Increased morbidity and mortality of hepatocellular carcinoma patients in lower cost of living areas

BACKGROUND The incidence and mortality rates of hepatocellular carcinoma(HCC)are increasing in the United States.However,the increases in different racial and socioeconomic groups have not been homogeneous.Access to healthcare based on socioeconomic status and cost of living index(COLI),especially in HCC management,is under characterized.AIM The aim was to investigate the relationship between the COLI and tumor characteristics,treatment modalities,and survival of HCC patients in the United States.METHODS A retrospective study of the Surveillance,Epidemiology,and End Results(SEER)database was conducted to identify patients with HCC between 2007 and 2015 using site code C22.0 and the International Classification of Disease for Oncology,3rd edition(ICD-O-3)codes 8170-8173,and 8175.Cases of fibrolamellar HCC were excluded.Variables collected included demographics,COLI,insurance status,marital status,stage,treatment,tumor size,and survival data.Interquartile ranges for COLI were obtained.Based on the COLI,the study population was separated into four groups:COLI≤901,902-1044,1045-1169,≥1070.Theχ2 test was used to compare categorical variables,and the Kruskal-Wallis test was used to compare continuous variables without normal distributions.Survival was estimated by the Kaplan-Meier method.We defined P<0.05 as statistically significant.RESULTS We identified 47,894 patients with HCC.Patients from the highest COLI areas were older(63 vs 61 years of age),more likely to be married(52.8%vs 48.0%),female(23.7%vs 21.1%),and of Asian and Pacific Islander descent(32.7%vs 4.8%).The patients were more likely to have stage I disease(34.2%vs 32.6%),tumor size≤30 mm(27.1%vs 23.1%),received locoregional therapy(11.5%vs 6.1%),and undergone surgical resection(10.7%vs 7.0%)when compared with the lowest quartile.The majority of patients with higher COLIs resided in California,Connecticut,Hawaii,and New Jersey.Patients with lower COLIs were more likely to be uninsured(5.7%vs 3.4%),have stage IV disease(15.2%vs 13%),and have received a liver transplant(6.6%vs 4.4%)compared with patients from with the highest COLI.Median survival increased with COLI from 8(95%CI:7-8),to 10(10-11),11(11-12),and 14(14-15)mo(P<0.001)among patients with COLIs of≤901,902-1044,1045-1169,≥1070,respectively.After stratifying by year,a survival trend was present:2007-2009,2010-2012,and 2013-2015.CONCLUSION Our study suggested that there were racial and socioeconomic disparities in HCC.Patients from lower COLI groups presented with more advanced disease,and increasing COLI was associated with improved median survival.Future studies should examine this further and explore ways to mitigate the differences.

Survival characteristics of fibrolamellar hepatocellular carcinoma:A Surveillance,Epidemiology,and End Results database study

BACKGROUND Fibrolamellar hepatocellular carcinoma(FL-HCC)is a rare and distinct type of hepatocellular carcinoma that frequently presents in an advanced stage in younger patients with no underlying liver disease.Currently,there is a limited understanding of factors that impact outcomes in FL-HCC.AIM To characterize the survival of FL-HCC by age,race,and surgical intervention.METHODS This is a retrospective study of The Surveillance,Epidemiology,and End Results database.We identified patients with FL-HCC between 2000-2018 by using an ICD-O-3 site code C22.0 and a histology code 8171/3:Hepatocellular carcinoma,fibrolamellar.In addition,demographics,tumor characteristics,types of surgical procedure,stages,and survival data were obtained.We conducted three separate survival analyses by age groups;≤19,20-59,and≥60-year-old,and race;White,Black,Hispanic,Asian and Pacific islanders(API),and surgical types;Wedge resection or segmental resection,lobectomy,extended lobectomy(lobectomy+locoregional therapy or resection of the other lobe),and transplant.The Chi-Square test analyzed categorical variables,and continuous variables were examined using the Mann-Whitney U test.The Kaplan-Meier survival curve was used to compare survival.Multivariate analysis was done with Cox regression analysis.RESULTS We identified 225 FL-HCC patients with a mean age of 36.9.Overall median survival was 34(95%CI:27-41)mo.Patients≤19-years-old had more advanced disease with positive lymph nodes status.However,they received more surgical interventions such as a wedge,segmental resection,lobectomy,extended lobectomy,and transplant.Survival for≤19 was 85(95%CI:37-137)mo,age 20-59 was 29(95%CI:18-41)mo,and age≥60 years was 12(95%CI:7-31)mo(P<0.001).There were no differences in stage,lymph node status,metastasis status,and surgical treatment among races.The median survival were;Whites had 39(95%CI:29-63),Blacks 26(95%CI:5-92),Hispanics 31(95%CI:11-54),and APIs 28(95%CI:5-39)mo(P=0.28).Of 225 patients,111 FL-HCC patients had surgical procedures.Median survivals for a wedge or segmental resection was 112(95%CI:78-NA),lobectomy was 92(95%CI:57-NA),extended lobectomy was 54(95%CI:23-NA),and a transplant was 63(95%CI:20-NA)mo(P<0.001).The median survival was better in patients who had surgical treatments regardless of lymph nodes or metastasis status(P<0.001).CONCLUSION FL-HCC occurs in a primarily younger population,but survival can be prolonged despite the aggressive disease.There were no racial differences in the survival of FL-HCC;however,Asians with FL-HCC tended to be older than in other races.Surgical treatment provided better survival even in those patients with nodal disease or metastases.Although future studies are needed to explore other therapies for FL-HCC,surgical options should be considered in all cases of FL-HCC unless contraindicated.

Current status of disparity in liver disease

Disparities have emerged as an important issue in many aspects of healthcare in developed countries and may be based on race,ethnicity,sex,geographical location,and socioeconomic status.For liver disease specifically,these potential disparities can affect access to care and outcome in viral hepatitis,chronic liver disease,and hepatocellular carcinoma.Shortages in hepatologists and medical providers versed in liver disease may amplify these disparities by compromising early detection of liver disease,surveillance for hepatocellular carcinoma,and prompt referral to subspecialists and transplant centers.In the United States,continued efforts have been made to address some of these disparities with better education of healthcare providers,use of telehealth to enhance access to specialists,reminders in electronic medical records,and modifying organ allocation systems for liver transplantation.This review will detail the current status of disparities in liver disease and describe current efforts to minimize these disparities.