95% CI, 40.4%-56.1%) among the public insurance group (P < .001). In competing-risks multivariable analysis compared with patients with Kaiser Permanente insurance, patients with public insurance were associated with increased risk of dropout (hazard ratio [HR], 1.69 [95% CI, 1.17-2.43]; P = .005), but patients with other private insurance were not (HR, 1.40 [95% CI, 0.94-2.08]; P = .10). Waiting list dropout was also significantly associated with an α-fetoprotein level 100 ng/mL or higher (HR, 2.8 [95% CI, 1.98-3.88]; P < .001), Model for End-Stage Liver Disease score at baseline (HR per point, 1.06 [95% CI, 1.03-1.09]; P < .001), and 3 or more lesions at baseline (HR vs 1 lesion of 2- to 3-cm diameter, 2.07 [95% CI, 1.27-3.37]; P = .004). CONCLUSIONS AND RELEVANCE In this large cohort of patients with HCC on an LT waiting list, patients with public insurance were associated with worse wait-list outcomes compared with patients with Kaiser Permanente insurance or other private insurance, despite similar tumor-related characteristics at baseline. Improved health care coordination and delivery may be options to reduce these disparities.
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Affiliation(s)
- Liat Gutin
- Department of Medicine, University of California, San Francisco
| | - Francis Yao
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco
| | - Jennifer L. Dodge
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco
| | - Joshua Grab
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco
| | - Neil Mehta
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco
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Wang Z, Gu X, Thrift AP. Factors associated with favorable survival outcomes for Asians with hepatocellular carcinoma: A sequential matching cohort study. PLoS One 2019; 14:e0214721. [PMID: 30943273 PMCID: PMC6447218 DOI: 10.1371/journal.pone.0214721] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 03/19/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Overall 5-year survival rates for patients diagnosed with hepatocellular carcinoma (HCC) are poor, but vary by race/ethnicity. We undertook a comprehensive assessment of underlying contributing factors to the favorable survival outcomes of HCC among Asians compared with non-Hispanic whites (NHW). METHODS We identified 1,284 Asian and 7,072 NHW patients newly diagnosed with HCC between 1994 and 2011 in the Surveillance, Epidemiology and End Results (SEER)-Medicare linked database. We used a novel three-step sequential matching approach to identify demographic, presentation and treatment factors that may explain survival differences between Asians and NHWs. Hazard ratios (HRs) and corresponding 95% confidence intervals (CIs) for the association between Asian race and risk of HCC-related mortality were estimated using Cox proportional hazards models. RESULTS The absolute difference in 5-year survival rates between Asians and NHWs was 8.4% (95% CI: 4.6%-12.0%) in the demographics match analysis. The disparity remained unchanged after additionally matching on stage, grade and comorbidities in the presentation match analysis. However, in the treatment match analysis, which accounts for differences in demographic, presentation and treatment factors, the absolute difference in 5-year survival rates was reduced to 5.8% (95% CI: 2.6%-9.3%). Treatment differences explained more of survival disparity in Asian and NHW patients with localized disease than for those with regional or distant stage HCC. CONCLUSIONS Asian patients with HCC continue to have more favorable survival outcomes than NHWs with HCC. This persistent disparity seems to be more related to treatment differences than to differences in presentation characteristics including stage.
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Affiliation(s)
- Zhensheng Wang
- Section of Epidemiology and Population Sciences, Department of Medicine, Baylor College of Medicine, Houston, Texas, United States of America
| | - Xiangjun Gu
- Section of Epidemiology and Population Sciences, Department of Medicine, Baylor College of Medicine, Houston, Texas, United States of America
| | - Aaron P. Thrift
- Section of Epidemiology and Population Sciences, Department of Medicine, Baylor College of Medicine, Houston, Texas, United States of America
- Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas, United States of America
- * E-mail:
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Yu JR, Wang J, Bhuket T, Liu B, Wong RJ. The Impact of Ethnic Subgroups on Tumor Stage at Diagnosis, Treatment Received, and Long-Term Survival Among Asian Adults With Hepatocellular Carcinoma. J Clin Exp Hepatol 2019; 9:182-190. [PMID: 31024200 PMCID: PMC6477129 DOI: 10.1016/j.jceh.2018.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 10/30/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND & AIMS Hepatocellular carcinoma (HCC) outcomes among Asians may differ by the Asian ethnic subgroup. We aim to evaluate the impact of the Asian ethnic subgroup on HCC tumor stage, treatment received, and overall survival among US adults. METHODS Using the 2004-2012 Surveillance, Epidemiology, and End Results U.S. cancer registry, we retrospectively evaluated disparities in HCC tumor stage at diagnosis, HCC treatment received, and overall survival among Asian adults, stratified by Asian ethnic subgroups. Multivariate regression models evaluated the independent impact of Asian ethnic subgroups on the HCC tumor stage at diagnosis, treatment received, and overall long-term survival. RESULTS Among 8160 Asians with HCC, Southeast Asian (SEA) patients accounted for 26% of all HCC, followed by Chinese (CH) (22%), and Filipinos (FP) (14.0%) patients. Japanese (JP) patients were significantly older than those of the other subgroups (mean 71.1, SD 10.8, P < 0.01). When evaluating HCC stage, FP patients were less likely to have localized HCC and less likely to have HCC within the Milan criteria than CH HCC patients. When evaluating HCC treatment, pacific islanders (PI), FP and SEA patients were significantly less likely to any receive HCC treatment than CH patients. Overall five-year HCC survival was highest among CH HCC patients (33.1%) and lowest among FP (19.9%) and JP patients (22.0%). CONCLUSION Among Asians with HCC in the US, significant disparities among Asian ethnic subgroups exist. More advanced disease was seen among FP patients, less HCC treatment was seen among FP and SEA patients, and significantly higher mortality was seen among FP, SEA, and JP patients with HCC.
