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Laffey M, Ashwat E, Lui H, Zhang X, Kaltenmeier C, Packiaraj G, Crane A, Alshamery S, Gunabushanam V, Ganoza A, Dharmayan S, Powers CA, Jonassaint N, Molinari M. Donor-recipient race-ethnicity concordance and patient survival after liver transplantation. HPB (Oxford) 2024; 26:772-781. [PMID: 38523016 DOI: 10.1016/j.hpb.2024.03.003] [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] [Received: 12/15/2023] [Revised: 02/27/2024] [Accepted: 03/08/2024] [Indexed: 03/26/2024]
Abstract
INTRODUCTION We assessed the association between patient survival after liver transplantation (LT) and donor-recipient race-ethnicity (R/E) concordance. METHODS The Scientific Registry of Transplant Recipients (SRTR) was retrospectively analyzed using data collected between 2002 and 2019. Only adults without history of prior organ transplant and recipients of LT alone were included. The primary outcome was patient survival. Donors and recipients were categorized into five R/E groups: White/Caucasian, African American/Black, Hispanic/Latino, Asian, and Others. Statistical analyses were performed using Kaplan-Meier survival curves and Cox Proportional Hazards models, adjusting for donor and recipient covariates. RESULTS 85,427 patients were included. Among all the R/E groups, Asian patients had the highest 5-year survival (81.3%; 95% CI = 79.9-82.7), while African American/Black patients had the lowest (71.4%; 95% CI = 70.3-72.6) (P < 0.001). Lower survival rates were observed in recipients who received discordant R/E grafts irrespective of their R/E group. The fully adjusted hazard ratio for death was statistically significant in African American/Black (aHR 1.07-1.18-1.31; P < 0.01) and in White∕Caucasian patients (aHR 1.00-1.04-1.07; P = 0.03) in the presence of donor-recipient R/E discordance. CONCLUSION Disparities in post-LT outcomes might be influenced by biological factors in addition to well-known social determinants of health.
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Affiliation(s)
- Makenna Laffey
- University of Pittsburgh Medical Center, Department of Surgery, Pittsburgh, PA, United States
| | - Eishan Ashwat
- University of Pittsburgh Medical Center, Department of Surgery, Pittsburgh, PA, United States
| | - Hao Lui
- University of Pittsburgh Medical Center, Department of Surgery, Pittsburgh, PA, United States
| | - Xingyu Zhang
- University of Pittsburgh, School of Health, and Rehabilitation Sciences, Pittsburgh, PA, United States
| | - Christof Kaltenmeier
- University of Pittsburgh Medical Center, Department of Surgery, Pittsburgh, PA, United States
| | - Godwin Packiaraj
- University of Pittsburgh Medical Center, Department of Surgery, Pittsburgh, PA, United States
| | - Andrew Crane
- University of Pittsburgh Medical Center, Department of Surgery, Pittsburgh, PA, United States
| | - Sarmad Alshamery
- University of Pittsburgh Medical Center, Department of Surgery, Pittsburgh, PA, United States
| | - Vikraman Gunabushanam
- University of Pittsburgh Medical Center, Department of Surgery, Pittsburgh, PA, United States
| | - Armando Ganoza
- University of Pittsburgh Medical Center, Department of Surgery, Pittsburgh, PA, United States
| | - Stalin Dharmayan
- University of Pittsburgh Medical Center, Department of Surgery, Pittsburgh, PA, United States
| | - Colin A Powers
- University of Pittsburgh Medical Center, Department of Surgery, Pittsburgh, PA, United States
| | - Naudia Jonassaint
- University of Pittsburgh Medical Center, Department of Medicine, Pittsburgh, PA, United States
| | - Michele Molinari
- University of Pittsburgh Medical Center, Department of Surgery, Pittsburgh, PA, United States.
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Ross-Driscoll K, Ayuk-Arrey AT, Lynch R, McCullough LE, Roccaro G, Nephew L, Hundley J, Rubin RA, Patzer R. Disparities in Access to Liver Transplant Referral and Evaluation among Patients with Hepatocellular Carcinoma in Georgia. CANCER RESEARCH COMMUNICATIONS 2024; 4:1111-1119. [PMID: 38517133 PMCID: PMC11034460 DOI: 10.1158/2767-9764.crc-23-0541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 02/16/2024] [Accepted: 03/15/2024] [Indexed: 03/23/2024]
Abstract
Liver transplantation offers the best survival for patients with early-stage hepatocellular carcinoma (HCC). Prior studies have demonstrated disparities in transplant access; none have examined the early steps of the transplant process. We identified determinants of access to transplant referral and evaluation among patients with HCC with a single tumor either within Milan or meeting downstaging criteria in Georgia.Population-based cancer registry data from 2010 to 2019 were linked to liver transplant centers in Georgia. Primary cohort: adult patients with HCC with a single tumor ≤8 cm in diameter, no extrahepatic involvement, and no vascular involvement. Secondary cohort: primary cohort plus patients with multiple tumors confined to one lobe. We estimated time to transplant referral, evaluation initiation, and evaluation completion, accounting for the competing risk of death. In sensitivity analyses, we also accounted for non-transplant cancer treatment.Among 1,379 patients with early-stage HCC in Georgia, 26% were referred to liver transplant. Private insurance and younger age were associated with increased likelihood of referral, while requiring downstaging was associated with lower likelihood of referral. Patients living in census tracts with ≥20% of residents in poverty were less likely to initiate evaluation among those referred [cause-specific hazard ratio (csHR): 0.62, 95% confidence interval (CI): 0.42-0.94]. Medicaid patients were less likely to complete the evaluation once initiated (csHR: 0.53, 95% CI: 0.32-0.89).Different sociodemographic factors were associated with each stage of the transplant process among patients with early-stage HCC in Georgia, emphasizing unique barriers to access and the need for targeted interventions at each step. SIGNIFICANCE Among patients with early-stage HCC in Georgia, age and insurance type were associated with referral to liver transplant, race, and poverty with evaluation initiation, and insurance type with evaluation completion. Opportunities to improve transplant access include informing referring providers about insurance requirements, addressing barriers to evaluation initiation, and streamlining the evaluation process.
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Affiliation(s)
- Katherine Ross-Driscoll
- Division of Transplantation, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
- Center for Health Services Research, Regenstrief Institute, Indianapolis, Indiana
- Department of Epidemiology, Rollins School of Public Health, Atlanta, Georgia
| | | | - Raymond Lynch
- Division of Transplantation, Department of Surgery, Pennsylvania State University School of Medicine, Hershey, Pennsylvania
| | - Lauren E. McCullough
- Department of Epidemiology, Rollins School of Public Health, Atlanta, Georgia
- Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Giorgio Roccaro
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Lauren Nephew
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University, Indianapolis, Indiana
| | - Jonathan Hundley
- Piedmont Transplant Institute, Piedmont Healthcare, Atlanta, Georgia
| | - Raymond A. Rubin
- Piedmont Transplant Institute, Piedmont Healthcare, Atlanta, Georgia
| | - Rachel Patzer
- Division of Transplantation, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
- Regenstrief Institute, Indianapolis, Indiana
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Shaltiel T, Sarpel U, Branch AD. The adverse characteristics of hepatocellular carcinoma in the non-cirrhotic liver disproportionately disadvantage Black patients. Cancer Med 2024; 13:e6654. [PMID: 38230878 PMCID: PMC10905547 DOI: 10.1002/cam4.6654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 08/24/2023] [Accepted: 10/12/2023] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND Black patients have higher hepatocellular carcinoma (HCC)-related mortality than White patients and more often develop HCC in non-cirrhotic liver. HCC surveillance is primarily directed toward cirrhotic patients. We aimed to characterize HCC in non-cirrhotic patients and to identify factors associated with HCC beyond Milan criteria. METHODS Demographic, imaging, laboratory, and pathology data of HCC patients at our institution, 2003-2018, were reviewed, retrospectively. Race/ethnicity were self-reported. Cirrhosis was defined as a Fibrosis-4 score ≥3.25. RESULTS Compared to 1146 cirrhotic patients, 411 non-cirrhotic patients had larger tumors (median 4.7 cm vs. 3.1 cm, p < 0.01) and were less likely to be within Milan criteria (42.6% vs. 57.7%, p < 0.01). Among non-cirrhotic patients, Black patients had larger tumors (4.9 cm vs. 4.3 cm, p < 0.01) and a higher percentage of poorly differentiated tumors (39.4% vs. 23.1%, p = 0.02). Among cirrhotic patients, Black patients had larger tumors (3.3 cm vs. 3.0 cm, p = 0.03) and were less likely to be within Milan criteria (52.3% vs. 83.2%, p < 0.01). In multivariable analysis, lack of commercial insurance (OR 1.45 [CI 95% 1.19-1.83], p < 0.01), male sex (OR 1.34 [CI 95% 1.05-1.70], p < 0.01), absence of cirrhosis (OR 1.58 [CI 95% 1.27-1.98], p < 0.01) and Black race/ethnicity (OR 1.34 [CI 95% 1.09-1.66], p = 0.01) were associated with HCC beyond Milan criteria. Black patients had lower survival rates than other patients (p < 0.01). CONCLUSIONS Non-cirrhotic patients had more advanced HCC than cirrhotic patients. Black patients (with or without cirrhosis) had more advanced HCC than comparable non-Black patients and higher mortality rates. Improved access to healthcare (commercial insurance) may increase early diagnosis (within Milan criteria) and reduce disparities.
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Affiliation(s)
- Tali Shaltiel
- Division of Surgical Oncology, Department of SurgeryIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Umut Sarpel
- Division of Surgical Oncology, Department of SurgeryIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Andrea D. Branch
- Division of Liver Diseases, Department of MedicineIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
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Reghupaty SC, Kanwal S, Mendoza RG, Davis E, Li H, Lai Z, Dozmorov MG, Faison MO, Siddiqui RA, Sarkar D. Dysregulation of Type I Interferon (IFN-I) Signaling: A Potential Contributor to Racial Disparity in Hepatocellular Carcinoma (HCC). Cancers (Basel) 2023; 15:4283. [PMID: 37686559 PMCID: PMC10486472 DOI: 10.3390/cancers15174283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 08/23/2023] [Accepted: 08/25/2023] [Indexed: 09/10/2023] Open
Abstract
African-American (AA)/Black hepatocellular carcinoma (HCC) patients have increased incidence and decreased survival rates compared to non-Hispanic (White) patients, the underlying molecular mechanism of which is not clear. Analysis of existing RNA-sequencing (RNA-seq) data in The Cancer Genome Atlas (TCGA) and in-house RNA-sequencing of 14 White and 18 AA/Black HCC patients revealed statistically significant activation of type I interferon (IFN-I) signaling pathway in AA/Black patients. A four-gene signature of IFN-stimulated genes (ISGs) showed increased expression in AA/Black HCC tumors versus White. HCC is a disease of chronic inflammation, and IFN-Is function as pro-inflammatory cytokines. We tested efficacy of ginger extract (GE), a dietary compound known for anti-inflammatory properties, on HCC cell lines derived from White (HepG2), AA/Black (Hep3B and O/20) and Asian (HuH-7) patients. GE exhibited a significantly lower IC50 on Hep3B and O/20 cells than on HepG2 and HuH-7 cells. The GE treatment inhibited the activation of downstream mediators of IFN-I signaling pathways and expression of ISGs in all four HCC cells. Our data suggest that ginger can potentially attenuate IFN-I-mediated signaling pathways in HCC, and cells from AA/Black HCC patients may be more sensitive to ginger. AA/Black HCC patients might benefit from a holistic diet containing ginger.
