Sociodemographic Characteristics as Predictors of Outcomes in Hepatocellular Carcinoma: A Retrospective Cohort Study

Changes in Incidence of Cirrhotic and Noncirrhotic Hepatocellular Carcinoma in the United States

INTRODUCTION

Hepatocellular carcinoma (HCC) occurs most often in a background of cirrhosis. Patients with noncirrhotic HCC represent a distinct population, which has been characterized in single-center studies, but has not been fully evaluated on a population level in the United States.

MATERIALS AND METHODS

HCC cases from Surveillance, Epidemiology, and End-Results diagnosed between 2000 and 2020 were categorized as cirrhotic or noncirrhotic. Clinical and pathologic factors, age-adjusted incidence rates (AAIR), and the overall HCC-specific survival were compared between groups.

RESULTS

There were 18,592 patients with cirrhosis (80.4%) and 4545 without (19.6%). AAIRs for noncirrhotic HCC remained relatively unchanged from 2010 to 2020, with a mean incidence of 0.35 per 100,000. The AAIR for cirrhotic HCC declined from 1.59 to 0.85 per 100,000 during the same period. Patients with cirrhosis were younger (median age 62 versus 65 y, P < 0.001). Patients without cirrhosis, compared to those with cirrhosis, were less likely to have elevated alpha fetoprotein (53.9% versus 62.0%, P < 0.001), had larger tumors (median tumor size 5.0 versus 3.5 cm, P < 0.001), presented more frequently with localized disease (59.9% versus 55.8%, P < 0.001), were more likely to undergo surgery (OR 2.21, 95% CI 2.07-2.36), and had better HCC-specific survival (median 40 versus 27 mo, P < 0.001).

CONCLUSIONS

The relative increase in the proportion of noncirrhotic HCC in the Untied States may be due to a decline in the incidence of cirrhotic HCC. Patients with noncirrhotic HCC have larger tumors, are more likely to undergo surgical resection, and have improved cancer-specific survival.

Impact of Social Determinants of Health on Outcomes Following Resection for Hepatocellular Carcinoma

BACKGROUND

We sought to determine the impact of social determinants of health (SDoH) on outcomes of patients undergoing resection for hepatocellular carcinoma (HCC).

PATIENTS AND METHODS

Patients with HCC in the National Cancer Database who underwent resection from 2009 to 2018 were identified. SDoH associated with length of stay (LOS), 30-day readmission, and 30-day mortality were analyzed using regression analyses adjusted for confounding variables.

RESULTS

Among 9235 patients, the median age (range) was 65.0 (18-90) years, 72.1% were male, and 57.9% were White. A total of 3% were uninsured, 11.1% had Medicaid, 21% resided in regions with a median household income within the lowest quartile of the US population, and 27.0% resided in regions within the lowest quartile of education level. The odds for having longer LOS were lower among patients with the highest regional education level compared with those with the lowest level [odds ratio (OR) 0.86, 95% confidence interval (CI) 0.77-0.97]. The risk of readmission was lower among patients with Medicare (OR 0.52; 95% CI 0.33-0.81), Medicaid (OR 0.52; 95% CI 0.31-0.87), or private insurance (OR 0.56; 95% CI 0.35-0.88) compared with uninsured patients. Thirty-day overall mortality was less likely among patients with Medicare (OR 0.45; 95% CI 0.27-0.75), Medicaid (OR 0.53; 95% CI 0.30-0.93), or private insurance (OR 0.40; 95% CI 0.24-0.66), and among patients with high regional income (OR 0.58; 95% CI 0.44-0.77).

CONCLUSIONS

Adjusted regression analyses identified SDoH that were associated with HCC outcomes. Increased awareness of how SDoH relate to outcomes may inform strategies that attempt to account for these associations and improve patient outcomes.

Ground Level Falls in Patients Over 60, Do Race and Socioeconomic Status Affect Outcome?

Background

Falls are a significant source of morbidity, mortality, and health care spending in the elderly. The objective was to identify whether race, insurance status, and median income by zip code were associated with discharge disposition, readmission within 90 days, or mortality within 1 year of ground-level falls in patients aged 60-90.

Materials and Methods

We conducted a retrospective chart review of 926 patients aged 60-90 treated for ground-level falls. We created a binomial linear regression model to identify predictors of discharge disposition, 90-day readmission, and mortality within 1 year of discharge.

Results

Length of stay (P < .01), having orthopedic surgery (P < .01), score on Charlson Comorbidity Index (CCI) (P < .01), increasing age (P = .014), female sex (P = .05), and admission to the ICU (P = .05) were associated with discharge to a secondary facility. Readmission within 90 days was only associated with higher scores on the CCI (P < .01). Charlson Comorbidity Index (P < .0001), hospital length of stay (P < .001), and admission to the ICU (P = .015) were associated with increased mortality at 1 year.

Discussion

Predictors of discharge to another facility included hospital length of stay, having orthopedic surgery, CCI scores, increasing age, female sex, and admission to the ICU. Charlson Comorbidity Index score was the only significant predictor of readmission. Predictors of mortality at 1-year post-fall included CCI score, hospital length of stay, and admission to the ICU. Race, median income by zip code, and insurance provider were not statistically significant.

Sex-Related Differences in Drugs with Anti-Inflammatory Properties

There is increasing evidence of sex differences in the action of anti-inflammatory drugs, with women being at significantly higher risk of adverse effects. Nevertheless, clinicians' awareness of the implications of these sex differences on dosing and adverse event monitoring in routine practice is still in need of improvement. We reviewed the literature evaluating sex differences in terms of pharmacokinetics and pharmacodynamics of anti-inflammatory drugs. The anti-thrombotic activity of selective and non-selective COX-inhibitors tends to be stronger in men than women. Side effect profiles differ with regards to gastro-intestinal, renal and hepatic complications. Glucocorticosteroids were found to be more effective in men; women were more sensitive to corticosteroids when their oestradiol levels were high, a finding important for women taking hormonal contraception. TNF-alpha inhibitors have a longer half-life in men, leading to stronger immunosuppression and this a higher incidence of infections as side effects. Although research on sex differences in the effectiveness and safety of drugs is increasing, findings are often anecdotal and controversial. There is no systematic sex-differentiated reporting from clinical trials, and women are often under-represented. As personalized medicine is gaining in importance, sex, and gender aspects need to become integral parts of future research and policy making.