Underutilization of therapy for hepatocellular carcinoma in the medicare population

Abstract

BACKGROUND:The incidence of hepatocellular carcinoma (HCC) is increasing in the United States, and the care of these patients remains highly specialized and complex. Multiple treatment options are available for HCC but their use and effectiveness remain unknown. METHODS: Using Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data, 8730 patients who were diagnosed with HCC between 1991 and 2005 were identified. Therapy included surgical resection (8.7%), liver transplantation (1.4%), ablation (3.6%), or transarterial chemoembolization (16%). Patients who received no or palliative-only treatment were grouped together (NoTx; 70.3%). Patient, disease, and tumor factors were examined as determinants of therapy. RESULTS: HCC is increasing in the Medicare population. The median age at diagnosis was 75.1 years and 73.6% of patients were coded as white, 17.2% as Asian, 8.3% as black, and 0.9% as other race. The rate of therapy increased over time, but only 29.7% of patients overall underwent therapy. In patients with early stage HCC, only 43.1% underwent therapy. In the NoTx group, 49.4% did not have cirrhosis, 36.0% had tumors that measured <5 cm, and 39.8% were diagnosed with stage I or II disease when variables were complete. The use of therapy for all HCC patients increased over time, correlating with a commensurate increase in median survival. In multivariate regression analysis, patients who received any modality of treatment achieved significant benefit compared with the NoTx group (odds ratio, 0.41; 95% confidence interval, 0.39-0.43). CONCLUSIONS: In the Medicare population, HCC patients who received therapy experienced a substantial survival advantage over their nonoperative peers (NoTx). Despite evidence that many patients had favorable biological characteristics, <30% of patients diagnosed with HCC received any treatment.

Application of the Barcelona Clinic Liver Cancer therapeutic strategy and impact on survival

“…Finally, the initially striking finding that 30% of HCC patients did not receive BCLC recommended first-line treatment should be viewed in the context of worldwide data, or at least those from Western countries, showing underutilisation of recommended HCC treatments. [36][37][38][39] Several studies have evaluated the use of curative and palliative treatments in different types of HCC populations, finding that only one third of patients actually received treatment. More recently, a European study, specifically designed to assess adherence to current guidelines, reported improper assignment to different therapeutic choices in 40% of patients, particularly those with early stage HCC.…”

Approximately one‐half of patients with early‐stage hepatocellular carcinoma meeting Milan criteria did not receive local tumor destructive or curative surgery in the post‐MELD exception era

“…Tertiary care hospital-based studies can demonstrate a bias toward higher rates of treatment use when compared with what may be observed in the general population. The inclusion of patients with HCC of all stages as noted in prior population-based studies [14][15][16][17] does not allow for the examination of use rates in a more focused population that generally should be eligible for some type of therapy. In the current study, the study population was limited to those patients presenting in the more recent time period, when more treatment modalities and MELD priority status were available, and in those patients with localized disease meeting the Milan criteria, who generally should not have been disqualified from therapy due to tumor factors.…”

Multispecialist Care and Mortality in Hepatocellular Carcinoma

“…A similar approach to categorizing multiple HCC treatments in a hierarchy has been used elsewhere. 33 The association between multispecialty physician encounters in the pretreatment period and the treatment received was explored using descriptive statistics. Multivariate Cox survival analyses estimated the relationship between the count of physician disciplines and all-cause mortality, controlling for treatment received, demographics, cancer stage, and comorbidity.…”