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Affiliation(s)
| | - Sadia Kanwal
- Food and Nutrition Science Laboratory, College of Agriculture, Virginia State University, Petersburg, VA 23806, USA; (S.K.); (H.L.)
| | - Rachel G. Mendoza
- Department of Human and Molecular Genetics, Virginia Commonwealth University, Richmond, VA 23298, USA;
| | - Eva Davis
- Department of Microbiology and Immunology, Virginia Commonwealth University, Richmond, VA 23298, USA;
| | - Haiwen Li
- Food and Nutrition Science Laboratory, College of Agriculture, Virginia State University, Petersburg, VA 23806, USA; (S.K.); (H.L.)
| | - Zhao Lai
- Greehey Children’s Cancer Research Institute, University of Texas Health Science Center San Antonio, San Antonio, TX 78229, USA;
| | - Mikhail G. Dozmorov
- Department of Biostatistics and Pathology, Virginia Commonwealth University, Richmond, VA 23298, USA;
| | - Milton Omar Faison
- Department of Biology, Virginia State University, Petersburg, VA 23806, USA;
| | - Rafat Ali Siddiqui
- Food and Nutrition Science Laboratory, College of Agriculture, Virginia State University, Petersburg, VA 23806, USA; (S.K.); (H.L.)
| | - Devanand Sarkar
- Department of Human and Molecular Genetics, Massey Cancer Center, VCU Institute of Molecular Medicine (VIMM), Virginia Commonwealth University, Richmond, VA 23298, USA
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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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Ray EM, Teal RW, Carda-Auten J, Coffman E, Sanoff HK. Qualitative evaluation of barriers and facilitators to hepatocellular carcinoma care in North Carolina. PLoS One 2023; 18:e0287338. [PMID: 37347754 PMCID: PMC10287003 DOI: 10.1371/journal.pone.0287338] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 06/02/2023] [Indexed: 06/24/2023] Open
Abstract
BACKGROUND Many patients with hepatocellular carcinoma (HCC) never receive cancer-directed therapy. In order to tailor interventions to increase access to appropriate therapy, we sought to understand the barriers and facilitators to HCC care. METHODS Patients with recently diagnosed HCC were identified through the University of North Carolina (UNC) HCC clinic or local hospital cancer registrars (rapid case ascertainment, RCA). Two qualitative researchers conducted in-depth, semi-structured interviews. Interviews were audiotaped, transcribed, and coded. RESULTS Nineteen interviews were conducted (10 UNC, 9 RCA). Key facilitators of care were: physician knowledge; effective communication regarding test results, plan of care, and prognosis; social support; and financial support. Barriers included: lack of transportation; cost of care; provider lack of knowledge about HCC; delays in scheduling; or poor communication with the medical team. Participants suggested better coordination of appointments and having a primary contact within the healthcare team. LIMITATIONS We primarily captured the perspectives of those HCC patients who, despite the challenges they describe, were ultimately able to receive HCC care. CONCLUSIONS This study identifies key facilitators and barriers to accessing care for HCC in North Carolina. Use of the RCA system to identify patients from a variety of settings, treated and untreated, enabled us to capture a broad range of perspectives. Reducing barriers through improving communication and care coordination, assisting with out-of-pocket costs, and engaging caregivers and other medical providers may improve access. This study should serve as the basis for tailored interventions aimed at improving access to appropriate, life-prolonging care for patients with HCC.
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Affiliation(s)
- Emily M Ray
- Department of Medicine, Division of Oncology, University of North Carolina, Chapel Hill, North Carolina, United States of America
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Randall W Teal
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, United States of America
- Connected Health Applications and Interventions Core, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Jessica Carda-Auten
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, United States of America
- Connected Health Applications and Interventions Core, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Erin Coffman
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Hanna K Sanoff
- Department of Medicine, Division of Oncology, University of North Carolina, Chapel Hill, North Carolina, United States of America
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, United States of America
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Bodek DD, Everwine MM, Lunsford KE, Okoronkwo N, Patel PA, Pyrsopoulos N. Racial Disparities in Liver Transplantation for Hepatocellular Carcinoma: Analysis of the National Inpatient Sample From 2007 to 2014. J Clin Gastroenterol 2023; 57:311-316. [PMID: 35180149 DOI: 10.1097/mcg.0000000000001675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 01/05/2022] [Indexed: 12/10/2022]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) remains a deadly disease, with patients' best hope for a cure being liver transplantation; however, access to health care resources, such as donor organs, between ethnic groups has historically been unbalanced. Ensuring equitable access to donor livers is crucial to minimize disparities in HCC outcomes. As a result, we sought to better elucidate the differences in transplantation rates among various ethnic groups. MATERIALS AND METHODS The National Inpatient Sample (NIS) was utilized to evaluate for disparities in liver transplantation in patients whose primary or secondary diagnosis was recorded as HCC or hepatoma. The study included admissions between 2007 and 2014 to centers with at least 1 documented liver transplant. RESULTS A total of 7244 transplants were performed over 70,406 weighted admissions. Black race was associated with lower transplantation rates, with an adjusted odds ratio of 0.46 (95% confidence interval: 0.42-0.51, P <0.01) when accounting for a number of possible confounders including socioeconomic and geographic factors. CONCLUSIONS Our study observed decreased rates of liver transplant in blacks compared with whites for HCC. Furthermore, improved economic status and private insurance had a significantly higher odds ratio for transplantation. Hospital-level studies are needed to clarify confounding factors not apparent in large administrative datasets and help better investigate factors that lead to less optimal transplant rates among blacks. Interventions may include more optimal screening policies and procedures, improved interdisciplinary management, and earlier referrals.
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Affiliation(s)
| | | | - Keri E Lunsford
- Division of Liver Transplant and HPB Surgery, Department of Surgery and Center for Immunity and Inflammation
| | - Nneoma Okoronkwo
- Department of Gastroenterology, Rutgers New Jersey Medical School, Newark, NJ
| | - Pavan A Patel
- Department of Gastroenterology, Rutgers New Jersey Medical School, Newark, NJ
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Mansour MM, Fard D, Basida SD, Obeidat AE, Darweesh M, Mahfouz R, Ahmad A. Disparities in Social Determinants of Health Among Patients Receiving Liver Transplant: Analysis of the National Inpatient Sample From 2016 to 2019. Cureus 2022; 14:e26567. [PMID: 35936191 PMCID: PMC9350951 DOI: 10.7759/cureus.26567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2022] [Indexed: 11/05/2022] Open
Abstract
Background Liver transplantation is the life-saving standard of care for those with end-stage liver disease. Unfortunately, many patients on the liver transplant list die waiting. Several studies have demonstrated significant differences based on disparities in race, gender, and multiple socioeconomic factors. We sought to evaluate recent disparities among patients receiving liver transplants using the latest available data from the National Inpatient Sample (NIS), the largest publicly available inpatient care database in the United States. Methods We performed an analysis of discharge data from the NIS between 2016 and 2019. We identified adult patients with chronic liver disease who underwent a liver transplant using the International Classification of Diseases, 10th revision (ICD-10) codes. Multivariate logistic regression was used to adjust for differences in race, gender, socioeconomic status, and comorbidities among those who received a liver transplant. Results A total of 24,595 liver transplants were performed over the study period. Female gender was independently associated with decreased transplant rates (adjusted odds ratio (AOR) 0.83, 95% confidence interval (CI), 0.78-0.89, P < 0.001). Compared to White patients, Black patients had decreased transplant rates (AOR 0.86, 95% CI, 0.75-0.99, P = 0.034), as did Native Americans (AOR 0.64; 95% CI, 0.42-0.97, P = 0.035). Hispanics and Asian Americans had increased rates of liver transplantation (AOR 1.16, 95% CI 1.02-1.32, P = 0.022, and 1.36, 95% CI 1.11-1.67, P = 0.003; respectively). The increase in income quartile was associated with an incremental increase in transplant rates. Additionally, patients with private insurance had much higher transplant rates compared to those with Medicare (AOR 2.50, 95% CI 2.31-2.70, P < 0.001) while patients without insurance had the lowest rates of transplantation (AOR 0.18, 95% CI 0.12-0.28, P < 0.001). Conclusions Our analysis demonstrates that race, gender, and other social determinants of health have significant impacts on the likelihood of receiving a liver transplant. Our study, on a national level, confirms previously described disparities in receiving liver transplantation. Patient-level studies are needed to better understand how these variables translate into differing liver transplantation rates.
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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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Huang DQ, Hoang JK, Leong J, Riveiro-Barciela M, Maeda M, Yang JD, Accarino EV, Thin K, Trinh L, Cheung RC, Roberts LR, Buti M, Schwartz M, Nguyen MH. Differential characteristics and outcomes of Asian and non-Asian patients with HBV-related hepatocellular carcinoma. Liver Int 2021; 41:1922-1932. [PMID: 33713386 DOI: 10.1111/liv.14877] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 02/16/2021] [Accepted: 03/07/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND & AIMS The epidemiology of hepatitis B virus (HBV) infection differs between Asians and non-Asians, but little is known regarding the effect of ethnicity on outcomes of HBV-related hepatocellular carcinoma (HCC). We aim to characterize the presentation and survival outcomes in Asian and non-Asian patients with HBV-related HCC. METHODS We analyzed the baseline characteristics and long-term survival of 613 Asian and 410 non-Asian patients with HBV-related HCC from three US and one Spanish centre. RESULTS Overall, non-Asian patients were more likely to have HIV or hepatitis C co-infection, cirrhosis, decompensated liver disease and advanced BCLC stage (all P ≤ .04). Compared with Asians, non-Asians were more likely to be listed for transplantation (P < .0001) and undergo HCC treatment with curative intent (P = .003). Propensity-score matching on HCC diagnosis year, gender and age was performed to balance the two groups for survival analysis and yielded 370 pairs of patients. There was no significant difference in survival overall (P = .43) and among patients with cirrhosis (P = .57). Among patients without cirrhosis, non-Asians had poorer 5-year survival compared with Asians (37.6% vs 53.7%, P = .01), and was associated with poorer survival after adjusting for age, gender, diabetes, alcohol, co-infections, diagnosis date, antiviral therapy, BCLC stage and HCC treatment (adjusted HR 2.01 [95% CI 1.07-3.74], P = .03). CONCLUSION Among HBV-related HCC patients, non-Asians presented with more advanced BCLC stage compared to Asians. Non-Asian ethnicity was independently associated with twice the risk of mortality among patients without cirrhosis, but not among those with cirrhosis. Additional studies are needed to clarify this disparity.
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Affiliation(s)
- Daniel Q Huang
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Division of Gastroenterology and Hepatology, National University Health System, Singapore
| | - Joseph K Hoang
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, CA, USA
| | - Jennifer Leong
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mar Riveiro-Barciela
- Liver Unit, Internal Medicine Department, Hospital Universitari Valle d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain.,CIBERehd, Instituto Carlos III, Madrid, Spain
| | - Mayumi Maeda
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, CA, USA
| | - Ju Dong Yang
- Division of Digestive and Liver Diseases, Department of Medicine, Cedars Sinai Medical Center, Los Angeles, USA
| | - Elena Vargas Accarino
- Liver Unit, Internal Medicine Department, Hospital Universitari Valle d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain.,CIBERehd, Instituto Carlos III, Madrid, Spain
| | - Khin Thin
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, CA, USA
| | - Lindsey Trinh
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, CA, USA
| | - Ramsey C Cheung
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, CA, USA
| | - Lewis R Roberts
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Maria Buti
- Liver Unit, Internal Medicine Department, Hospital Universitari Valle d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain.,CIBERehd, Instituto Carlos III, Madrid, Spain
| | - Myron Schwartz
- Recanati-Miller Transplantation Institute, Mount Sinai School of Medicine, New York, NY, USA
| | - Mindie H Nguyen
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, CA, USA.,Department of Epidemiology and Population Health, Stanford University, Palo Alto, CA, USA
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11
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Hung YC, Chen YW, Rickert CG, Hsu YT, Yeh H, Chang DC. Practitioner availability rather than surgical quality impacts the utilization of liver transplantation for hepatocellular carcinoma. HPB (Oxford) 2021; 23:861-867. [PMID: 33579641 DOI: 10.1016/j.hpb.2020.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 12/05/2020] [Accepted: 12/27/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Liver transplantation (LT) provides better outcome than surgical resection (SR) although both are acceptable surgical options for hepatocellular carcinoma (HCC). It is unclear whether non-clinical factors drive treatment decisions. Our goal is to identify factors that may affect treatment decisions. METHODS Patients aged 18-74 with T2 HCC undergoing either LT or SR in Surveillance, Epidemiology, and End Results Database from 2004 to 2014 were included. Healthcare resources data were analyzed to assess factors that predict utilization of LT versus SR, adjusted for demographic, clinical outcomes, and socioeconomic factors. RESULTS 51% of patients (Total N = 2616) received LT, with a substantial state-level variation in LT rates (0.0%-66.9%). Higher LT center density [OR = 1.04 per 1% increment, P < 0.01], male gender (OR = 1.38, P = 0.02), and numbers of potential donors (OR = 1.19, P = 0.03) were positively associated with LT utilization. Conversely, higher incidence of chronic liver disease/cirrhosis (OR = 0.41 per one additional case per 100,000 populations, P = 0.001) and minority populations were negatively correlated with LT utilization. Notably, short-term surgical outcomes (in-hospital LT & SR mortality) were not associated with LT utilization. CONCLUSION Liver transplant center density and organ availability, but not surgical outcomes, affect utilization of LT. Future studies should focus on increasing availability of resources.