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Key Words
- Asians
- CH, Chinese
- Epidemiology, and End Results
- FP, Filipino
- HBV, hepatitis B virus
- HCC, hepatocellular carcinoma
- HCV, hepatitis C virus
- JP, Japanese
- KR, Korean
- Milan criteria
- NAFLD, nonalcoholic fatty liver disease
- PI, Pacific Islander
- SA, South Asian
- SEA, Southeast Asian
- SEER
- SEER, Surveillance
- TACE, transarterial chemoembolization
- hepatocellular carcinoma
- liver cancer
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Affiliation(s)
- Justin R. Yu
- Department of Medicine, California Pacific Medical Center, San Francisco, CA, USA
| | - Jennifer Wang
- Department of Medicine, California Pacific Medical Center, San Francisco, CA, USA
| | - Taft Bhuket
- Department of Medicine, Division of Gastroenterology and Hepatology, Alameda Health System - Highland Hospital, Oakland, CA, USA
| | - Benny Liu
- Department of Medicine, Division of Gastroenterology and Hepatology, Alameda Health System - Highland Hospital, Oakland, CA, USA
| | - Robert J. Wong
- Department of Medicine, Division of Gastroenterology and Hepatology, Alameda Health System - Highland Hospital, Oakland, CA, USA
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Frenette CT. Increasing Awareness on Racial Disparities in Liver Transplantation for Hepatocellular Carcinoma in the United States. Hepatol Commun 2019; 3:5-7. [PMID: 30619989 PMCID: PMC6312649 DOI: 10.1002/hep4.1299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 11/26/2018] [Indexed: 11/07/2022] Open
Abstract
Hepatocellular carcinoma (HCC) is one of the main indications for liver transplantation in the United States. Studies have shown racial disparities in rates of liver transplant for HCC. The underlying etiologies of these disparities are important to understand in order to overcome barriers to liver transplant in disadvantaged racial and ethnic groups.
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Affiliation(s)
- Catherine T. Frenette
- Department of Organ Transplantation, Scripps Center for Organ TransplantScripps Green HospitalLa JollaCA
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Abstract
BACKGROUND AND AIMS Hepatocellular carcinoma's (HCC) epidemiology and prognosis differs among regions across the globe, largely because of environmental factors and underlying liver disease. Little is known about the changes led by immigration and the effect on HCC outcome. We aimed to understand the effect of immigration on HCC. PATIENTS AND METHODS A retrospective cohort study of patients diagnosed with HCC was carried out in a tertiary center in the USA between 2005 and 2016. We characterized individuals as US born or having immigrated there after being born elsewhere. Variables related to clinical presentation, surveillance, therapy, and survival were evaluated. RESULTS A total of 232 HCC cases were included, 169 US born (73%) and 63 immigrants (27%). Both groups were diagnosed with HCC at similar ages (60 vs. 62 years, P=0.13). Hepatitis C was the most common underlying liver disease in the US-born population compared with the immigrant population (83 vs. 52%, P<0.001), whereas hepatitis B was more common in the latter (4 vs. 29%, P<0.001). Interestingly, hepatitis B virus-related HCC was diagnosed at similar ages in US-born and immigrant individuals (59 and 57 years). At the time of diagnosis, both populations had similar tumor sizes, rates of metastasis, and diagnosis during surveillance. One-year survival was similar in both groups (65 vs. 63%). CONCLUSION Immigrants that develop HCC have different underlying liver disease than those born in the USA, but similar HCC characteristics and outcomes, even when including hepatitis B virus-related HCCs. Our study, albeit small, suggests that changes in the environment by immigration leads to clinical adaptation of HCC.
