Multispecialist Care and Mortality in Hepatocellular Carcinoma

Chirikov, Viktor; Mullins, C. Daniel; Hanna, Nader; Breunig, Ian M.; Seal, Brian; Shaya, Fadia T.

doi:10.1097/coc.0000000000000000

Cited by 14 publications

(16 citation statements)

References 42 publications

(48 reference statements)

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“…Thus, whether management by a hepatologist per se, or management at an institution with hepatology services, explains improved outcomes requires further study. The finding that multidisciplinary tumor board discussion was associated with a survival benefit has been noted in previous smaller investigations showing that multidisciplinary tumor board, 36,37 multi-specialty-involvement, 9,38 and receipt of care at hospitals with liver transplant programs and National Cancer Institute-designated Comprehensive Cancer Centers 39 resulted in superior utilization of curative treatments and improved patient outcomes. 40 …”

Section: Discussionsupporting

confidence: 61%

“…These studies demonstrate that curative therapies for HCC are underutilized and care is geographically heterogeneous. 9–12 While informative, SEER-Medicare linked data are limited by: (1) inclusion of older patients less likely to be candidates for transplantation and other curative therapies; (2) American Joint Committee on Cancer TNM staging that is rarely utilized for clinical decision-making; and (3) non-documentation of liver disease severity, a strong predictor of treatment and survival. 13 …”

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confidence: 99%

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Association of Provider Specialty and Multidisciplinary Care With Hepatocellular Carcinoma Treatment and Mortality

et al. 2017

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BACKGROUND & AIMS Little is known about provider and health system factors that affect receipt of active therapy and outcomes of patients with hepatocellular carcinoma (HCC). We investigated patient, provider, and health system factors associated with receipt of active HCC therapy and overall survival. METHODS We performed a national, retrospective cohort study of all patients diagnosed with HCC from January 1, 2008 through December 31, 2010 (n = 3988) and followed through December 31 2014 who received care through the Veterans Administration (128 centers). Outcomes were receipt of active HCC therapy (liver transplantation, resection, local ablation, transarterial therapy, or sorafenib) and overall survival. RESULTS In adjusted analyses, receiving care at an academically affiliated Veterans Administration hospital (odds ratio [OR], 1.97; 95% confidence interval [CI], 1.60–2.41) or a multi-specialist evaluation (OR, 1.60; 95% CI, 1.15–2.21), but not review by a multidisciplinary tumor board (OR, 1.19; 95% CI, 0.98–1.46), was associated with a higher likelihood of receiving active HCC therapy. In time-varying Cox proportional hazards models, liver transplantation (hazard ratio [HR], 0.22; 95% CI, 0.16–0.31), liver resection (HR, 0.38; 95% CI, 0.28–0.52), ablative therapy (HR, 0.63; 95% CI, 0.52–0.76), and transarterial therapy (HR, 0.83; 95% CI, 0.74–0.92) were associated with reduced mortality. Subspecialist care by hepatologists (HR, 0.70; 95% CI, 0.63–0.78), medical oncologists (HR, 0.82; 95% CI, 0.74–0.91), or surgeons (HR, 0.79; 95% CI, 0.71–0.89) within 30 days of HCC diagnosis, and review by a multidisciplinary tumor board (HR, 0.83; 95% CI, 0.77–0.90), were associated with reduced mortality. CONCLUSIONS In a retrospective cohort study of almost 4000 patients with HCC cared for at VA centers, geographic, provider, and system differences in receipt of active HCC therapy are associated with patient survival. Multidisciplinary methods of care delivery for HCC should be prospectively evaluated and standardized to improve access to HCC therapy and optimize outcomes.