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Affiliation(s)
- Ya-Ching Hung
- Sinai Hospital of Baltimore, Baltimore, MD, USA; Department of Surgery, Massachusetts General Hospital/Harvard Medical, Boston, MA, USA.
| | - Ya-Wen Chen
- Department of Surgery, Massachusetts General Hospital/Harvard Medical, Boston, MA, USA
| | - Charles G Rickert
- Department of Surgery, Massachusetts General Hospital/Harvard Medical, Boston, MA, USA
| | - Yu-Tien Hsu
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, USA
| | - Heidi Yeh
- Department of Surgery, Massachusetts General Hospital/Harvard Medical, Boston, MA, USA
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital/Harvard Medical, Boston, MA, USA
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12
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Moon AM, Sanoff HK, Chang Y, Lund JL, Barritt AS, Hayashi PH, Stitzenberg KB. Medicare/Medicaid Insurance, Rurality, and Black Race Associated With Provision of Hepatocellular Carcinoma Treatment and Survival. J Natl Compr Canc Netw 2021; 19:285-293. [PMID: 33578376 PMCID: PMC9899074 DOI: 10.6004/jnccn.2020.7616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 07/01/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Early treatment of hepatocellular carcinoma (HCC) is associated with improved survival, but many patients with HCC do not receive therapy. We aimed to examine factors associated with HCC treatment and survival among incident patients with HCC in a statewide cancer registry. MATERIALS AND METHODS All patients with HCC from 2003 through 2013 were identified in the North Carolina cancer registry. These patients were linked to insurance claims from Medicare, Medicaid, and large private insurers in North Carolina. Associations between prespecified covariates and more advanced HCC stage at diagnosis (ie, multifocal cancer), care at a liver transplant center, and provision of HCC treatment were examined using multivariate logistic regression. A Cox proportional hazards model was developed to assess the association between these factors and survival. RESULTS Of 1,809 patients with HCC, 53% were seen at a transplant center <90 days from diagnosis, with lower odds among those who were Black (adjusted odds ratio [aOR], 0.54; 95% CI, 0.39-0.74), had Medicare insurance (aOR, 0.35; 95% CI, 0.21-0.59), had Medicaid insurance (aOR, 0.46; 95% CI, 0.28-0.77), and lived in a rural area; odds of transplant center visits were higher among those who had prediagnosis alpha fetoprotein screening (aOR, 1.74; 95% CI, 1.35-2.23) and PCP and gastroenterology care (aOR, 1.66; 95% CI, 1.27-2.18). Treatment was more likely among patients who had prediagnosis gastroenterology care (aOR, 1.68; 95% CI, 0.98-2.86) and transplant center visits (aOR, 2.42; 95% CI, 1.74-3.36). Survival was strongly associated with age, cancer stage, cirrhosis complications, and receipt of HCC treatment. Individuals with Medicare (adjusted hazard ratio [aHR], 1.58; 95% CI, 1.20-2.09) and Medicaid insurance (aHR, 1.55; 95% CI, 1.17-2.05) had shorter survival than those with private insurance. CONCLUSIONS In this population-based cohort of patients with HCC, Medicare/Medicaid insurance, rural residence, and Black race were associated with lower provision of HCC treatment and poorer survival. Efforts should be made to improve access to care for these vulnerable populations.
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Affiliation(s)
- Andrew M. Moon
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill NC
| | - Hanna K. Sanoff
- Division of Hematology/Oncology, Department of Medicine, University of North Carolina, Chapel Hill NC,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill NC
| | - YunKyung Chang
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill NC
| | - Jennifer L. Lund
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill NC,,Center for Pharmacoepidemiology, Department of Epidemiology, University of North Carolina, Chapel Hill NC
| | - A. Sidney Barritt
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill NC
| | - Paul H. Hayashi
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill NC
| | - Karyn B. Stitzenberg
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill NC,,Division of Surgical Oncology, Department of Surgery, University of North Carolina, Chapel Hill NC
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13
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Scaglione S, Adams W, Caines A, Devlin P, Mittal S, Singal AG, Parikh ND. Association Between Race/Ethnicity and Insurance Status with Outcomes in Patients with Hepatocellular Carcinoma. Dig Dis Sci 2020; 65:1669-1678. [PMID: 31643036 PMCID: PMC7603399 DOI: 10.1007/s10620-019-05890-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 10/03/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Racial/ethnic disparities in prognosis have been reported in patients with hepatocellular carcinoma (HCC); however, few studies have evaluated racial/ethnic disparities in the context of insurance status. AIMS Characterize racial/ethnic and insurance status in early tumor detection, receipt of curative therapy and overall survival in a multicenter diverse cohort of HCC patients from the USA. STUDY We included patients with HCC diagnosed between June 2012 and May 2013 at four centers in the USA. Generalized linear mixed effects models were used to compare early tumor detection (defined using Milan Criteria) and curative treatment receipt (liver transplantation, surgical resection, or local ablation) as a function of patient race/ethnicity and insurance status. A multivariable frailty survival model was used to compare risk of death between patient groups. RESULTS Of 379 HCC patients (52.8% non-Hispanic White, 19.5% Hispanic White, 19.8% Black), 46.4% and 48.0% were found at an early stage and underwent curative therapy, respectively, and median overall survival of the cohort was 25.7 months. Early detection of HCC was associated with gastroenterology subspecialty care and receipt of HCC surveillance but not race/ethnicity or insurance status in adjusted models. However, commercial insurance was significantly associated with higher odds of curative treatment receipt, which in turn was the strongest correlate for overall survival. After adjusting for health system and insurance status, race/ethnicity was not associated with curative treatment receipt or overall survival. CONCLUSIONS Insurance status and access to gastroenterology subspecialty care may be important drivers of racial/ethnic disparities in prognosis among HCC patients.
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Affiliation(s)
- Steve Scaglione
- Department of Internal Medicine, Loyola University Medical Center, 2160 S, 1st Avenue, Maywood, IL, 60153, USA.
| | - William Adams
- Department of Public Health Sciences, Loyola University Medical Center, Maywood, IL, USA
| | - Allyce Caines
- Department of Internal Medicine, Loyola University Medical Center, 2160 S, 1st Avenue, Maywood, IL, 60153, USA
| | - Pauline Devlin
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Sahil Mittal
- Department of Internal Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Amit G Singal
- Department of Internal Medicine, UT Southwestern Medical Center and Parkland Health and Hospital System, Dallas, TX, USA
- Harold C. Simmons Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA
| | - Neehar D Parikh
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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14
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A Comprehensive Analysis of Liver Transplantation Outcomes Among Ethnic Minorities in the United States. J Clin Gastroenterol 2020; 54:263-270. [PMID: 31169758 DOI: 10.1097/mcg.0000000000001236] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
GOALS The aim of this study was to perform a comprehensive assessment of liver transplant (LT) outcomes among US adults with a specific focus on understanding race/ethnicity-specific disparities. BACKGROUND Despite improvements in the liver allocation and LT-related care, disparities in LT outcomes persist. STUDY Using data from the 2005 to 2016 United Networks for Organ Sharing LT registry, we evaluated waitlist survival, probability of receiving LT, and post-LT survival among US adults stratified by race/ethnicity and liver disease etiology. Kaplan-Meier methods evaluated unadjusted waitlist and post-LT outcomes, and multivariate regression models evaluated adjusted waitlist and post-LT outcomes. RESULTS Among 88,542 listed for LT patients (41.3% hepatitis C virus, 25.3% alcoholic liver disease, 22.3% nonalcoholic steatohepatitis, 11.1% hepatitis C virus/alcoholic liver disease), significant race/ethnicity-specific disparities were observed. Compared with non-Hispanic whites, Hispanics had a significantly lower risk of waitlist death [hazard ratio (HR)=0.84, 95% confidence interval (CI): 0.79-0.90, P<0.001]. Compared with non-Hispanic whites, significantly lower likelihood of receiving LT was observed in African Americans (HR=0.94, 95% CI: 0.91-0.98, P<0.001), Hispanics (HR=0.70, 95% CI: 0.68-0.73, P<0.001) and Asians (HR=0.74, 95% CI: 0.69-0.80, P<0.001). Compared with non-Hispanic whites, African Americans had a significantly higher risk of 5-year post-LT death (HR=1.31, 95% CI: 1.23-1.39, P<0.001). CONCLUSION Among US adults awaiting LT, significant race/ethnicity-specific disparities in LT outcomes were observed. Despite evaluating an era after implementation of the Model for End-Stage Liver Disease, ethnic minorities continue to demonstrate a lower probability of receiving LT, and significantly higher risk of death post-LT in African Americans.
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15
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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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16
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Duininck G, Lopez-Aguiar AG, Lee RM, Miller L, Dariushnia S, Wu C, Alese OB, Lin JY, Wedd J, Adams A, Maithel SK, Russell MC. Optimizing cancer care for hepatocellular carcinoma at a safety-net hospital: The value of a multidisciplinary disease management team. J Surg Oncol 2019; 120:1365-1370. [PMID: 31642056 DOI: 10.1002/jso.25738] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 10/08/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hepatitis C (HCV) is the primary etiology of hepatocellular carcinoma (HCC) in the US multidisciplinary disease management teams (DMT) that optimize oncologic care. The impact of DMT for HCC in safety-net hospitals is unknown. METHODS Patients diagnosed with HCC from 2009 to 2016 at Grady Memorial Hospital (GMH) were included. The primary aim was to evaluate referrals to care, receipt of therapy, and overall survival (OS) after DMT formation. Screening patterns of HCV patients for HCC were also examined. RESULTS Of 204 HCC patients, median age was 58 years, with 81% male, 83% black. 46% presented with stage 4 disease, 53% had treatment with median OS 9.8 months. DMT formation was associated with increased referrals to surgery (49% vs 30%; P = .02), liver-directed therapy (58% vs 31%; P = .001), and radiation (13% vs 3%; P = .019). Patients were also more likely to get treatment (59% vs 41%; P = .026), with improved median OS (30.7 vs 4.9 months; P < .001). DMT did not alter HCV screening for HCC (23%). HCV patients screened for HCC had earlier stage disease (P = .001). CONCLUSION Implementation of a DMT at GMH is associated with increased HCC patients referred for/receiving treatment, as well as improved survival. Few patients with HCV at risk for HCC are screened, despite DMT. Future efforts should aim to establish screening programs for HCV patients at risk for HCC.
