Journal of Gastrointestinal Surgery

, Volume 11, Issue 12, pp 1636–1646 | Cite as

Racial and Geographic Disparities in the Utilization of Surgical Therapy for Hepatocellular Carcinoma

  • Christopher J. Sonnenday
  • Justin B. Dimick
  • Richard D. Schulick
  • Michael A. Choti


The incidence of hepatocellular carcinoma (HCC) continues to increase, a trend that will likely continue because of the rising prevalence of chronic hepatitis C infection. This study sought to determine the recent patterns of utilization of surgical therapy (hepatectomy, ablation, or liver transplantation) for HCC from the Surveillance, Epidemiology, and End Results national cancer registry. Data were extracted for 16,121 patients with HCC diagnosed between 1998 and 2004. Twenty-three percent of patients underwent surgical therapy (9.5% resection, 7.8% ablation, 6% transplant); the proportion of patients treated with surgical therapy increased ∼9% over the study period. On multivariate analysis, female sex, younger age, and smaller solitary tumors were associated with increased utilization of surgical therapy. Blacks and Hispanics were 24–27% less likely to receive surgical therapy than white individuals (P < 0.001). Racial and geographic disparities persisted despite the adjustment for Health Service Area and limitation of the cohort to small localized HCC. Blacks were especially disadvantaged in the utilization of liver transplant for small HCC (OR= 0.42, P < 0.001). Further investigation to understand the etiology of these profound racial and geographic disparities is essential to ensure equitable provision of surgical therapies, which provide the only potentially curative treatments for HCC.


Hepatocellular cancer Racial disparity Geographic disparity Liver transplantation Surgery 


