Abstract
Transplantation, surgical resection, radiofrequency ablation, and percutaneous ethanol injection are generally considered potentially curative treatments for patients with hepatocellular carcinoma (HCC). With the increasing incidence of HCC, it is critical to investigate geographic variations in curative treatments and their associations with survival among patients. A total of 6,782 patients with HCC during 2004 to 2011 were identified in the SEER-Medicare linked database and placed in quartiles based on the proportions undergoing potentially curative treatments per hospital referral region (HRR). Hierarchical Cox proportional hazards models were used to examine the association between regional potentially curative treatment patterns and survival across quartiles. An average of 16.9% of patients with HCC underwent potentially curative treatments during 2004 to 2011, varying substantially from 0% to 34.5% across HRRs. Compared with patients residing in the lowest-quartile regions, those in the highest-quartile regions were more likely to be of other races (vs white or black), be infected with hepatitis B virus, and have more comorbidities. The 5-year survival was 4.7% in the lowest-quartile regions and 11.4% in the highest-quartile regions (P<.001). After controlling for confounders, patients in the highest-quartile regions had a lower risk of mortality (adjusted hazard ratio, 0.78; 95% CI, 0.72-0.85). Patients with HCC who resided in HRRs with higher proportions of potentially curative treatments had better survival. Given its proven survival benefits, prompt clinical and policy actions are needed to reduce variations in treatment utilization.
Highlights
Transplantation, surgical resection, radiofrequency ablation, and percutaneous ethanol injection are generally considered potentially curative treatments for patients with hepatocellular carcinoma (HCC)
Patients were included if their source of diagnosis was not death certificate or autopsy, they had continuous fee-for-service Medicare Part A or B coverage from 1 year before diagnosis through either death or 6 months after HCC diagnosis, and they had a known ZIP code of residence to be linked to the hospital referral region (HRR)
This is the first study to show that patients with HCC residing in areas with high use of potentially curative treatments had better survival than those residing in lowutilization areas, after controlling for clinical and tumorrelated features
Summary
Transplantation, surgical resection, radiofrequency ablation, and percutaneous ethanol injection are generally considered potentially curative treatments for patients with hepatocellular carcinoma (HCC). Hepatocellular carcinoma (HCC) is the dominant histologic type of liver cancer, affecting approximately 20,000 Americans annually.[1] HCC incidence and mortality have been increasing in the United States during the past 3 decades.[2] Evidence-based HCC management guidelines have been updated to take full advantage of current treatment options, including transplantation, surgical resection, radiofrequency ablation (RFA), percutaneous ethanol injection (PEI), transarterial chemoembolization (TACE), and chemotherapy.[3,4,5,6] Many studies have reported beneficial effects of these options—in particular, transplantation, surgical resection, RFA, and PEI are considered potentially curative treatments because these interventions can markedly improve survival among patients with early-stage HCC.[7,8,9,10]. Because hospital referral regions (HRRs) represent regional healthcare resources where most potentially curative treatments may be given, investigating HRR-level geographic variations in HCC curative treatments and their associations with survival may help identify treatment needs, guide public health resource allocations, and improve HCC outcomes
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