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Affiliation(s)
- Grace Duininck
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Alexandra G Lopez-Aguiar
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Rachel M Lee
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Lesley Miller
- Department of Internal Medicine, Division of General Medicine and Geriatrics, Emory University, Atlanta, Georgia
| | - Sean Dariushnia
- Department of Radiology and Imaging Sciences, Division of Interventional Radiology and Image-Guided Medicine, Emory University, Atlanta, Georgia
| | - Christina Wu
- Department of Hematology and Oncology, Emory University, Atlanta, Georgia
| | - Olatunji B Alese
- Department of Hematology and Oncology, Emory University, Atlanta, Georgia
| | - Jolinta Y Lin
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
| | - Joel Wedd
- Department of Internal Medicine, Division of Digestive Diseases, Transplant Hepatology, Emory University, Atlanta, Georgia
| | - Andrew Adams
- Department of Surgery, Division of Transplantation, Emory University, Atlanta, Georgia
| | - Shishir K Maithel
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Maria C Russell
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
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17
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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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18
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Effect of Donor Race-Matching on Overall Survival for African-American Patients Undergoing Liver Transplantation for Hepatocellular Carcinoma. J Am Coll Surg 2019; 228:245-254. [DOI: 10.1016/j.jamcollsurg.2018.11.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 11/29/2018] [Accepted: 11/30/2018] [Indexed: 12/11/2022]
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19
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Rich NE, Hester C, Odewole M, Murphy CC, Parikh ND, Marrero JA, Yopp AC, Singal AG. Racial and Ethnic Differences in Presentation and Outcomes of Hepatocellular Carcinoma. Clin Gastroenterol Hepatol 2019; 17:551-559.e1. [PMID: 29859983 PMCID: PMC6274621 DOI: 10.1016/j.cgh.2018.05.039] [Citation(s) in RCA: 139] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Revised: 04/26/2018] [Accepted: 05/24/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Racial and ethnic minorities are reported to have higher mortality related to hepatocellular carcinoma (HCC) than non-Hispanic whites. However, it is not clear whether differences in tumor characteristics or liver dysfunction among racial or ethnic groups affect characterization of causes for this disparity. We aimed to characterize racial and ethnic differences in HCC presentation, treatment, and survival. METHODS We performed a retrospective study of patients diagnosed with HCC from January 2008 through July 2017 at 2 large health systems in the United States. We used multivariable logistic regression and Cox proportional hazard models to identify factors associated with receipt of curative therapy and overall survival. RESULTS Among 1117 patients with HCC (35.9% white, 34.3% black, 29.7% Hispanic), 463 (41.5%) were diagnosed with early stage HCC (Barcelona Clinic Liver Cancer stage 0/A) and 322 (28.8%) underwent curative treatment. Hispanic (odds ratio [OR], 0.75; 95% CI, 0.55-1.00) and black patients (OR, 0.74; 95% CI, 0.56-0.98) were less likely to be diagnosed with early stage HCC than white patients. Among patients with early stage HCC, Hispanics were less likely to undergo curative treatment than whites (OR, 0.58; 95% CI, 0.36-0.91). Black patients with early stage HCC were also less likely to undergo curative treatment than white patients, but this difference was not statistically significant (OR, 0.66; 95% CI, 0.43-1.03). Black and Hispanic patients had shorter median survival times than white patients (10.6 and 14.4 mo vs 16.3 mo). After adjusting for type of medical insurance, Child-Pugh class, Barcelona Clinic Liver Cancer stage, and receipt of HCC treatment, black patients had significantly higher mortality (hazard ratio, 1.12; 95% CI, 1.10-1.14) and Hispanic patients had lower mortality (hazard ratio, 0.83; 95% CI, 0.74-0.94) than white patients. CONCLUSIONS In a retrospective study of patients diagnosed with HCC, we found racial/ethnic differences in outcomes of HCC to be associated with differences in detection of tumors at early stages and receipt of curative treatment. These factors are intervention targets for improving patient outcomes and reducing disparities.
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Affiliation(s)
- Nicole E. Rich
- Department of Internal Medicine, UT Southwestern Medical Center and Parkland Health and Hospital System, Dallas, TX
| | - Caitlin Hester
- Department of Surgery, University of Texas Southwestern, Dallas, TX
| | - Mobolaji Odewole
- Department of Internal Medicine, UT Southwestern Medical Center and Parkland Health and Hospital System, Dallas, TX
| | - Caitlin C. Murphy
- Department of Clinical Sciences, University of Texas Southwestern, Dallas, TX
| | - Neehar D. Parikh
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Jorge A. Marrero
- Department of Internal Medicine, UT Southwestern Medical Center and Parkland Health and Hospital System, Dallas, TX
| | - Adam C. Yopp
- Department of Surgery, University of Texas Southwestern, Dallas, TX
| | - Amit G. Singal
- Department of Internal Medicine, UT Southwestern Medical Center and Parkland Health and Hospital System, Dallas, TX,Department of Clinical Sciences, University of Texas Southwestern, Dallas, TX
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20
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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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21
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Sarpel U, Huang X, Austin C, Gany F. Barriers to Care in Chinese Immigrants with Hepatocellular Carcinoma: A Focus Group Study in New York City. J Community Health 2018; 43:1161-1171. [PMID: 29948526 DOI: 10.1007/s10900-018-0536-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The incidence of hepatocellular carcinoma (HCC) is rising sharply in the United States and deaths from HCC have increased at the highest rate of all cancers. Though Asians have the highest incidence of HCC of all ethnicities in the US, racial/ethnic minorities, including Asians, have worse survival from HCC. We sought to identify barriers to care in treatment of HCC among affected individuals in the NYC Chinese immigrant community. We held focus groups with Chinese immigrant patients in NYC with HCC. 29 individuals participated in the focus groups. We analyzed focus group data using grounded theory methodology. Barriers to care identified included insurance, money, time, language, residency status, and stigma. The impact of provider bias and culture were also discussed. Knowledge gathering with minority patients with HCC is essential for us to fully comprehend the barriers to healthcare experienced by this community. Future policy and intervention efforts must be founded in this reality.
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Affiliation(s)
- Umut Sarpel
- Division of Surgical Oncology, Icahn School of Medicine at Mount Sinai, 19 E 98th St., Ste 7A, New York, NY, 10029, USA.
| | - Xiaoxiao Huang
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Francesca Gany
- Immigrant Health and Cancer Disparities Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Jones PD, Diaz C, Wang D, Gonzalez-Diaz J, Martin P, Kobetz E. The Impact of Race on Survival After Hepatocellular Carcinoma in a Diverse American Population. Dig Dis Sci 2018; 63:515-528. [PMID: 29275448 DOI: 10.1007/s10620-017-4869-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 11/23/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Hepatocellular carcinoma (HCC) incidence is increasing at differential rates depending on race. We aimed to identify associations between race and survival after HCC diagnosis in a diverse American population. METHODS Using the cancer registry from Sylvester Comprehensive Cancer Center, University of Miami and Jackson Memorial Hospitals, we performed retrospective analysis of 999 patients diagnosed with HCC between 9/24/2004 and 12/19/2014. We identified clinical characteristics by reviewing available electronic medical records. The association between race and survival was analyzed using Cox proportional hazards regression. RESULTS Median survival in days was 425 in Blacks, 904.5 in non-Hispanic Whites, 652 in Hispanics, 570 in Asians, and 928 in others, p < 0.01. Blacks and Asians presented at more advanced stages with larger tumors. Although Whites had increased severity of liver disease at diagnosis compared to other races, they had 36% reduced rate of death compared to Blacks, [hazard ratio (HR) 0.64, 95% confidence interval (CI) 0.51-0.8, p < 0.01]. After adjusting for significant covariates, Whites had 22% (HR 0.78, 95% CI 0.61-0.99, p 0.04) reduced risk of death, compared to Blacks. Transplant significantly reduced rate of death; however, only 13.3% of Blacks had liver transplant, compared to 40.1% of Whites, p < 0.01. CONCLUSIONS In this diverse sample of patients, survival among Blacks is the shortest after HCC diagnosis. Survival differences reflect a more advanced tumor stage at presentation rather than severity of underlying liver disease precluding treatment. Improving survival in minority populations, in whom HCC incidence is rapidly increasing, requires identification and modification of factors contributing to late-stage presentation.
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Affiliation(s)
- Patricia D Jones
- Division of Hepatology, Department of Medicine, University of Miami Miller School of Medicine, 1120 NW 14th Street, Miami, FL, 33136, USA.
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, 33136, USA.
| | - Carlos Diaz
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, 33136, USA
| | - Danlu Wang
- Department of Medicine, University of Miami Miller School of Medicine/JFK Medical Center Palm Beach Regional GME Consortium, Miami, FL, 33136, USA
| | - Joselin Gonzalez-Diaz
- Division of Hepatology, Department of Medicine, University of Miami Miller School of Medicine, 1120 NW 14th Street, Miami, FL, 33136, USA
| | - Paul Martin
- Division of Hepatology, Department of Medicine, University of Miami Miller School of Medicine, 1120 NW 14th Street, Miami, FL, 33136, USA
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, 33136, USA
| | - Erin Kobetz
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, 33136, USA
- Division of Computational Medicine and Population Health, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, 33136, USA
- Jay Weiss Institute for Health Equity, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, 33136, USA
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Momin BR, Pinheiro PS, Carreira H, Li C, Weir HK. Liver cancer survival in the United States by race and stage (2001-2009): Findings from the CONCORD-2 study. Cancer 2017; 123 Suppl 24:5059-5078. [PMID: 29205306 DOI: 10.1002/cncr.30820] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 05/16/2017] [Accepted: 05/16/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND Worldwide, liver cancer is a leading cause of death for both men and women. The number of Americans who are diagnosed with and die of liver cancer has been rising slowly each year. Using data from the CONCORD-2 study, this study examined population-based survival by state, race, and stage at diagnosis. METHODS Data from 37 statewide registries, which covered 81% of the US population, for patients diagnosed during 2001-2009 were analyzed. Survival up to 5 years was adjusted for background mortality (net survival) with state- and race-specific life tables, and it was age-standardized with the International Cancer Survival Standard weights. RESULTS Liver cancer was diagnosed overall more often at the localized stage, with blacks being more often diagnosed at distant and regional stages than whites. 5-year net survival was 12.2% in 2001-2003 and 14.8% in 2004-2009. Whites had higher survival than blacks in both calendar periods (11.7% vs 9.1% and 14.3% vs 11.4%, respectively). During 2004-2009, 5-year survival was 25.7% for localized-stage disease, 9.5% for regional-stage disease, and 3.5% for distant-stage disease. CONCLUSIONS Some progress has occurred in survival for patients with liver cancer, but 5-year survival remains low, even for those diagnosed at the localized stage. Efforts directed at controlling well-established risk factors such as hepatitis B may have the greatest impact on reducing the burden of liver cancer in the United States. Cancer 2017;123:5059-78. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.
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Affiliation(s)
- Behnoosh R Momin
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Paulo S Pinheiro
- Epidemiology and Biostatistics, University of Nevada at Las Vegas, Las Vegas, Nevada
| | - Helena Carreira
- Cancer Survival Group, Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Chunyu Li
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Hannah K Weir
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
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24
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Smith AA, Darden M, Al-Qurayshi Z, Paramesh AS, Killackey M, Kandil E, Parker G, Balart L, Friedlander P, Buell JF. Liver transplantation in New Orleans: parity in a world of disparity? HPB (Oxford) 2017. [PMID: 28647164 DOI: 10.1016/j.hpb.2017.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Racial disparity in access to liver transplantation among African Americans (AA) compared to Caucasians (CA) has been well described. The aim of this investigation was to examine the presentation of AA liver transplant recipients in a socioeconomically challenged region. METHODS 680 adult liver transplant candidates and 233 resultant recipients between 2007 and 2015 were analyzed using univariate and multivariate analyses to evaluate factors significant for transplantation. RESULTS Percentages of wait list patients transplanted were similar between CA and AA (34.9% vs. 32.2%, p = 0.5205). AA were younger (50.4 ± 1.8 vs. 56.3 ± 0.7 yrs, p = 0.0003) with higher average MELD scores (22.9 ± 1.6 vs. 19.4 ± 0.7, p = 0.0230). Overall patient mortality was similar (AA 22.7% vs. CA 26.3%, p = 0.5931). A multiple linear regression showed that male gender was strongly associated with transplantation. CONCLUSIONS Equal access to liver transplantation remains challenging for racial minorities. At our institution, AA were accepted and transplanted at an equivalent rate as CA despite a higher AA population, HCV rate and diagnosed HCC. AA were younger and sicker at the time of transplant, but overall had similar outcomes compared to CA. Our study highlights the need for studies to delineate the underpinnings of disparity in transplantation access.
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Affiliation(s)
- Alison A Smith
- Tulane University School of Medicine, Louisiana State University School of Medicine, USA
| | - Michael Darden
- Department of Economics, Tulane University, New Orleans, LA, USA
| | - Zaid Al-Qurayshi
- Tulane University School of Medicine, Louisiana State University School of Medicine, USA
| | - Anil S Paramesh
- Tulane University School of Medicine, Louisiana State University School of Medicine, USA
| | - Mary Killackey
- Tulane University School of Medicine, Louisiana State University School of Medicine, USA
| | - Emad Kandil
- Tulane University School of Medicine, Louisiana State University School of Medicine, USA
| | - Geoffrey Parker
- Tuck School of Business Administration at Dartmouth, Hannover, NH, USA
| | - Luis Balart
- Tulane University School of Medicine, Louisiana State University School of Medicine, USA
| | - Paul Friedlander
- Tulane University School of Medicine, Louisiana State University School of Medicine, USA
| | - Joseph F Buell
- Tulane University School of Medicine, Louisiana State University School of Medicine, USA; Department of Economics, Tulane University, New Orleans, LA, USA.