  1. 1.
    Bosch FX, et al. Primary liver cancer: worldwide incidence and trends. Gastroenterology. 2004;127(5 supp 1):S5–16.Google Scholar
  2. 2.
    El-Serag HB, Mason AC. Rising incidence of hepatocellular carcinoma in the United States. N Engl J Med. 1999;340(10):745–750.PubMedCrossRefGoogle Scholar
  3. 3.
    Ries LAG, et al. SEER Cancer Statistics Review, 1975–2004. Bethesda, MD: National Cancer Insititute; 2007.Google Scholar
  4. 4.
    El-Serag HB. Epidemiology of hepatocellular carcinoma. Clin Liver Dis. 2001;5(1):87–107. vi.PubMedCrossRefGoogle Scholar
  5. 5.
    Davila JA, et al. Hepatitis C infection and the increasing incidence of hepatocellular carcinoma: a population-based study. Gastroenterology. 2004;127(5):1372–1380.PubMedCrossRefGoogle Scholar
  6. 6.
    Llovet JM. Updated treatment approach to hepatocellular carcinoma. J Gastroenterol. 2005;40(3):225–235.PubMedCrossRefGoogle Scholar
  7. 7.
    Llovet JM, Schwartz M, Mazzaferro V. Resection and liver transplantation for hepatocellular carcinoma. Semin Liver Dis. 2005;25(2):181–200.PubMedCrossRefGoogle Scholar
  8. 8.
    Cha CH, et al. Resection of hepatocellular carcinoma in patients otherwise eligible for transplantation. Ann Surg. 2003;238(3):315–321. discussion 321–323.PubMedGoogle Scholar
  9. 9.
    Shiina S, et al. A randomized controlled trial of radiofrequency ablation with ethanol injection for small hepatocellular carcinoma. Gastroenterology. 2005;129(1):122–130.PubMedCrossRefGoogle Scholar
  10. 10.
    Lin SM, et al. Radiofrequency ablation improves prognosis compared with ethanol injection for hepatocellular carcinoma < or = 4 cm. Gastroenterology. 2004;127(6):1714–1723.PubMedCrossRefGoogle Scholar
  11. 11.
    Livraghi T, et al. Small hepatocellular carcinoma: treatment with radio-frequency ablation versus ethanol injection. Radiology. 1999;210(3):655–661.PubMedGoogle Scholar
  12. 12.
    Marrero JA, Pelletier S. Hepatocellular carcinoma. Clin Liver Dis. 2006;10(2):339–51. ix.PubMedCrossRefGoogle Scholar
  13. 13.
    Hemming AW, et al. Liver transplantation for hepatocellular carcinoma. Ann Surg. 2001;233(5):652–659.PubMedCrossRefGoogle Scholar
  14. 14.
    Mazzaferro V, et al. Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis. N Engl J Med. 1996;334(11):693–699.PubMedCrossRefGoogle Scholar
  15. 15.
    National Center for Health Statistics (US). Atlas of United States Mortality NCHS Atlas CD-ROM No.1. Hyattsville, MD: Dept. of Health and Human Services; 1997.Google Scholar
  16. 16.
    Makuc DM, et al. Health service areas for the United States. Vital Health Stat. 1991;2(112):1–102.Google Scholar
  17. 17.
    Makuc DM, et al. The use of health service areas for measuring provider availability. J Rural Health. 1991;7(4 supp):347–356.PubMedGoogle Scholar
  18. 18.
    Cha C, et al. Predictors and patterns of recurrence after resection of hepatocellular carcinoma. J Am Coll Surg. 2003;197(5):753–758.PubMedCrossRefGoogle Scholar
  19. 19.
    Fong Y, et al. An analysis of 412 cases of hepatocellular carcinoma at a Western center. Ann Surg. 1999;229(6):790–799. discussion 799–800.PubMedCrossRefGoogle Scholar
  20. 20.
    Yao FY, et al. Liver transplantation for hepatocellular carcinoma: comparison of the proposed UCSF criteria with the Milan criteria and the Pittsburgh modified TNM criteria. Liver Transpl. 2002;8(9):765–774.PubMedCrossRefGoogle Scholar
  21. 21.
    Yao FY, Roberts JP. Applying expanded criteria to liver transplantation for hepatocellular carcinoma: too much too soon, or is now the time? Liver Transpl. 2004;10(7):919–921.PubMedCrossRefGoogle Scholar
  22. 22.
    Yao FY, et al. A prospective study on downstaging of hepatocellular carcinoma prior to liver transplantation. Liver Transpl. 2005;11(12):1505–1514.PubMedCrossRefGoogle Scholar
  23. 23.
    Sloane D, Chen H, Howell C. Racial disparity in primary hepatocellular carcinoma: tumor stage at presentation, surgical treatment and survival. J Natl Med Assoc. 2006;98(12):1934–1939.PubMedGoogle Scholar
  24. 24.
    Davila JA, El-Serag HB. Racial differences in survival of hepatocellular carcinoma in the United States: a population-based study. Clin Gastroenterol Hepatol. 2006;4(1):104–110. quiz 4–5.PubMedCrossRefGoogle Scholar
  25. 25.
    El-Serag HB, et al. Treatment and outcomes of treating of hepatocellular carcinoma among Medicare recipients in the United States: a population-based study. J Hepatol. 2006;44(1):158–166.PubMedCrossRefGoogle Scholar
  26. 26.
    Morris AM, et al. Racial disparities in late survival after rectal cancer surgery. J Am Coll Surg. 2006;203(6):787–794.PubMedCrossRefGoogle Scholar
  27. 27.
    Dominitz JA, et al. Race, treatment, and survival of veterans with cancer of the distal esophagus and gastric cardia. Med Care. 2002;40(1 supp):I14–I26.PubMedGoogle Scholar
  28. 28.
    Eloubeidi MA, et al. Prognostic factors for survival in pancreatic cancer: a population-based study. Am J Surg. 2006;192(3):322–329.PubMedCrossRefGoogle Scholar
  29. 29.
    Smedley BD, et al. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, vol xvi. Washington, DC: National Academies; 2003. p. 764.Google Scholar
  30. 30.
    Dartmouth Medical School. Center for the Evaluative Clinical Sciences. The Dartmouth Atlas of Health Care 1998, 1 Atlas. Chicago, IL: American Hospital; 1998. 305 pp.Google Scholar
  31. 31.
    Skinner J, et al. Racial, ethnic, and geographic disparities in rates of knee arthroplasty among Medicare patients. N Engl J Med. 2003;349(14):1350–1359.PubMedCrossRefGoogle Scholar
  32. 32.
    Weinstein JN, et al. United States’ trends and regional variations in lumbar spine surgery: 1992–2003. Spine. 2006;31(23):2707–2714.PubMedGoogle Scholar
  33. 33.
    Pope GD, Birkmeyer JD, Finlayson SR. National trends in utilization and in-hospital outcomes of bariatric surgery. J Gastrointest Surg. 2002;6(6):855–860. discussion 861.PubMedCrossRefGoogle Scholar
  34. 34.
    Dimick JB, Finlayson SR, Birkmeyer JD. Regional availability of high-volume hospitals for major surgery. Health Aff (Millwood) 2004;Suppl Web Exclusives:VAR45–VAR53.Google Scholar
  35. 35.
    Finlayson SR, et al. Patient preferences for location of care: implications for regionalization. Med Care. 1999;37(2):204–209.PubMedCrossRefGoogle Scholar
  36. 36.
    Baicker K, Chandra A, Skinner JS. Geographic variation in health care and the problem of measuring racial disparities. Perspect Biol Med. 2005;48(1 supp):S42–53.PubMedGoogle Scholar
  37. 37.
    Reid AE, et al. Disparity in use of orthotopic liver transplantation among blacks and whites. Liver Transpl. 2004;10(7):834–841.PubMedCrossRefGoogle Scholar
  38. 38.
    Powe NR, Boulware LE. The uneven distribution of kidney transplants: getting at the root causes and improving care. Am J Kidney Dis. 2002;40(4):861–863.PubMedCrossRefGoogle Scholar
  39. 39.
    Pomfret EA, et al. Liver and intestine transplantation in the United States, 1996–2005. Am J Transplant. 2007;7(supp 1):1376–1389.PubMedCrossRefGoogle Scholar
  40. 40.
    Bruix J, et al. Transarterial embolization versus symptomatic treatment in patients with advanced hepatocellular carcinoma: results of a randomized, controlled trial in a single institution. Hepatology. 1998;27(6):1578–1583.PubMedCrossRefGoogle Scholar
  41. 41.
    Llovet JM, Bruix J. Systematic review of randomized trials for unresectable hepatocellular carcinoma: chemoembolization improves survival. Hepatology. 2003;37(2):429–442.PubMedCrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2007

Authors and Affiliations

  • Christopher J. Sonnenday
    • 1
    • 3
  • Justin B. Dimick
    • 1
  • Richard D. Schulick
    • 2
  • Michael A. Choti
    • 2
  1. 1.The Department of SurgeryThe University of MichiganAnn ArborUSA
  2. 2.The Department of SurgeryThe Johns Hopkins University School of MedicineBaltimoreUSA
  3. 3.The University of Michigan Medical CenterAnn ArborUSA

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