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Section: Discussionsupporting

confidence: 61%

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confidence: 99%

Association of Provider Specialty and Multidisciplinary Care With Hepatocellular Carcinoma Treatment and Mortality

et al. 2017

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“…In the integrated conference/clinic format (n = 20), patients were seen by co‐located providers who also convened during the clinic day to formally review all cases and finalize the treatment recommendations, which were subsequently discussed with the patient. Two studies did not specify the delivery format . Descriptions of the structural and operational components of the MTP intervention were generally limited, which restricted interpretations about the correlation between structural and operational components and the observed outcomes.…”

Section: Resultsmentioning

confidence: 99%

“…The diverse range of outcomes examined across studies is presented in Table . Table summarizes the outcome data with studies grouped according to MTP delivery format and disease site. Sixteen of 19 studies demonstrated an association between MTP and receipt of guideline‐concordant treatment.…”

Section: Resultsmentioning

confidence: 99%

Outcomes of multidisciplinary treatment planning in US cancer care settings

Das

Baker

Altice

et al. 2018

Cancer

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Multidisciplinary treatment planning (MTP) is a process of engaging multiple disciplines to develop or refine the disease management plan. It is widely implemented in US cancer treatment settings and is considered to have favorable effects on both care quality and other outcomes. However, evidence reviews to date regarding MTP effectiveness have based their conclusions on studies conducted predominantly outside the United States. The authors conducted a systematic review of US-based studies to synthesize and critically appraise evidence of the effects of MTP on cancer care quality, health services outcomes, and survival. Database searches identified studies of MTP outcomes conducted in US cancer care settings from 2000 to 2017. Forty-five studies met criteria for inclusion. MTP was associated with favorable effects on several indicators of cancer care quality, including delivery of guideline-concordant treatment and improvements in diagnostic accuracy, staging completeness, surgical technique, and timeliness. Effects on survival and clinical trials enrollment were mixed. Delivery formats for MTP were generally not well described, and study designs were nonrandomized, limiting the ability to identify mediators of intervention effects. Continued study is warranted to clarify effective components of MTP interventions, and to understand the mechanism(s) through which MTP produces favorable effects on outcomes.

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“…Prior studies have demonstrated that utilization of multidisciplinary tumor directed care is associated with improved HCC patient outcomes, unfortunately our analysis does not account for tumor board involvement. 24 The HCC patient cohort was large, thus some reported statistical differences might not be clinically meaningful. Furthermore, missingness of patient and tumor characteristics occurs at a higher frequency in HCC patients who did not receive any oncologic intervention, which may bias the propensity score matching process.…”

Section: Discussionmentioning

confidence: 99%

A SEER Database Analysis of the Survival Advantage of Transarterial Chemoembolization for Hepatocellular Carcinoma: An Underutilized Therapy

Gray

White

Liu

et al. 2017

Journal of Vascular and Interventional Radiology

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Purpose To measure TACE utilization and survival benefit among patients with HCC in the SEER patient population. Method and Methods A retrospective study identified 37, 832 patients with HCC diagnosed between 1991 and 2011. Survival was estimated by Kaplan-Meier method and compared using the log rank test. Propensity score matching was used to address imbalance of covariates. Results Over 75% of HCC patients did not receive any HCC directed treatment. TACE was the most common initial therapy (15.9%). Factors associated with TACE utilization included younger age, more HCC risk factors, more comorbidities, higher socio-economic status, intrahepatic tumor, unifocal tumor, vascular invasion, and smaller tumor size (all p<0.001). Median survival was improved in patients treated with TACE compared to those not treated with TACE (20.1 vs. 4.3 months, p<0.0001). Similar findings were demonstrated in propensity scoring analysis (14.5 vs. 4.2 months, p<0.0001) and immortal time bias sensitivity analysis (9.5 vs. 3.6 months, p<0.0001). There was a significantly improved survival hazard ratio in patients treated with TACE [HR 0.42 (95%CI 0.39 – 0.45)]. Conclusions HCC patients treated with TACE experienced significant survival advantage compared to those not treated with TACE. Over 75% of SEER-Medicare patients diagnosed with HCC received no identifiable oncologic treatment. There is a significant public health need to increase awareness of efficacious HCC treatments such as TACE.

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Multispecialist Care and Mortality in Hepatocellular Carcinoma

Cited by 14 publications

References 42 publications

Association of Provider Specialty and Multidisciplinary Care With Hepatocellular Carcinoma Treatment and Mortality

Association of Provider Specialty and Multidisciplinary Care With Hepatocellular Carcinoma Treatment and Mortality

Outcomes of multidisciplinary treatment planning in US cancer care settings

A SEER Database Analysis of the Survival Advantage of Transarterial Chemoembolization for Hepatocellular Carcinoma: An Underutilized Therapy

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