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Li J, Hansen BE, Peppelenbosch MP, De Man RA, Pan Q, Sprengers D. Factors associated with ethnical disparity in overall survival for patients with hepatocellular carcinoma. Oncotarget 2017; 8:15193-15204. [PMID: 28122352 PMCID: PMC5362478 DOI: 10.18632/oncotarget.14771] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 01/10/2017] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is an important cause of cancer-related death worldwide. Ethnical disparity in overall survival has been demonstrated for HCC patients in the United States (U.S.). We aimed to evaluate the contributors to this survival disparity. The SEER database was used to identify HCC patients from 2004 to 2012. Kaplan-Meier curves and Cox proportional hazard models were used to evaluate overall survival by ethnicity and the contributors to ethnical survival disparity. A total of 33 062 patients were included: 15 986 Non-Hispanic Whites, 6535 Hispanic Whites, 4842 African Americans, and 5699 Asians. Compared to Non-Hispanic Whites, African Americans had worse survival (HR, 1.18; 95%CI, 1.14-1.23), while Asians had a better survival (HR, 0.85; 95%CI, 0.82-0.89), and Hispanic Whites had a similar survival (HR, 1.01; 95%CI, 0.97-1.05). Multivariate Cox analysis identified that tumor presentation- and treatment-related factors significantly contributed to the ethnical survival disparity. Especially, tumor size was the most important contributor (HR, 1.11; 95%CI, 1.07-1.16). There is no ethnical survival disparity in patients undergoing liver transplantation and sub-analysis of patients within the Milan criteria for liver transplantation demonstrated no significant survival disparity between African Americans and non-Hispanic Whites in transplantation adjustment analysis (HR, 1.23; 95%CI, 1.11-1.35 in non-adjustment analysis to HR, 1.05; 95%CI, 0.95-1.15 after adjustment). Finally, no important contributor to the superior overall survival in Asians was identified. In conclusion, poor tumor presentation at diagnosis, limited benefit from resection and restricted utilization of liver transplantation are important contributors to poorer survival of African Americans with HCC.
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Affiliation(s)
- Juan Li
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Bettina E Hansen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Maikel P. Peppelenbosch
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Robert. A. De Man
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Qiuwei Pan
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Dave Sprengers
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
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Alkhalili E, Greenbaum A, Luo L, Rodriguez R, Munoz OE, O'Neill J, Nir I, Morris KT. Racial disparities in treatment and survival of hepatocellular carcinoma in native Americans and Hispanics. Am J Surg 2016. [PMID: 28624027 DOI: 10.1016/j.amjsurg.2016.09.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND We investigated if there were any differences in disease presentation and survival between the 3 major ethnicities in New Mexico; non-Hispanic whites (NHW), native Americans (NA), and Hispanics (H). METHODS A retrospective analysis of patients with hepatocellular carcinoma treated at our institution between 2000 and 2014 was performed. Overall survival was analyzed using the Kaplan-Meier and Cox regression models. RESULTS We identified 326 patients; 106 (32.5%) NHW, 183 (56.1%) H, and 37 (11.4%) NA. No difference in disease stage, resectability, rate of offering surgery, or chemotherapy was found. Advanced cirrhosis was more common in H and NA than NHW (P = .01). NA had a higher incidence of nonviral hepatocellular carcinoma (P = .0009). NHW were more likely to receive transarterial chemoembolization/radiofrequency than NA or H (P = .04). Median survivals for NA, NHW, H were 24, 14, and 11 months, respectively, (P = .01). CONCLUSIONS Although there was no difference in disease stage or resectability, NA and H had more advanced cirrhosis and were less likely to undergo transarterial chemoembolization and/or radiofrequency than NHW. NA had the best survival, whereas H had the worst survival.
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Affiliation(s)
- Eyas Alkhalili
- Department of Surgery, School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Alissa Greenbaum
- Department of Surgery, School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Li Luo
- Department of Surgery, School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Rodrigo Rodriguez
- Department of Surgery, School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Oscar Estrada Munoz
- Department of Surgery, School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Jacqueline O'Neill
- Department of Surgery, School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Itzhak Nir
- Department of Surgery, School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Katherine T Morris
- Department of Surgery, School of Medicine, University of New Mexico, Albuquerque, NM, USA.
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Rajbhandari R, Simon RE, Chung RT, Ananthakrishnan AN. Racial Disparities in Inhospital Outcomes for Hepatocellular Carcinoma in the United States. Mayo Clin Proc 2016; 91:1173-82. [PMID: 27497857 DOI: 10.1016/j.mayocp.2016.06.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 06/02/2016] [Accepted: 06/03/2016] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To study racial disparities in therapeutic interventions and hospitalization outcomes for hepatocellular cancer (HCC) in the United States. PATIENTS AND METHODS Using the 2011 Nationwide Inpatient Sample (comprising hospitalizations between January 1 and December 31, 2011), we identified patients with HCC-related admissions using previously validated International Classification of Diseases, Ninth Revision, Clinical Modification codes. Among these, we also identified those that were procedure-related (associated with liver transplantation, hepatic resection, radiofrequency ablation, or transarterial chemoembolization). Multivariate regression was performed to identify the contribution of race to therapeutic interventions and outcomes. RESULTS A total of 22,933 HCC-related hospitalizations were included, of which 10,285 were procedure related (45%). Blacks had a smaller proportion (35%) of procedure-related HCC hospitalizations than did whites (46%) (odds ratio [OR], 0.65; 95% CI, 0.49-0.86). Specifically, blacks had lower odds of liver transplantation (OR, 0.43; 95% CI, 0.26-0.71), hepatic resection (OR, 0.57; 95% CI, 0.33-0.98), and ablation (OR, 0.46; 95% CI, 0.29-0.74) (P=.002) than did whites. Overall, 10.9% of HCC-related admissions resulted in death in blacks as compared with 6.4% in whites (OR, 1.58; 95% CI, 1.12-2.24). CONCLUSION Among patients admitted for HCC-related hospitalizations, blacks were less likely to receive liver transplantation, hepatic resection, and ablation than whites and had higher inhospital mortality. Identifying racial disparities in health care is a necessary first step to appropriately address and eliminate them.
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Affiliation(s)
- Ruma Rajbhandari
- Gastroenterology Division, Massachusetts General Hospital, Boston, MA; Department of Medicine, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | | | - Raymond T Chung
- Gastroenterology Division, Massachusetts General Hospital, Boston, MA; Department of Medicine, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA.
| | - Ashwin N Ananthakrishnan
- Gastroenterology Division, Massachusetts General Hospital, Boston, MA; Department of Medicine, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
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Race/Ethnicity-specific Disparities in Hepatocellular Carcinoma Stage at Diagnosis and its Impact on Receipt of Curative Therapies. J Clin Gastroenterol 2016; 50:423-30. [PMID: 26583267 DOI: 10.1097/mcg.0000000000000448] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
GOALS To evaluate race/ethnicity-specific disparities in hepatocellular carcinoma (HCC) stage at diagnosis and how this impacts receiving curative therapies. BACKGROUND HCC is a leading cause of morbidity and mortality worldwide. The highest incidence of HCC is seen among ethnic minorities in the United States. STUDY Using the 2003-2011 Surveillance, Epidemiology, and End Results database and United Network of Organ Sharing, population-based registries for cancer and liver transplantation (LT) in the United States, race/ethnicity-specific cancer stage at diagnosis and treatment received among adults with HCC were evaluated. RESULTS Compared with non-Hispanic whites, blacks had significantly more advanced HCC at diagnosis [odds ratio (OR), 1.20; 95% confidence interval (CI), 1.10-1.30; P<0.001], whereas Asians were less likely to have advanced disease (OR, 0.87; CI, 0.80-0.94; P<0.001). Among patients with HCC meeting Milan criteria, Hispanics (OR, 0.64; 95% CI, 0.57-0.71; P<0.001) and blacks (OR, 0.67; 95% CI, 0.59-0.76; P<0.001) were significantly less likely to receive curative therapy (resection or LT), whereas Asians were more likely to receive curative therapy (OR, 1.22; 95% CI, 1.10-1.35; P<0.001) compared with non-Hispanic whites. However, Asians (OR, 0.49; 95% CI, 0.42-0.58; P<0.001) and Hispanics (OR, 0.51; 95% CI, 0.44-0.60; P<0.001) were less likely to receive LT. CONCLUSIONS Among US adults with HCC, blacks consistently had more advanced stage at diagnosis and lower rates of receiving treatment. After correcting for cancer stage and evaluating the subset of patients eligible for curative therapies, blacks and Hispanics had significantly lower rates of curative HCC treatment.
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Sarpel U, Suprun M, Sofianou A, Berger Y, Tedjasukmana A, Sekendiz Z, Bagiella E, Schwartz ME. Disentangling the effects of race and socioeconomic factors on liver transplantation rates for hepatocellular carcinoma. Clin Transplant 2016; 30:714-21. [PMID: 27027869 DOI: 10.1111/ctr.12739] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2016] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Liver transplantation is the most effective treatment for hepatocellular carcinoma (HCC) in eligible patients, but is not accessed equally by all. We explored the effects of race and socioeconomic factors on transplantation for HCC while controlling for stage, resection status, and transplant candidacy. PATIENTS AND METHODS All HCC patients, 2003-2013, were retrospectively analyzed using multivariate analysis to explore differences in transplantation rates among cohorts. RESULTS Of 3078 HCC patients, 754 (24%) were considered transplant eligible. Odds of transplantation were significantly higher for those with commercial insurance (OR = 1.99, 95% CI [1.42, 2.79]) and lower for black patients (OR = 0.55, 95% CI [0.33, 0.91]). Asians were more likely to be resected than white patients with similarly staged tumors and transplant criteria (p < 0.001). Patients not listed for transplantation for non-medical reasons were more likely to be government-insured (p = 0.02) and not white (p = 0.05). No step along the transplantation pathway was identified as the dominant hurdle. DISCUSSION Patients who are black or government-insured are significantly less likely to undergo transplantation for HCC despite controlling for tumor stage, resection status, and transplant eligibility. Asian patients have higher rates of hepatic resection, but also appear to have lower transplantation rates beyond this effect.
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Affiliation(s)
- Umut Sarpel
- Division of Surgical Oncology, Department of Surgery, New York, NY, USA
| | - Maria Suprun
- Department of Population, Health Science and Policy, New York, NY, USA
| | | | - Yaniv Berger
- Division of Surgical Oncology, Department of Surgery, New York, NY, USA
| | | | | | - Emilia Bagiella
- Department of Population, Health Science and Policy, New York, NY, USA
| | - Myron E Schwartz
- The Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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30
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Yan M, Ha J, Aguilar M, Bhuket T, Liu B, Gish RG, Cheung R, Wong RJ. Birth cohort-specific disparities in hepatocellular carcinoma stage at diagnosis, treatment, and long-term survival. J Hepatol 2016; 64:326-332. [PMID: 26386160 DOI: 10.1016/j.jhep.2015.09.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Revised: 08/05/2015] [Accepted: 09/09/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Individuals born between 1945 and 1965 account for nearly 75% of hepatitis C virus (HCV) infections in the United States. As this cohort ages, progressive HCV-related liver disease leading to cirrhosis and hepatocellular carcinoma (HCC) will place a significant burden on the healthcare system. We aim to evaluate birth cohort-specific disparities in HCC stage at diagnosis, treatment rates, and overall survival with a focus on the 1945-1965 birth cohort. METHODS A population-based retrospective cohort study of adult patients with HCC identified in the Surveillance, Epidemiology, and End Results 2003-2011 registry evaluated birth cohort-specific disparities in the prevalence and outcomes of HCC, including multivariate logistic regression models to evaluate disparities in HCC stage at diagnosis and HCC treatment received. Birth cohort-specific survival was evaluated with Kaplan-Meier methods and multivariate Cox proportional hazard models. RESULTS The proportion of HCC represented by the 1945-1965 cohort increased by 64% from 2003-2011, and accounted for 57.4% of all HCC in 2011. Compared to patients born after 1965, the 1945-1965 cohort were more likely to have HCC within Milan criteria (OR, 3.66; 95% CI, 3.13-4.28; p<0.001). However, among patients with HCC within Milan criteria, the 1945-1965 cohort had no difference in receipt of surgical treatment, but had higher overall long-term survival (HR, 0.82; 95% CI, 0.69-0.97; p<0.03). CONCLUSIONS The 1945-1965 birth cohort accounts for the majority of HCC in the United States. Despite earlier HCC stage at diagnosis, no difference in receipt of surgical treatment was observed, but higher overall survival was achieved.
