Medicare/Medicaid Insurance, Rurality, and Black Race Associated With Provision of Hepatocellular Carcinoma Treatment and Survival

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  • 1 Division of Gastroenterology and Hepatology, Department of Medicine, and
  • 2 Division of Hematology/Oncology, Department of Medicine;
  • 3 Lineberger Comprehensive Cancer Center;
  • 4 Center for Pharmacoepidemiology, Department of Epidemiology; and
  • 5 Division of Surgical Oncology, Department of Surgery, University of North Carolina, Chapel Hill, North Carolina.
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Background: Early treatment of hepatocellular carcinoma (HCC) is associated with improved survival, but many patients with HCC do not receive therapy. We aimed to examine factors associated with HCC treatment and survival among incident patients with HCC in a statewide cancer registry. Materials and Methods: All patients with HCC from 2003 through 2013 were identified in the North Carolina cancer registry. These patients were linked to insurance claims from Medicare, Medicaid, and large private insurers in North Carolina. Associations between prespecified covariates and more advanced HCC stage at diagnosis (ie, multifocal cancer), care at a liver transplant center, and provision of HCC treatment were examined using multivariate logistic regression. A Cox proportional hazards model was developed to assess the association between these factors and survival. Results: Of 1,809 patients with HCC, 53% were seen at a transplant center <90 days from diagnosis, with lower odds among those who were Black (adjusted odds ratio [aOR], 0.54; 95% CI, 0.39–0.74), had Medicare insurance (aOR, 0.35; 95% CI, 0.21–0.59), had Medicaid insurance (aOR, 0.46; 95% CI, 0.28–0.77), and lived in a rural area; odds of transplant center visits were higher among those who had prediagnosis alpha fetoprotein screening (aOR, 1.74; 95% CI, 1.35–2.23) and PCP and gastroenterology care (aOR, 1.66; 95% CI, 1.27–2.18). Treatment was more likely among patients who had prediagnosis gastroenterology care (aOR, 1.68; 95% CI, 0.98–2.86) and transplant center visits (aOR, 2.42; 95% CI, 1.74–3.36). Survival was strongly associated with age, cancer stage, cirrhosis complications, and receipt of HCC treatment. Individuals with Medicare (adjusted hazard ratio [aHR], 1.58; 95% CI, 1.20–2.09) and Medicaid insurance (aHR, 1.55; 95% CI, 1.17–2.05) had shorter survival than those with private insurance. Conclusions: In this population-based cohort of patients with HCC, Medicare/Medicaid insurance, rural residence, and Black race were associated with lower provision of HCC treatment and poorer survival. Efforts should be made to improve access to care for these vulnerable populations.

Submitted February 4, 2020; accepted for publication July 1, 2020. Published online February 12, 2021.

Author contributions: Study concept and design: Sanoff, Chang, Lund, Barritt, Hayashi, Stitzenberg. Data interpretation: All authors. Statistical analysis: Chang. Drafting of manuscript: Sanoff. Critical revision: All authors.

Disclosures: Dr. Sanoff has disclosed that she has received grant/research support from Bayer. Dr. Lund has disclosed that her spouse is employed by GlaxoSmithKline. Dr. Barritt has disclosed that he has received grant/research support from Intercept Pharmaceuticals, Genfit Pharmaceuticals, Bristol-Myers Squibb, NuSirt, and Target Pharmasolutions. The remaining authors have disclosed that they have not received any financial consideration from any person or organization to support the preparation, analysis, results, or discussion of this article.

Funding: Research reported in this article was supported by the NCI of the NIH under award number K07CA160722 (H.K.S.) and by the NIH under award number T32 DK007634 (A.M.M.). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. Additional support was provided by the Cancer Information & Population Health Resource, UNC Lineberger Comprehensive Cancer Center, with funding provided by the University Cancer Research Fund via the State of North Carolina.

Correspondence: Hanna K. Sanoff, MD, MPH, University of North Carolina, Division of Hematology/Oncology, Department of Medicine, 170 Manning Drive, CB 7305, Chapel Hill, NC 27599. Email: hanna_sanoff@med.unc.edu

Supplementary Materials

    • Supplemental Materials (PDF 555.04 KB)
  • 1.