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Robinson A, Ohri A, Liu B, Bhuket T, Wong RJ. One in five hepatocellular carcinoma patients in the United States are Hispanic while less than 40% were eligible for liver transplantation. World J Hepatol 2018; 10:956-965. [PMID: 30631400 PMCID: PMC6323520 DOI: 10.4254/wjh.v10.i12.956] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 08/09/2018] [Accepted: 08/21/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate trends and disparities in hepatocellular carcinoma (HCC) outcomes among Hispanic patients in the United States with a focus on tumor stage at diagnosis.
METHODS We retrospectively evaluated all Hispanic adults (age > 20) with HCC diagnosed from 2004 to 2014 using United States Surveillance, Epidemiology, and End Results (SEER) cancer registry data. Tumor stage was assessed by SEER-specific staging systems and whether HCC was within Milan criteria at diagnosis. Multivariate logistic regression models evaluated for predictors of HCC within Milan criteria at diagnosis.
RESULTS Overall, Hispanics accounted for 19.8% of all HCC (73.3% men, 60.9% had Medicare or commercial insurance, 33.5% Medicaid, and 5.6% uninsured). Thirty-eight percent of Hispanic HCC patients were within Milan criteria at diagnosis. With latter time periods, significantly more patients were diagnosed with HCC within Milan criteria, and in 2013-2014, 42.6% had HCC within Milan criteria. On multivariate regression, Hispanic males (OR vs females: 0.76, 95%CI: 0.68-0.83, P < 0.001), Hispanics > 65 years (OR vs age < 50: 0.67, 95%CI: 0.58-0.79, P < 0.001), and uninsured patients (OR vs Medicare/commercial: 0.49, 95%CI: 0.40-0.59, P < 0.001) were significantly less likely to have HCC within Milan criteria at diagnosis.
CONCLUSION While one in five HCC patients in the United States are of Hispanic ethnicity, only 38% were within Milan criteria at time of diagnosis, and thus over 60% were ineligible for liver transplantation, one of the primary curative options for HCC patients. Improved efforts at HCC screening and surveillance are needed among this group to improve early detection.
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Affiliation(s)
- Ann Robinson
- Division of Gastroenterology and Hepatology, Alameda Health System, Highland Hospital, Oakland, CA 94620, United States
| | - Ajay Ohri
- Division of Gastroenterology and Hepatology, Alameda Health System, Highland Hospital, Oakland, CA 94620, United States
| | - Benny Liu
- Division of Gastroenterology and Hepatology, Alameda Health System, Highland Hospital, Oakland, CA 94620, United States
| | - Taft Bhuket
- Division of Gastroenterology and Hepatology, Alameda Health System, Highland Hospital, Oakland, CA 94620, United States
| | - Robert J Wong
- Division of Gastroenterology and Hepatology, Alameda Health System, Highland Hospital, Oakland, CA 94620, United States
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Dakhoul L, Gawrieh S, Jones KR, Ghabril M, McShane C, Orman E, Vilar-Gomez E, Chalasani N, Nephew L. Racial Disparities in Liver Transplantation for Hepatocellular Carcinoma Are Not Explained by Differences in Comorbidities, Liver Disease Severity, or Tumor Burden. Hepatol Commun 2018; 3:52-62. [PMID: 30619994 PMCID: PMC6312653 DOI: 10.1002/hep4.1277] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 10/15/2018] [Indexed: 12/11/2022] Open
Abstract
Black patients have higher mortality and are less likely to receive liver transplantation for hepatocellular carcinoma (HCC) than white patients. Reasons for these disparities have not been fully elucidated. Comorbid disease, liver disease severity, cirrhosis etiologies, and tumor characteristics were compared between black and white patients with HCC seen at the Indiana University Academic Medical Center from January 2000 to June 2014. Logistic regression was used to investigate the primary outcome, which was liver transplantation. Log-rank testing was used to compare survival between the two groups. Subgroup analysis explored reasons for failure to undergo liver transplantation in patients within Milan criteria. The cohort included 1,032 (86%) white and 164 (14%) black patients. Black and white patients had similar Model for End-Stage Liver Disease (MELD) and Child-Pugh scores (CPSs). There was a trend toward larger tumor size (5.3 cm versus 4.7 cm; P = 0.05) in black patients; however, Barcelona Clinic Liver Cancer (BCLC) staging and Milan criteria were similar. Black patients were less likely to undergo liver transplantation than white patients; this was a disparity that was not attenuated (odds ratio [OR], 0.43; 95% confidence interval [CI], 0.21-0.90) on multivariable analysis. Substance abuse was more frequently cited as the reason black patients within Milan criteria failed to undergo transplantation compared to white patients. Survival was similar between the two groups. Conclusion: Racial differences in patient and tumor characteristics were small and did not explain the disparity in liver transplantation. Higher rates of substance abuse in black patients within Milan criteria who failed to undergo transplantation suggest social factors contribute to this disparity in this cohort.