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Affiliation(s)
- Melissa Yan
- Department of Medicine, Alameda Health System - Highland Hospital, Oakland, CA, United States
| | - John Ha
- Department of Medicine, Alameda Health System - Highland Hospital, Oakland, CA, United States
| | - Maria Aguilar
- Department of Medicine, Alameda Health System - Highland Hospital, Oakland, CA, United States
| | - Taft Bhuket
- Division of Gastroenterology and Hepatology, Alameda Health System - Highland Hospital, Oakland, CA, United States
| | - Benny Liu
- Division of Gastroenterology and Hepatology, Alameda Health System - Highland Hospital, Oakland, CA, United States
| | - Robert G Gish
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, United States
| | - Ramsey Cheung
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, United States; Division of Gastroenterology and Hepatology, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, United States
| | - Robert J Wong
- Division of Gastroenterology and Hepatology, Alameda Health System - Highland Hospital, Oakland, CA, United States.
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Alawadi ZM, Phatak UR, Kao LS, Ko TC, Wray CJ. Race not rural residency is predictive of surgical treatment for hepatocellular carcinoma: Analysis of the Texas Cancer Registry. J Surg Oncol 2015; 113:84-8. [PMID: 26696033 DOI: 10.1002/jso.24101] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 11/06/2015] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND OBJECTIVES Rural patients have poor access to specialists and are less likely to receive evidence-based cancer care. We hypothesized that hepatocellular carcinoma (HCC) patients from rural counties in Texas would be less likely to receive surgical therapy than those from urban areas. METHODS The Texas Cancer Registry was queried (2000-2008). County-level data included "rural or urban" designation and income variables derived by zip code. Surgical intervention included: (i) ablation, (ii) resection-partial or total lobectomy, or (iii) transplantation. A multinomial logistic regression was created to determine predictors of intervention. RESULTS Five thousand thirty seven HCC patients were identified (86% urban) for study. A multinomial regression demonstrated, older age, African-American race, and lower income reduced the likelihood of ablation. Younger age, female gender, Caucasian, and Asian/other race predicted surgical resection, or transplantation. Hispanic race was associated with lower likelihood of resection (RRR 0.75) and transplantation (RRR 0.74), whereas African-American race was associated with pronounced decrease for transplantation (RRR 0.48). Area of residency was not predictive of intervention. CONCLUSIONS Rural residency did not decrease the likelihood of surgical intervention for hepatocellular carcinoma. Race and income continue to be associated with significant treatment disparity. Additional investigation should focus on factors that govern the selection of resection or transplantation for potentially eligible patients.
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Affiliation(s)
- Zeinab M Alawadi
- UTHealth Center for Clinical and Translational Sciences, Houston, Texas.,University of Texas Health Science Center at Houston, Houston, Texas
| | - Uma R Phatak
- UTHealth Center for Clinical and Translational Sciences, Houston, Texas.,University of Texas Health Science Center at Houston, Houston, Texas
| | - Lillian S Kao
- UTHealth Center for Clinical and Translational Sciences, Houston, Texas.,University of Texas Health Science Center at Houston, Houston, Texas
| | - Tien C Ko
- University of Texas Health Science Center at Houston, Houston, Texas
| | - Curtis J Wray
- UTHealth Center for Clinical and Translational Sciences, Houston, Texas.,University of Texas Health Science Center at Houston, Houston, Texas
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32
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Cherqui D. Laparoscopic liver resection: A new paradigm in the management of hepatocellular carcinoma? J Hepatol 2015; 63:540-2. [PMID: 26144660 DOI: 10.1016/j.jhep.2015.06.028] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 06/30/2015] [Indexed: 12/07/2022]
Affiliation(s)
- Daniel Cherqui
- Hepatobiliary Center, Paul Brousse Hospital, Université Paris Sud, 14 Avenue Paul Vaillant Couturier, 94800 Villejuif, France.
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Kluger MD, Salceda JA, Laurent A, Tayar C, Duvoux C, Decaens T, Luciani A, Van Nhieu JT, Azoulay D, Cherqui D. Liver resection for hepatocellular carcinoma in 313 Western patients: tumor biology and underlying liver rather than tumor size drive prognosis. J Hepatol 2015; 62:1131-40. [PMID: 25529622 DOI: 10.1016/j.jhep.2014.12.018] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Revised: 12/08/2014] [Accepted: 12/10/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Treatment decisions for hepatocellular carcinoma are mostly guided by tumor size. The aim of this study was to analyze resection outcomes according to tumor size and characterize prognostic factors. METHODS Patients resected at a Western center between 1989 and 2010 were grouped by largest tumor size: <50mm, 50-100mm, and >100mm. The primary end points were overall- and recurrence-free survival. Univariate associations with primary endpoints were entered into a Cox proportional hazard regression model. RESULTS Three hundred thirteen patients underwent resection: 111 (36%) had tumors <50mm, 113 (36%) had tumors between 50 and 100mm, and 89 (28%) had tumors >100mm. Five-year overall and disease-free survival rates for the three groups were 67%, 46%, and 34%, and 32%, 27%, and 27%, respectively. Thirty-five patients, mostly from <50mm group, underwent transplantation which was associated with a 91% 5 year survival rate. Tumor size was not an independent predictor of overall or recurrence-free survival on multivariate analyses. Independent predictors of decreased overall survival were: intraoperative transfusion (HR=2.60), cirrhosis (HR=2.42), poorly differentiated tumor (HR=2.04), satellite lesions (HR=1.69), alpha-fetoprotein >200 (HR=1.53), and microvascular invasion (HR=1.48). The use of salvage transplantation was an independent predictor of improved survival (HR=0.21). Recurrence-free survival was predicted by intraoperative transfusion (HR=2.15), poorly differentiated tumor (HR=1.87), microvascular invasion (HR=1.71) and cirrhosis (HR=1.69). CONCLUSION By studying a large group of patients across a distribution of tumor sizes and background liver diseases, it is demonstrated that size alone is a limited prognostic factor. Tumor biology and condition of the underlying liver are better prognosticators and should be given closer attention. Although hampered by recurrence rates, resection is safe and offers good overall survival. In addition, it may allow for better selection for salvage transplantation after consideration of histopathological risk factors.
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Affiliation(s)
- Michael D Kluger
- Service de Chirurgie Digestive et Hépatobiliaire, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris-Université Paris-Est, Créteil, France; Section of Gastrointestinal Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY, United States
| | - Juan A Salceda
- Service de Chirurgie Digestive et Hépatobiliaire, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris-Université Paris-Est, Créteil, France
| | - Alexis Laurent
- Service de Chirurgie Digestive et Hépatobiliaire, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris-Université Paris-Est, Créteil, France
| | - Claude Tayar
- Service de Chirurgie Digestive et Hépatobiliaire, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris-Université Paris-Est, Créteil, France
| | - Christophe Duvoux
- Service d'Hepatologie, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris-Université Paris-Est, Créteil, France
| | - Thomas Decaens
- Service d'Hepatologie, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris-Université Paris-Est, Créteil, France
| | - Alain Luciani
- Service d'Imagerie Medicale, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris-Université Paris-Est, Créteil, France
| | - Jeanne Tran Van Nhieu
- Service d'Anatomie et Cytologie Pathologiques, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris-Université Paris-Est, Créteil, France
| | - Daniel Azoulay
- Service de Chirurgie Digestive et Hépatobiliaire, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris-Université Paris-Est, Créteil, France
| | - Daniel Cherqui
- Service de Chirurgie Digestive et Hépatobiliaire, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris-Université Paris-Est, Créteil, France; Centre Hépato Biliaire, Paul Brousse Hôpital, Université Paris Sud, Villejuif, France.
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Siegel AB, El-Khoueiry AB, Finn RS, Guthrie KA, Goyal A, Venook AP, Blanke CD, Verna EC, Dove L, Emond J, Kato T, Samstein B, Busuttil R, Remotti H, Coffey A, Brown Jr RS. Phase I trial of sorafenib following liver transplantation in patients with high-risk hepatocellular carcinoma. Liver Cancer 2015; 4:115-25. [PMID: 26020033 PMCID: PMC4439789 DOI: 10.1159/000367734] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Liver transplantation offers excellent long-term survival for hepatocellular carcinoma (HCC) patients who fall within established criteria. For those outside such criteria, or with high-risk pathologic features in the explant, HCC recurrence rates are higher. We conducted a multicenter phase I trial of sorafenib in liver transplantation patients with high-risk HCC. Subjects had HCC outside the Milan criteria (pre- or post-transplant), poorly differentiated tumors, or vascular invasion. We used a standard 3+3 phase I design with a planned duration of treatment of 24 weeks. Correlative studies included the number of circulating endothelial cells (CECs), plasma biomarkers, and tumor expression of p-Erk, p-Akt, and c-Met in tissue micro-arrays. We enrolled 14 patients with a median age of 63 years. Of these, 93% were men and 71% had underlying hepatitis C virus (HCV) and 21% had HBV. The maximum tolerated dose of sorafenib was 200 mg BID. Grade 3-4 toxicities seen in >10% of subjects included leukopenia (21%), elevated gamma-glutamyl transferase (21%), hypertension (14%), hand-foot syndrome (14%) and diarrhea (14%). Over a median follow-up of 953 days, one patient died and four recurred. The mean CEC number at baseline was 21 cells/4 ml for those who recurred, and 80 cells/4 ml for those who did not (p=0.10). Mean soluble vascular endothelial growth factor receptor-2 levels decreased after 1 month on sorafenib (p=0.09), but did not correlate with recurrence. There was a trend for tumor c-Met expression to correlate with increased risk of recurrence. Post-transplant sorafenib was found to be feasible and tolerable at 200 mg PO BID. The effect of post-transplant sorafenib on recurrence-free survival is potentially promising but needs further validation in a larger study.
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Affiliation(s)
- Abby B. Siegel
- Columbia University Medical Center Departments of Medicine and Surgery, New York, N.Y., USA
| | | | | | | | - Abhishek Goyal
- Columbia University Medical Center Departments of Medicine and Surgery, New York, N.Y., USA
| | - Alan P. Venook
- Helen Diller Family Comprehensive Cancer Center, San Francisco, Calif., USA
| | | | - Elizabeth C. Verna
- Columbia University Medical Center Departments of Medicine and Surgery, New York, N.Y., USA
| | - Lorna Dove
- Columbia University Medical Center Departments of Medicine and Surgery, New York, N.Y., USA
| | - Jean Emond
- Columbia University Medical Center Departments of Medicine and Surgery, New York, N.Y., USA
| | - Tomoaki Kato
- Columbia University Medical Center Departments of Medicine and Surgery, New York, N.Y., USA
| | - Benjamin Samstein
- Columbia University Medical Center Departments of Medicine and Surgery, New York, N.Y., USA
| | | | - Helen Remotti
- Division of Pathology and Cell Biology, Columbia University, New York, N.Y., USA
| | - Amy Coffey
- Division of Pathology and Cell Biology, Columbia University, New York, N.Y., USA
| | - Robert S. Brown Jr
- Columbia University Medical Center Departments of Medicine and Surgery, New York, N.Y., USA
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Bogdanos D, Leung PS, Gershwin ME. Liver and the Biliary Tract. Mucosal Immunol 2015. [DOI: 10.1016/b978-0-12-415847-4.00087-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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36
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Hepatitis C in African Americans. Am J Gastroenterol 2014; 109:1576-84; quiz 1575, 1585. [PMID: 25178700 DOI: 10.1038/ajg.2014.243] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Accepted: 07/01/2014] [Indexed: 12/11/2022]
Abstract
The care of hepatitis C virus (HCV) in African Americans represents an opportunity to address a major health disparity in medicine. In all facets of HCV infection, African Americans are inexplicably affected, including in the prevalence of the virus, which is higher among them compared with most of the racial and ethnic groups. Ironically, although fibrosis rates may be slow, hepatocellular carcinoma and mortality rates appear to be higher among African Americans. Sustained viral response (SVR) rates have historically significantly trailed behind Caucasians. The reasons for this gap in SVR are related to both viral and host factors. Moreover, low enrollment rates in clinical trials hamper the study of the efficacy of anti-viral therapy. Nevertheless, the gap in SVR between African Americans and Caucasians may be narrowing with the use of direct-acting agents. Gastroenterologists, hepatologists, primary care physicians, and other health-care providers need to address modifiable risk factors that affect the natural history, as well as treatment outcomes, for HCV among African Americans. Efforts need to be made to improve awareness among health-care providers to address the differences in screening and referral patterns for African Americans.
