Disparities in Care and Survival for Patients with Early-Stage HCC

In recent years, there has been an increasing incidence of hepatocellular carcinoma (HCC) in the United States. Survival in patients with advanced HCC has an overall 5-year rate of 5%; patients diagnosed in the early stages of HCC have the best chance of a cure. Current treatments, including tumor ablation, hepatic resection, liver transplant, or combined modalities, require complex care and are only available at tertiary referral centers. According to researchers, recent data from the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) program suggest that there are racial/ethnic disparities in the use of surgical therapy for HCC. SEER data reveal that black patients with HCC receive surgical treatment less often than white patients; it is not known whether these differences in the receipt of invasive therapy are linked to racial/ethnic differences in survival. Researchers recently conducted a retrospective cohort study to determine whether controlling for differences in the use of invasive therapy affects racial/ethnic difference in survival of early-stage HCC. They reported study results in Archives of Surgery [2010;145(12):1158-1163]. The primary study outcome was patient survival. Invasive therapy was defined as tumor ablation or local tumor destruction, hepatic resection, or liver transplant. Race/ethnicity was defined as white, black, Asian, Hispanic, or other (native Americans and Alaskans, Native Hawaiians, and those of unknown or mixed race/ethnicity; those of nonwhite Hispanic ethnicity were also categorized as other). The analysis included variables that could affect access to invasive therapy or patient survival. Clinical variables included age at diagnosis, date of diagnosis, and size of tumor. Educational and socioeconomic variables included percentage of individuals with a high school diploma, median annual household income, percentage of individuals living below the federal poverty line, percentage of individuals with white-collar jobs, and percentage of households self-identified as being isolated by language. The study included 13,244 patients who were diagnosed with early-stage HCC between January 1, 1995, and December 31, 2006. Of the total cohort, 47.7% (n=6316) were white, 22.8% (n=3022) were Asian, 16.8% (n=2230) were Hispanic, 10.5% (n=1397) were black, and 2.1% (n=279) were categorized as other. Mean age of the cohort was 63.6 years. White patients were older at diagnosis: 65.1 years of age compared with 60.4 years for black patients, 61.89 years for Hispanic patients, 63.1 years for Asian patients, and 61.3 years for patients categorized as other (P<.001). Across races/ethnicities, 73.5% of the patients were male. Asian and other patients had larger tumors compared with those in the other 3 groups. A significantly lower percentage of black patients were married compared with the other groups (P<.001). Asian patients resided in areas of higher socioeconomic status compared with patients in the other groups (P<.001). Only 32.8% of patients received invasive therapy for HCC during the study period. Compared with white, Asian, and other patients, the black and Hispanic groups had higher proportions of untreated patients (P<.001). The rates of hepatic resection were significantly higher in Asian patients compared with the other groups (P<.001). The rate of tumor ablation was fairly uniform for each group (range, 9.6%-12.0%); liver transplant was more common in white patients compared with the other groups. In the base survival model, the analysis found higher mortality rates for black (hazard ratio [HR], 1.24; 95% confidence interval [CI], 1.15-1.33) and Hispanic (HR, 1.08; 95% CI, 1.01-1.15) patients and lower mortality rates for Asians (HR, 0.87; 95% CI, 0.82-0.93) compared with white patients. After stratification for treatment type, blacks had a 12% higher mortality rate compared with white patients (HR, 1.11; 95% CI, 1.03-1.20). The mortality rate among Hispanics was similar to that of white patients (HR, 0.97; 95% CI, 0.91-1.04), and Asians had a 16% lower mortality rate than the white patients (HR, 0.84; 95% CI, 0.79-0.89). In summary, the researchers stated: “For early-stage HCC, racial/ethnic disparities in survival between minority and white patients are notable. After accounting for differences in stage, use of invasive therapy, and treatment benefit, no racial/ethnic survival disparity is evident between Hispanics and whites, but blacks have persistently poor survival.”