Impact Of Hepatitis C Treatment On Long-Term Outcomes For Patients With Hepatocellular Carcinoma: A United States Safety-Net Collaborative Study

Abstract

Presenter: Michael Turgeon MD | Emory University Background: Hepatitis C Virus (HCV) is a common risk factor for the development of hepatocellular carcinoma (HCC). Although HCV treatment has dramatically changed the landscape for HCV management, its widespread use is limited by its high cost. Given this potential obstacle, our aim was to assess barriers to receiving HCV treatment and the impact of HCV treatment on survival in patients with concurrent HCC treated at safety-net hospitals compared to academic referral centers. Methods: Patients in the US Safety-Net Collaborative Database (2012-2014) with HCV and primary, non-metastatic HCC were included. The collaborative consists of five large safety-net hospitals and their academic referral center counterparts. Primary and secondary outcomes were overall survival (OS) and recurrence-free survival (RFS) based on HCV treatment status. Results: Of 941 patients who had HCV-induced cirrhosis, median age was 60 years (IQR 56-64), 78% were male (n=734), 57% received care at an academic referral center (n=533) and 43% at a safety-net hospital (n=408). 25% received HCV treatment (n=245), while 74% did not (n=696). Among those who received HCV treatment, 76% of patients received care at an academic referral center (n=186) while 24% received care at a safety-net hospital (n=59). 6% underwent resection (n=54), 17% liver transplant (n=163), 50% liver-directed therapy (radiofrequency ablation, transarterial chemoembolization, Y90, and/or radiation therapy; n=473), 7% received chemotherapy (n=60), and 20% received no HCC treatment (n=191). Median follow-up was 37 months. For all patients, HCV treatment was associated with improved median OS compared to no HCV treatment (70 vs 21 months, p<0.01; Figure1A). This association persisted across clinical stages I, II, III, and IVa (all p<0.01) and all HCC treatment modalities (all p<0.01). On multivariable Cox regression, accounting for age, insurance type, treatment facility type, MELD score, clinical stage, and HCC treatment type, HCV treatment was still associated with improved OS. In a subset analysis for patients who underwent complete tumor extirpation (surgical resection or liver transplant), patients who received HCV treatment had improved median RFS compared to those who did not (91 vs 80 months, p=0.03; Figure1B). On multivariable analysis, factors associated with not receiving HCV treatment included Black race, uninsured status, and treatment at a safety-net hospital (all p<0.03). When this patient demographic did receive HCV treatment, however, the degree of improvement in survival was similar regardless if treated at an academic referral center (5-yr OS: 56 vs 30%, p<0.01; Figure 1C) or a safety-net hospital (5-yr OS: 52 vs 23%, p<0.01; Figure 1D). Conclusion: HCV treatment for patients with HCC portends improved survival and oncologic outcomes, irrespective of clinical stage, HCC treatment modality, or type of treatment facility. Despite this, given its high cost and associated barriers, a minority of patients treated at safety-net hospitals receive HCV treatment. Efforts must be directed towards removing obstacles that prevent this vulnerable patient population from receiving the standard of care treatment for HCV with concurrent HCC.