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Wong RJ, Devaki P, Nguyen L, Cheung R, Cho-Phan C, Nguyen MH. Increased long-term survival among patients with hepatocellular carcinoma after implementation of Model for End-stage Liver Disease score. Clin Gastroenterol Hepatol 2014; 12:1534-40.e1. [PMID: 24361414 DOI: 10.1016/j.cgh.2013.12.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Revised: 11/14/2013] [Accepted: 12/06/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Assignment of Model for End-stage Liver Disease (MELD) exception points to patients with hepatocellular carcinoma (HCC) who fall within Milan criteria, which began in 2003, increases their priority on liver transplantation waitlists. However, little is known about how this change affected survival of all patients with HCC (transplant eligible and ineligible). We compared long-term survival of HCC patients before and after this change. METHODS We performed a large population-based cohort study by using the Surveillance, Epidemiology, and End Results cancer registry to investigate survival times of patients with HCC before those who met the Milan criteria were given MELD exception points (1998-2003) and afterward (2004-2010) by using Kaplan-Meier methods. Multivariate Cox proportional hazards models evaluated independent predictors of survival. RESULTS During 2004-2010, a significantly higher percentage of patients with HCC survived for 5 years compared with 1998-2003 (21.9% vs 13.0%, P < .001). This difference remained significant among all treatment groups (no therapy: 15.2% vs 10.2%, P < .001; local tumor destruction: 37.6% vs 22.1%, P < .001; resection: 55.5% vs 39.2%, P < .001; transplantation: 77.2% vs 73.1%, P = .12). Multivariate Cox proportional hazards models, inclusive of sex, age, ethnicity, Milan criteria, number and stage of tumor, and time period, showed increased survival of patients during 2004-2010 (hazard ratio [HR], 0.87; 95% confidence interval [CI], 0.83-0.91; P < .001). Compared with non-Hispanic whites, Asians (HR, 0.81; 95% CI, 0.77-0.86; P < .001) and Hispanics (HR, 0.89; 95% CI, 0.84-0.95; P < .001) had longer survival times, whereas blacks had a trend toward shorter survival times (HR, 1.05; 95% CI, 0.98-1.13; P = .16). CONCLUSIONS Patients with HCC who met Milan criteria had significantly longer survival times after implementation of the MELD exception points, regardless of sex or ethnicity. Blacks continued to have the lowest rates of 5-year survival.
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Affiliation(s)
- Robert J Wong
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, California; Division of Gastroenterology and Hepatology, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Pardha Devaki
- Department of Internal Medicine, Detroit Medical Center/Wayne State University, Detroit, Michigan
| | - Long Nguyen
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Ramsey Cheung
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, California; Division of Gastroenterology and Hepatology, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Cheryl Cho-Phan
- Division of Medical Oncology, Stanford University Medical Center, Stanford, California
| | - Mindie H Nguyen
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, California.
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Parsikia A, Ortiz J. Disparities in the reporting of distribution of health care. Liver Transpl 2014; 20:1149. [PMID: 24839271 DOI: 10.1002/lt.23913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 05/06/2014] [Indexed: 01/12/2023]
Affiliation(s)
- Afshin Parsikia
- Department of Transplant Surgery, Einstein Healthcare Network, Einstein Medical Center, Philadelphia, PA
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Aparo S, Goel S, Lin D, Ohri N, Schwartz JM, Lo Y, Kaubisch A. Survival analysis of Hispanics in a cohort of patients with hepatocellular carcinoma. Cancer 2014; 120:3683-90. [PMID: 25081065 DOI: 10.1002/cncr.28867] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Revised: 04/25/2014] [Accepted: 05/07/2014] [Indexed: 12/26/2022]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) appears to have worse prognosis among Hispanics and other ethnic minorities in the United States. We investigated the overall survival (OS) of Hispanics with HCC and compared it with non-Hispanic (NH) whites and NH blacks. METHODS Patients diagnosed and treated for HCC at an urban medical center between 2000 and 2011 were identified from the institutional cancer registry. A Cox proportional-hazard model was used to assess survival differences between Hispanics, NH whites, and NH blacks after adjusting for clinically and statistically significant variables. RESULTS A total of 681 patients were identified, 24 of whom were excluded due to inability to confirm the diagnosis of HCC based on radiologic criteria and 24 due to unavailable ethnicity data. The remaining 633 patients were used for analysis. Of this final cohort, 49% (n = 309) were Hispanic, 23% (n = 144) were NH white, and 28% (n = 180) were NH black. The median OS among Hispanics was 16.3 months and was similar to that of NH whites (14.0 months) and NH blacks (17.3 months) (P = 0.76). Multivariate analysis revealed a hazard ratio for death for Hispanics of 0.78 (95% confidence interval 0.58-1.07, P = .12) when compared with NH whites and a hazard ratio for death of 0.89 (95% confidence interval 0.68-1.19, P = 0.46) when compared with NH blacks. CONCLUSIONS In contrast to previous reports, Hispanics with HCC from this cohort experienced similar OS when compared with NH whites and NH blacks.
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Affiliation(s)
- Santiago Aparo
- Department of Medical Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
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Wong RJ, Devaki P, Nguyen L, Cheung R, Nguyen MH. Ethnic disparities and liver transplantation rates in hepatocellular carcinoma patients in the recent era: results from the Surveillance, Epidemiology, and End Results registry. Liver Transpl 2014; 20:528-35. [PMID: 24415542 DOI: 10.1002/lt.23820] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2013] [Accepted: 01/06/2014] [Indexed: 12/31/2022]
Abstract
Hepatocellular carcinoma (HCC) is a leading cause of morbidity and mortality. After the implementation of the Model for End-Stage Liver Disease system, rates of liver transplantation (LT) for HCC patients increased. However, it is not clear whether this trend has continued into recent times. Using the Surveillance, Epidemiology, and End Results registry (1998-2010), we retrospectively analyzed trends for LT among HCC patients in 3 time periods: 1998-2003, 2004-2008, and 2009-2010. A total of 60,772 HCC patients were identified. In the more recent time periods, the proportion of localized-stage HCC increased (45.0% in 1998-2003, 50.4% in 2004-2008, and 51.7% in 2009-2010; P < 0.001). Although the proportion of HCC patients within the Milan criteria also increased with time (22.8% in 1998-2003, 31.8% in 2004-2008, and 37.1% in 2009-2010; P < 0.001), the proportion of those patients undergoing LT increased from 1998-2003 to 2004-2008 but decreased from 2004-2008 to 2009-2010. However, the actual frequencies of LT were similar in 2004-2008 (208.2 per year) and 2009-2010 (201.5 per year). A multivariate logistic regression, including sex, age, ethnicity, Milan criteria, tumor stage, tumor size and number, and time periods, demonstrated a lower likelihood of LT in 2009-2010 versus 1998-2003 [odds ratio (OR) = 0.63, 95% confidence interval (CI) = 0.57-0.71]. Blacks (OR = 0.48, 95% CI = 0.41-0.56), Asians (OR = 0.65, 95% CI = 0.57-0.73), and Hispanics (OR = 0.76, 95% CI = 0.68-0.85) were all less likely to undergo LT in comparison with non-Hispanic whites. Despite the increasing proportion of patients with HCC diagnosed at an earlier stage, LT rates declined in the most recent era. In addition, ethnic minorities were significantly less likely to undergo LT. The growing imbalance between the number of transplant-eligible HCC patients and the shortage of donor livers emphasizes the need to improve donor availability and curative alternatives to LT.
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Affiliation(s)
- Robert J Wong
- Liver Transplant Program, Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University Medical Center, Palo Alto, CA; Division of Gastroenterology and Hepatology, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
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Yip B, Wantuck JM, Kim LH, Wong RJ, Ahmed A, Garcia G, Nguyen MH. Clinical presentation and survival of Asian and non-Asian patients with HCV-related hepatocellular carcinoma. Dig Dis Sci 2014; 59:192-200. [PMID: 24282055 DOI: 10.1007/s10620-013-2948-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2013] [Accepted: 11/11/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIM Hepatitis C virus (HCV) is an important cause of hepatocellular carcinoma (HCC) in Asians; however, it is often overlooked due to the high prevalence of hepatitis B virus in Asians. This study examines HCV-related HCC in Asians. METHODS We conducted a retrospective cohort study of 792 consecutive Asian (n = 220) and non-Asian (n = 572) patients with HCV-related HCC identified at Stanford University Medical Center using International Classification of Diseases-9 diagnosis between July 1996 and June 2012. RESULTS Asian patients were much older [66 (38-88) vs. 56 (31-87) years, P < 0.0001] and more likely to be female (33 vs. 19 %, P < 0.0001). A larger proportion of Asians were diagnosed with HCC within 2 years of HCV diagnosis (35 vs. 20 %, P = 0.001). Asian patients were more likely to undergo palliative therapy (46 vs. 28 %) and less likely to be listed for liver transplantation (20 vs. 48 %, P < 0.001), despite similar rates of meeting Milan criteria (52 vs. 58 %, P = 0.16). Overall, there was a trend for higher median survival rates in Asians (30 vs. 21 months, P = 0.091). Asians had higher long-term survival with palliative therapy only (5-year survival: 28 vs. 10 %, P < 0.0001); however, survival was similar among patients listed for liver transplantation. CONCLUSIONS There were distinct differences in clinical presentations of Asian and non-Asian patients with HCV-related HCC. Asians with HCV-related HCC are less likely to undergo liver transplantation and more likely to have delayed HCV diagnosis. Improved strategies in HCV screening in Asians are needed, as it may lead to earlier diagnosis and treatment of HCV infection and possible prevention of HCC development.
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Affiliation(s)
- Benjamin Yip
- Medical School, Eastern Virginia Medical School, Norfolk, VA, 23507, USA,
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Tan D, Yopp A, Beg MS, Gopal P, Singal AG. Meta-analysis: underutilisation and disparities of treatment among patients with hepatocellular carcinoma in the United States. Aliment Pharmacol Ther 2013; 38:703-12. [PMID: 23957569 PMCID: PMC3777750 DOI: 10.1111/apt.12450] [Citation(s) in RCA: 92] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Revised: 06/18/2013] [Accepted: 07/21/2013] [Indexed: 12/23/2022]
Abstract
BACKGROUND Despite wide availability of treatment options for hepatocellular carcinoma (HCC), several studies have suggested underutilisation in clinical practice. AIMS To quantify utilisation rates for HCC treatment among patients with HCC in the United States, and to summarise patterns of association between utilisation rates and patient socio-demographic characteristics. METHODS We performed a systematic literature review using the Medline database from January 1989 to March 2013. Two investigators independently extracted data on patient populations, study methods and results using standardised forms. Pooled treatment rates for any treatment and curative treatment, with 95% confidence intervals, were calculated. Prespecified subgroup analysis was performed to identify patient-level correlates of treatment utilisation. RESULTS We identified 24 studies that met inclusion criteria. The pooled rates of any treatment and curative treatment were 52.8% (95% CI 52.2-53.4%) and 21.8% (95% CI 21.4-22.1%) respectively. Among patients diagnosed at an early stage, the pooled curative treatment rate was 59.0% (95% CI 58.1-59.9%). Elderly, non-Caucasians and patients of low socioeconomic status had lower treatment rates than their counterparts. CONCLUSIONS Rates of HCC treatment in the United States, including curative treatment rates among patients detected at an early stage, are disappointingly low. Future efforts should focus on identifying appropriate intervention targets to increase treatment rates and reduce socio-demographic disparities.
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Affiliation(s)
- D Tan
- School of Public Health, UNT Health Science Center, Fort Worth, TX, USA
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Singal AG, Waljee AK, Patel N, Chen EY, Tiro JA, Marrero JA, Yopp AC. Therapeutic delays lead to worse survival among patients with hepatocellular carcinoma. J Natl Compr Canc Netw 2013; 11:1101-8. [PMID: 24029125 PMCID: PMC5568242 DOI: 10.6004/jnccn.2013.0131] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Although prior studies have shown underuse of appropriate therapy in patients with hepatocellular carcinoma (HCC), no studies to date have assessed the prevalence and clinical impact of therapeutic delays among patients with HCC. The goal of this study was to characterize and identify factors associated with underuse and delays in treatment of these patients. A retrospective cohort study was conducted of patients with cirrhosis diagnosed with HCC at a large urban safety net hospital between January 2005 and June 2012. Dates for HCC diagnosis and any treatments were recorded. Univariate and multivariate analysis was used to determine factors associated with treatment underuse and delayed treatment, which was defined as time from diagnosis to treatment exceeding 3 months. The authors identified 267 treatment-eligible patients with HCC, of whom only 62% received HCC therapy. On multivariate analysis, tumor stage (odds ratio [OR], 0.48; 95% CI, 0.36-0.65), Child-Pugh class (OR, 0.49; 95% CI, 0.28-0.84), and black race (OR, 0.55; 95% CI, 0.31-0.99) were associated with lower rates of treatment use. The median time to treatment was 1.7 months, with 31% of patients experiencing delayed treatment. Delayed treatment was associated with the presence of ascites (hazard ratio [HR], 2.8; 95% CI, 1.3-6.1) and current treatment with transarterial chemoembolization (HR, 4.8; 95% CI, 1.8-12.5). After adjusting for tumor stage and Child-Pugh class, treatment underuse (HR, 0.33; 95% CI, 0.24-0.46) and delayed treatment (HR, 0.50; 95% CI, 0.30-0.84) were both associated with significantly worse survival. Results showed that, in addition to one-third of patients not receiving HCC-directed therapy, another 30% experienced significant therapeutic delays, leading to worse survival.