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Affiliation(s)
- Lara Dakhoul
- Division of Gastroenterology and Hepatology Indianapolis IN
| | - Samer Gawrieh
- Division of Gastroenterology and Hepatology Indianapolis IN
| | - Keaton R Jones
- Division of Gastroenterology and Hepatology Indianapolis IN
| | - Marwan Ghabril
- Division of Gastroenterology and Hepatology Indianapolis IN
| | - Chelsey McShane
- Department of Internal Medicine Indiana University School of Medicine Indianapolis IN
| | - Eric Orman
- Division of Gastroenterology and Hepatology Indianapolis IN
| | | | - Naga Chalasani
- Division of Gastroenterology and Hepatology Indianapolis IN
| | - Lauren Nephew
- Division of Gastroenterology and Hepatology Indianapolis IN
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Magistri P, Rosenblatt R, Halazun KJ. Liver Transplantation for HCC Beyond Milan. CURRENT TRANSPLANTATION REPORTS 2018. [DOI: 10.1007/s40472-018-0212-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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50
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Robinson A, Tavakoli H, Liu B, Bhuket T, Wong RJ. Advanced Hepatocellular Carcinoma Tumor Stage at Diagnosis in the 1945-1965 Birth Cohort Reflects Poor Use of Hepatocellular Carcinoma Screening. Hepatol Commun 2018; 2:1147-1155. [PMID: 30202827 PMCID: PMC6128228 DOI: 10.1002/hep4.1236] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 06/20/2018] [Indexed: 01/20/2023] Open
Abstract
Individuals from the 1945-1965 birth cohort account for the majority of hepatocellular carcinoma (HCC) cases in the United States. Understanding trends in HCC among this birth cohort is vital given the increasing burden of chronic liver disease among this group. We retrospectively evaluated trends and disparities in HCC tumor stage at the time of diagnosis among the 1945-1965 birth cohort in the United States using the Surveillance, Epidemiology, and End Results (SEER) cancer registry. Tumor stage at the time of HCC diagnosis was assessed using Milan criteria and SEER HCC staging systems. Among 38,045 patients with HCC within the 1945-1965 birth cohort (81.6% male, 50.1% non-Hispanic white, 16.2% African American, 12.6% Asian, 19.8% Hispanic), 66.2% had Medicare or commercial insurance, 27.2% had Medicaid, and 6.6% were uninsured. During the period 2004-2006 to 2013-2014, the number of patients with HCC from the 1945-1965 birth cohort increased by 58.7% (5.9% increase per year). While the proportion of patients with HCC within the Milan criteria increased with time (36.4% in 2003-2006 to 46.3% in 2013-2014; P < 0.01), less than half were within the Milan criteria. On multivariate analysis within the Milan criteria, men were 12% less likely to have HCC compared to women, and African Americans were 27% less likely to have HCC compared to non-Hispanic whites (odds ratio, 0.73; 95% confidence interval, 0.68-0.78; P < 0.01). Conclusion: From 2004 to 2014, the burden of newly diagnosed HCC among the 1945-1965 birth cohort increased by 5.9% per year. While improvements in earlier staged HCC at diagnosis were observed, the majority of patients with HCC among the 1945-1965 birth cohort were beyond the Milan criteria at diagnosis; this may reflect poor utilization or suboptimal performance of HCC screening tests.
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Affiliation(s)
- Ann Robinson
- Department of Medicine, Division of Gastroenterology and HepatologyAlameda Health System – Highland HospitalOaklandCA
| | - Hesam Tavakoli
- Department of Medicine, Division of Gastroenterology and HepatologyAlameda Health System – Highland HospitalOaklandCA
| | - Benny Liu
- Department of Medicine, Division of Gastroenterology and HepatologyAlameda Health System – Highland HospitalOaklandCA
| | - Taft Bhuket
- Department of Medicine, Division of Gastroenterology and HepatologyAlameda Health System – Highland HospitalOaklandCA
| | - Robert J. Wong
- Department of Medicine, Division of Gastroenterology and HepatologyAlameda Health System – Highland HospitalOaklandCA
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