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Trends and Disparities in Treatment Utilization for Early-Stage Hepatocellular Carcinoma in the Veteran Population

  • Hepatobiliary Tumors
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Abstract

Background

The incidence of hepatocellular carcinoma (HCC) has substantially increased over the last two decades within the Veteran Affairs Health System (VAHS). This study aims to describe the temporal trend of early-stage HCC (ES-HCC) treatment in the VAHS and identify patient/hospital factors associated with treatment disparities.

Patients and Methods

VA Corporate Data Warehouse was used to identify patients diagnosed with ES-HCC (stages I/II) from 2001 to 2015. Initial course of therapy was categorized as curative treatment (CT), noncurative treatment (NCT), or no treatment (NT). Univariate logistic regression and stepwise multivariate logistic regression models were used to analyze factors associated with receipt of treatment (CT/NCT) versus NT and receipt of CT versus NCT.

Results

Our study included 9504 patients (15% CT, 51% NCT, and 34% NT). During the study period, the rate of overall treatment increased, while the rate of CT decreased (p < 0.001). Stage II, age > 65 years, presence of non-alcoholic fatty liver disease (NAFLD), Child–Pugh C, higher Model for End-Stage Liver Disease (MELD) score, platelets < 100,000/mm3, low hospital complexity score, and Southwest location were significantly associated with higher rates of NT (all p < 0.05). Factors significantly associated with decreased utilization of CT included Hispanic race, lower hospital complexity score, and treatment in the Midwest, West, or Southeast regions (all p < 0.05).

Conclusions

There is a significant trend toward increased overall treatment utilization with decreased use of curative-intent approaches for ES-HCC in the national veteran population, and significant hospital and regional disparities exist. Further characterization and investigation of these factors may facilitate implementation of interventions to improve treatment utilization for the veteran population with HCC.

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References

  1. Bray F, Ferlay J, Soerjomataram I. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. 2018;394-424. https://doi.org/10.3322/caac.21492

  2. Outcomes M. The burden of primary liver cancer and underlying etiologies from 1990 to 2015 at the global, regional, and national level results from the global burden of disease study 2015. JAMA Oncol. 2017;98121(12):1683–91. https://doi.org/10.1001/jamaoncol.2017.3055.

    Article  Google Scholar 

  3. Beste LA, Leipertz SL, Green PK, Dominitz JA, Ross D, Ioannou GN. Trends in burden of cirrhosis and hepatocellular carcinoma by underlying liver disease in US veterans, 2001–2013. Gastroenterology. 2015;149(6):1471-1482.e5. https://doi.org/10.1053/j.gastro.2015.07.056.

    Article  PubMed  Google Scholar 

  4. Mittal S, El-Serag HB, Sada YH, et al. Hepatocellular carcinoma in the absence of cirrhosis in United States veterans is associated with nonalcoholic fatty liver disease. Clin Gastroenterol Hepatol. 2016;14(1):124-131.e1. https://doi.org/10.1016/j.cgh.2015.07.019.

    Article  CAS  PubMed  Google Scholar 

  5. Mittal S, Sada YH, El-Serag HB, et al. Temporal trends of nonalcoholic fatty liver disease-related hepatocellular carcinoma in the veteran affairs population. Clin Gastroenterol Hepatol. 2015. https://doi.org/10.1016/j.cgh.2014.08.013.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Fisher ES, Welch HG. The future of the department of veterans affairs health care system. JAMA. 1995. https://doi.org/10.1001/jama.1995.03520320061042.

    Article  PubMed  Google Scholar 

  7. Serper M, Kaplan DE, Serper M, et al. Association of provider specialty and multidisciplinary care with hepatocellular carcinoma treatment and mortality. Gastroenterology. 2017. https://doi.org/10.1053/j.gastro.2017.02.040.

    Article  PubMed  Google Scholar 

  8. Huerta S, Pham T, Foster S, Livingston EH, Dineen S. Outcomes of emergent inguinal hernia repair in veteran octogenarians. Am Surg. 2014. https://doi.org/10.1177/000313481408000519.

    Article  PubMed  Google Scholar 

  9. Rodriguez Villalvazo Y, McDanel JS, Beste LA, Sanchez AJ, Vaughan-Sarrazin M, Katz DA. Effect of travel distance and rurality of residence on initial surveillance for hepatocellular carcinoma in VA primary care patient with cirrhosis. Health Serv Res. 2020. https://doi.org/10.1111/1475-6773.13241.