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Affiliation(s)
- Amit G. Singal
- Department of Internal Medicine, University of Texas Southwestern Medical Center and Parkland Health Hospital System, Dallas, Texas
- Harold C. Simmons Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Akbar K. Waljee
- Department of Internal Medicine, University of Michigan, and VA Ann Arbor Health Services Research & Development Center for Clinical Management Research, Ann Arbor, Michigan
| | - Nishant Patel
- Department of Internal Medicine, University of Texas Southwestern Medical Center and Parkland Health Hospital System, Dallas, Texas
| | - Emerson Y. Chen
- Department of Internal Medicine, University of Texas Southwestern Medical Center and Parkland Health Hospital System, Dallas, Texas
| | - Jasmin A. Tiro
- Harold C. Simmons Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jorge A. Marrero
- Department of Internal Medicine, University of Texas Southwestern Medical Center and Parkland Health Hospital System, Dallas, Texas
| | - Adam C. Yopp
- Harold C. Simmons Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
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Czaja AJ. Autoimmune hepatitis in diverse ethnic populations and geographical regions. Expert Rev Gastroenterol Hepatol 2013; 7:365-85. [PMID: 23639095 DOI: 10.1586/egh.13.21] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Autoimmune hepatitis has diverse clinical phenotypes and outcomes in ethnic groups within a country and between countries, and these differences may reflect genetic predispositions, indigenous etiological agents, pharmacogenomic mechanisms and socioeconomic reasons. In the USA, African-American patients have cirrhosis more commonly, treatment failure more frequently and higher mortality than white American patients. Survival is poorest in Asian-American patients. Autoimmune hepatitis in other countries is frequently associated with genetic predispositions that may favor susceptibility to indigenous etiological agents. Cholestatic features influence treatment response; acute-on-chronic liver disease increases mortality and socioeconomic and cultural factors affect prognosis. Ethnic-based deviations from classical phenotypes and the frequency of late-stage disease can complicate the diagnosis and management of autoimmune hepatitis in non-white populations.
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Affiliation(s)
- Albert J Czaja
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
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Abstract
UNLABELLED Hepatitis C is the most prevalent bloodborne viral disease in the United States and the deadliest. This year, the U.S. Preventive Services Task Force (USPSTF) will update its 2004 hepatitis C guideline, which recommends against screening asymptomatic adults for hepatitis C. This guideline has hampered public health efforts to encourage screening and identify and refer infected persons for care by declaring that such interventions were not supported by the evidence. A draft revision of the guideline, released on November 26, 2012, concludes that testing persons born between 1945 and 1965 probably has at least a small net benefit, but stops short of definitively recommending that this cohort be screened. This article examines the Task Force's process for writing its guidelines. It recommends that the Task Force adopt a balanced approach to evaluating the benefits and harms of screening; use the preponderance of the evidence as a standard for evaluating interventions that target serious public health problems; be transparent about the value judgments that go into its decisions; consider the wide variation in disease prevalence in diverse patient populations; and recommend screening asymptomatic adults for hepatitis C. CONCLUSION By taking a broader view of the evidence, the Task Force can write new guidelines that will serve efforts to curb the hepatitis C epidemic, rather than frustrate them.
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Affiliation(s)
- Brian R. Edlin
- National Development and Research Institutes, New York, NY, 10010; and the Departments of Public Health and Medicine, Weill Cornell Medical Center, New York, NY
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Diabetes, body mass index, and outcomes in hepatocellular carcinoma patients undergoing liver transplantation. Transplantation 2012; 94:539-43. [PMID: 22864187 DOI: 10.1097/tp.0b013e31825c58ea] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
UNLABELLED For many cancers, features of the metabolic syndrome, such as diabetes and obesity, have been associated with both increased risk of cancer development and poor outcomes. METHODS We examined a large retrospective cohort of 342 consecutive patients who underwent liver transplantation for hepatocellular carcinoma between January 1999 and July 2010 at our institution. We evaluated the relationship between diabetes, obesity, hepatocellular carcinoma (HCC) recurrence, and overall survival. RESULTS We found that a body mass index (BMI) higher than 30 was an independent predictor of poor overall survival in a multivariable Cox model, approximately doubling the risk of death after transplantation. A BMI higher than 30 was also a predictor of recurrent HCC, although this was of borderline statistical significance (hazard ratio for recurrence, 1.9; 95% confidence interval, 0.9-4.1). We also found increased BMI to be an independent predictor of microvascular invasion within HCC tumors, lending a possible explanation to these results. Those with diabetes showed worsened overall survival compared with those without diabetes in univariate but not multivariable analysis, possibly related to longer wait times. CONCLUSIONS Our findings suggest a relationship between higher BMI, tumor vascular invasion, increased recurrence, and worsened overall survival. These findings may help explain why those with high BMI have worse outcomes from their cancers. A better understanding of the role of obesity and diabetes in patients with cancer should help develop better predictors of outcome and improved treatment options for patients with HCC.
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Kanwal F, Befeler A, Chari RS, Marrero J, Kahn J, Afdhal N, Morgan T, Roberts L, Mohanty SR, Schwartz J, VanThiel D, Li J, Zeringue A, Di'Bisceglie A. Potentially curative treatment in patients with hepatocellular cancer--results from the liver cancer research network. Aliment Pharmacol Ther 2012; 36:257-65. [PMID: 22670798 DOI: 10.1111/j.1365-2036.2012.05174.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2011] [Revised: 10/18/2011] [Accepted: 05/15/2012] [Indexed: 12/17/2022]
Abstract
BACKGROUND The extent to which potentially curative therapies are used in patients with hepatocellular cancer (HCC) and their related outcomes are unknown in the US. AIM To determine the rate and outcomes of potentially curative treatment in patients with HCC. METHODS Eleven US centers followed patients with HCC between 2001 and 2007. We determined rates of liver transplantation, surgical resection, or tumour ablation during follow-up, examined differences in adjusted survival of patients receiving these treatments, and determined the factors associated with receipt of potentially curative treatment. RESULTS Of the 267 patients, 76 (28%) patients had early HCC, defined as Child A or B cirrhosis, with a solitary HCC or ≤ 3 nodules, each ≤ 3 cm. Of these, 53 (69.7%) received curative treatment. Thirty six percent of patients with non-early HCC received curative treatment. Compared to patients with non-early HCC who did not receive curative treatment, patients with early HCC and curative treatment had the best survival [hazard ratio, HR = 0.19 (95% CI, 0.08-0.42)] followed by patients with advanced HCC who received curative treatment [HR = 0.37 (95% CI, 0.22-0.64)]. Baseline performance status was significantly associated with receipt of curative treatment as well as survival after adjusting for demographics, clinical characteristics, and HCC stage. CONCLUSIONS In this multicenter database, most of the patients with early HCC received potentially curative treatment. However, only 28% of patients had early HCC. One-third of patients with non-early HCC also underwent curative therapy. Potentially curative treatment improved survival and this effect was seen in patients with early as well as non-early HCC.
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Affiliation(s)
- F Kanwal
- John Cochran VA Medical Center, Saint Louis, MO, USA.
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Singal AG, Yopp A, S Skinner C, Packer M, Lee WM, Tiro JA. Utilization of hepatocellular carcinoma surveillance among American patients: a systematic review. J Gen Intern Med 2012; 27:861-7. [PMID: 22215266 PMCID: PMC3378733 DOI: 10.1007/s11606-011-1952-x] [Citation(s) in RCA: 216] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Revised: 10/13/2011] [Accepted: 11/29/2011] [Indexed: 12/14/2022]
Abstract
BACKGROUND Although surveillance for hepatocellular carcinoma (HCC) is recommended in high-risk patients, several studies have suggested it is being underutilized in clinical practice. The aim of our study was to quantify utilization rates for HCC surveillance among patients with cirrhosis and summarize patterns of association between utilization rates and patient socio-demographic characteristics. DATA SOURCES We performed a systematic literature review using the Medline database from January 1990 through March 2011 and a manual search of national meeting abstracts from 2008-2010. METHODS Two investigators independently extracted data on patient populations, study methods, and results using standardized forms. A pooled surveillance rate with 95% confidence intervals was calculated. Pre-specified subgroup analysis was performed to find correlates of surveillance utilization. RESULTS We identified nine studies that met inclusion criteria. The pooled surveillance rate was 18.4% (95%CI 17.8%-19.0%). Surveillance rates were significantly higher among patients followed in subspecialty gastroenterology clinics compared to those followed in primary care clinics (51.7% vs. 16.9%, p < 0.001). Non-Caucasians and patients of low socioeconomic status had lower surveillance rates than their counterparts. CONCLUSIONS Utilization rates for HCC surveillance are low, although they are significantly higher among patients followed in subspecialty clinics. Current studies fail to determine why HCC surveillance is not being performed. Future efforts should focus on identifying appropriate intervention targets to increase surveillance rates and reduce socio-demographic disparities.
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Affiliation(s)
- Amit G Singal
- Division of Gastroenterology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA.
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Wong LL, Hernandez B, Kwee S, Albright CL, Okimoto G, Tsai N. Healthcare disparities in Asians and Pacific Islanders with hepatocellular cancer. Am J Surg 2012; 203:726-32. [PMID: 22227170 DOI: 10.1016/j.amjsurg.2011.06.055] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Revised: 06/03/2011] [Accepted: 06/03/2011] [Indexed: 12/15/2022]
Abstract
BACKGROUND Hawaii has the highest incidence of hepatocellular cancer (HCC) in the United States and the largest proportion of Asians and Pacific Islanders. HCC studies generally combine these groups into 1 ethnicity, and we sought to examine differences between Asian and Pacific Islander subpopulations. METHODS Demographic, clinical, and treatment data for 617 patients with HCC (420 Asians, 114 whites, and 83 Pacific Islanders) were reviewed. Main outcome measures included HCC screening and liver transplantation. RESULTS Asian and Pacific Islander subgroups had significantly more immigrants, and age was different between groups. Compared with whites, Pacific Islanders and Filipinos had less HCC screening and liver transplantation procedures, fewer met Milan criteria, and a smaller proportion of those with Milan criteria actually underwent transplantation. CONCLUSIONS There were significant differences in risk factors, clinical presentation, treatment, and access to care among Asian, Pacific Islander, and white patients with HCC. Future HCC studies may benefit from differentiating subgroups within Asian and Pacific Islander populations to better focus these efforts.
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Affiliation(s)
- Linda L Wong
- University of Hawaii Cancer Center, Honolulu, HI, USA.
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Chronic liver disease in the Hispanic population of the United States. Clin Gastroenterol Hepatol 2011; 9:834-41; quiz e109-10. [PMID: 21628000 PMCID: PMC4184097 DOI: 10.1016/j.cgh.2011.04.027] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Revised: 04/01/2011] [Accepted: 04/28/2011] [Indexed: 02/07/2023]
Abstract
Chronic liver disease is a major cause of morbidity and mortality among Hispanic people living in the United States. Environmental, genetic, and behavioral factors, as well as socioeconomic and health care disparities among this ethnic group have emerged as important public health concerns. We review the epidemiology, natural history, and response to therapy of chronic liver disease in Hispanic patients. The review covers nonalcoholic fatty liver disease, viral hepatitis B and C, coinfection of viral hepatitis with human immunodeficiency virus, alcoholic cirrhosis, hepatocellular carcinoma, autoimmune hepatitis, and primary biliary cirrhosis. For most of these disorders, the Hispanic population has a higher incidence and more aggressive pattern of disease and overall worse treatment outcomes than in the non-Hispanic white population. Clinicians should be aware of these differences in caring for Hispanic patients with chronic liver disease.
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