    Article  PubMed  Google Scholar 

  10. Davila JA, Kramer JR, Duan Z, et al. Referral and receipt of treatment for hepatocellular carcinoma in United States veterans: effect of patient and nonpatient factors. Hepatology. 2013;57(5):1858–68. https://doi.org/10.1002/hep.26287.

    Article  CAS  PubMed  Google Scholar 

  11. Zou WY, El-Serag HB, Sada YH, et al. Determinants and outcomes of hospice utilization among patients with advance-staged hepatocellular carcinoma in a Veteran affairs population. Dig Dis Sci. 2018. https://doi.org/10.1007/s10620-018-4989-4.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Fihn SD, Francis J, Clancy C, et al. Insights from advanced analytics at the veterans health administration. Health Aff. 2014. https://doi.org/10.1377/hlthaff.2014.0054.

    Article  Google Scholar 

  13. Health Services Research and Development. Corporate Data Warehouse. US Department of Veterans Affairs.

  14. Quan H, Fong A, Burnand B, Saunders LD, Feasby TE, Ghali WA. Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care. 2005. https://doi.org/10.1016/j.aquaculture.2009.07.004.

    Article  PubMed  Google Scholar 

  15. Kaplan DE, Dai F, Aytaman A, et al. Development and performance of an algorithm to estimate the Child–Turcotte–Pugh score from a national electronic healthcare database. Clin Gastroenterol Hepatol. 2015;13(13):2333-2341.e6. https://doi.org/10.1016/j.cgh.2015.07.010.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Kamath PS, Kim WR. The model for end-stage liver disease (MELD). Hepatology. 2007;45(3):797–805. https://doi.org/10.1002/hep.21563.

    Article  PubMed  Google Scholar 

  17. Trombold J, Farmer RW, McCafferty M. The impact of colorectal cancer screening in a Veteran Hospital population. Am Surg. 2013. https://doi.org/10.1177/000313481307900330.

    Article  PubMed  Google Scholar 

  18. N. T, P. R, D.L. W, et al. Evaluating screening approaches for hepatocellular carcinoma in a cohort of HCV related cirrhosis patients from the Veteran’s Affairs Health Care System. BMC Med Res Methodol. 2018. https://doi.org/10.1186/s12874-017-0458-6 LK - http://ucelinks.cdlib.org:8888/sfx_local?sid=&genre=&issn=&date=2018&volume=18&issue=1&spage=1&epage=&title=BMC+medical+research+methodology&atitle=Evaluating+screening+approaches+for+hepatocellular+carcinoma+in+a+cohort+of+HCV+related+cirrhosis+patients+from+the+Veteran%27s+Affairs+Health+Care+System&aulast=Tayob&aufirst=Nabihah&isbn=&id=DOI:10.1186%2Fs12874-017-0458-6&ABBR=&arnumber=&sid=EMBASE&issn=14712288&id=doi:10.1186%2Fs12874-017-0458-6&atitle=Evaluating+s

  19. Tayob N, Christie I, Richardson P, et al. Validation of the hepatocellular carcinoma early detection screening (HES) algorithm in a cohort of veterans with cirrhosis. Clin Gastroenterol Hepatol. 2019. https://doi.org/10.1016/j.cgh.2018.12.005.

    Article  PubMed  Google Scholar 

  20. Heimbach JK, Kulik LM, Finn RS, et al. AASLD guidelines for the treatment of hepatocellular carcinoma. Hepatology. 2018. https://doi.org/10.1002/hep.29086.

    Article  PubMed  Google Scholar 

  21. Vitale A, Morales RR, Zanus G, et al. Barcelona clinic liver cancer staging and transplant survival benefit for patients with hepatocellular carcinoma: a multicentre, cohort study. Lancet Oncol. 2011. https://doi.org/10.1016/S1470-2045(11)70144-9.

    Article  PubMed  Google Scholar 

  22. Bruix J, Reig M, Sherman M. Evidence-based diagnosis, staging, and treatment of patients with hepatocellular carcinoma. Gastroenterology. 2016. https://doi.org/10.1053/j.gastro.2015.12.041.

    Article  PubMed  Google Scholar 

  23. Shah SA, Smith JK, Li YF, Ng SC, Carroll JE, Tseng JF. Underutilization of therapy for hepatocellular carcinoma in the medicare population. Cancer. 2011;117(5):1019–26. https://doi.org/10.1002/cncr.25683.

    Article  PubMed  Google Scholar 

  24. Hoehn RS, Hanseman DJ, Jernigan PL, Wima K, Ertel AE, Abbott DE, Shah SA. Cincinnati research in outcomes and safety in surgery (CROSS). Disparities in care for patients with curable hepatocellular carcinoma. HPB (Oxford). 2015;17(9):747–52. https://doi.org/10.1111/hpb.12427.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Yopp AC, Mansour JC, Beg MS, et al. Establishment of a multidisciplinary hepatocellular carcinoma clinic is associated with improved clinical outcome. Ann Surg Oncol. 2014. https://doi.org/10.1245/s10434-013-3413-8.

    Article  PubMed  Google Scholar 

  26. Chang TT, Sawhney R, Monto A, Davoren JBEN. Implementation of a multidisciplinary treatment team for hepatocellular cancer at a Veterans Affairs Medical Center improves survival. 2008. https://doi.org/10.1080/13651820802356572

  27. Lau K, Salami A, Barden G, et al. The effect of a regional hepatopancreaticobiliary surgical program on clinical volume, quality of cancer care, and outcomes in the veterans affairs system. JAMA Surg. 2014. https://doi.org/10.1001/jamasurg.2014.1711.

    Article  PubMed  Google Scholar 

  28. Goldberg DS, Taddei TH, Serper M, et al. Identifying barriers to hepatocellular carcinoma surveillance in a national sample of patients with cirrhosis. Hepatology. 2017. https://doi.org/10.1002/hep.28765.

    Article  PubMed  Google Scholar 

  29. Singal AG, Yopp AS, Skinner C, Packer M, Lee WM, Tiro JA. Utilization of hepatocellular carcinoma surveillance among American patients: a systematic review. J Gen Intern Med. 2012. https://doi.org/10.1007/s11606-011-1952-x.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Hwa KJ, Dua MM, Wren SM, Visser BC. Missing the obvious: psychosocial obstacles in veterans with hepatocellular carcinoma. HPB. 2015. https://doi.org/10.1111/hpb.12508.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Shiina S, et al. Percutaneous ablation for hepatocellular carcinoma: comparison of various ablation techniques and surgery. Can J Gastroenterol Hepatol, 2018. 2018.

  32. Putzer D, et al. Thermal ablation—an option in curative treatment of HCC. Memo Mag Eur Med Oncol. 2020;13(2):207–11.

    Google Scholar 

  33. Zhu F, Rhim H. Thermal ablation for hepatocellular carcinoma: what’s new in 2019. Chin Clin Oncol. 2019;8(6):58–58.

    Article  Google Scholar 

  34. O’Leary C, Mahler M, Soulen MC. Curative-intent therapies in localized hepatocellular carcinoma. Curr Treat Options Oncol. 2020;21(4):1–14.

    Article  Google Scholar 

Download references

Funding

Dr. Polanco received financial support from the New Investigator Program of the Veterans Affairs North Texas Healthcare System for this project.

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Authors and Affiliations

  1. Department of Surgery, Division of Surgical Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA

    Patricio M. Polanco MD, Michelle R. Ju MD, MPH, M. Mathew Augustine MD, Herbert J. Zeh III MD & Adam C. Yopp MD

  2. Department of Population and Clinical Science, University of Texas Southwestern Medical Center, Dallas, TX, USA

    Matthieu Chansard MCRC

  3. Dallas VA Medical Center, Department of Veterans Affairs, Dallas, TX, USA

    Patricio M. Polanco MD, M. Mathew Augustine MD & Jennie Meier MD

  4. Department of Medicine, University of Connecticut Health Center, Farmington, CT, USA

    Eric Mortensen MD

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  1. Patricio M. Polanco MD
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  2. Michelle R. Ju MD, MPH
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  4. M. Mathew Augustine MD
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  7. Herbert J. Zeh III MD
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  8. Adam C. Yopp MD
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Contributions

All authors contributed to the study conception/design and preparation of the final manuscript. M.C. performed the statistical analysis.

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Correspondence to Patricio M. Polanco MD.

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Polanco, P.M., Ju, M.R., Chansard, M. et al. Trends and Disparities in Treatment Utilization for Early-Stage Hepatocellular Carcinoma in the Veteran Population. Ann Surg Oncol 29, 5488–5497 (2022). https://doi.org/10.1245/s10434-022-11897-3

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