    White DL, Thrift AP, Kanwal F, . Incidence of hepatocellular carcinoma in all 50 United States, from 2000 through 2012. Gastroenterology 2017;152:812820.e5.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2.

    Petrick JL, Kelly SP, Altekruse SF, . Future of hepatocellular carcinoma incidence in the United States forecast through 2030. J Clin Oncol 2016;34:17871794.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3.

    Kohler BA, Sherman RL, Howlader N, . Annual report to the nation on the status of cancer, 1975-2011, featuring incidence of breast cancer subtypes by race/ethnicity, poverty, and state. J Natl Cancer Inst 2015;107:djv048.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4.

    El-Serag HB, Siegel AB, Davila JA, . Treatment and outcomes of treating of hepatocellular carcinoma among Medicare recipients in the United States: a population-based study. J Hepatol 2006;44:158166.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5.

    Sanoff HK, Chang Y, Stavas JM, . Effectiveness of initial transarterial chemoembolization for hepatocellular carcinoma among Medicare beneficiaries. J Natl Compr Canc Netw 2015;13:11021110.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6.

    Davila JA, Kramer JR, Duan Z, . Referral and receipt of treatment for hepatocellular carcinoma in United States veterans: effect of patient and nonpatient factors. Hepatology 2013;57:18581868.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7.

    Shah SA, Smith JK, Li Y, . Underutilization of therapy for hepatocellular carcinoma in the Medicare population. Cancer 2011;117:10191026.

  • 8.

    Lopez PM, Villanueva A, Llovet JM. Systematic review: evidence-based management of hepatocellular carcinoma—an updated analysis of randomized controlled trials. Aliment Pharmacol Ther 2006;23:15351547.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9.

    Wang J, Ha J, Lopez A, . Medicaid and uninsured hepatocellular carcinoma patients have more advanced tumor stage and are less likely to receive treatment. J Clin Gastroenterol 2018;52:437443.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10.

    Mokdad AA, Zhu H, Marrero JA, . Hospital volume and survival after hepatocellular carcinoma diagnosis. Am J Gastroenterol 2016;111:967975.

  • 11.

    Tan D, Yopp A, Beg MS, . Meta-analysis: underutilisation and disparities of treatment among patients with hepatocellular carcinoma in the United States. Aliment Pharmacol Ther 2013;38:703712.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12.

    Artinyan A, Mailey B, Sanchez-Luege N, . Race, ethnicity, and socioeconomic status influence the survival of patients with hepatocellular carcinoma in the United States. Cancer 2010;116:13671377.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13.

    Davila JA, El-Serag HB. Racial differences in survival of hepatocellular carcinoma in the United States: a population-based study. Clin Gastroenterol Hepatol 2006;4:104110.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14.

    Siegel AB, McBride RB, El-Serag HB, . Racial disparities in utilization of liver transplantation for hepatocellular carcinoma in the United States, 1998-2002. Am J Gastroenterol 2008;103:120127.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15.

    Davila JA, Duan Z, McGlynn KA, . Utilization and outcomes of palliative therapy for hepatocellular carcinoma: a population-based study in the United States. J Clin Gastroenterol 2012;46:7177.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16.

    Rich NE, Hester C, Odewole M, . Racial and ethnic differences in presentation and outcomes of hepatocellular carcinoma. Clin Gastroenterol Hepatol 2019;17:551559.e1.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17.

    Serper M, Taddei TH, Mehta R, . Association of provider specialty and multidisciplinary care with hepatocellular carcinoma treatment and mortality. Gastroenterology 2017;152:19541964.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18.

    Meyer AM, Olshan AF, Green L, . Big data for population-based cancer research: the integrated cancer information and surveillance system. N C Med J 2014;75:265269.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19.

    Forner A, Reig ME, de Lope CR, . Current strategy for staging and treatment: the BCLC update and future prospects. Semin Liver Dis 2010;30:6174.

  • 20.

    Llovet JM, Brú C, Bruix J. Prognosis of hepatocellular carcinoma: the BCLC staging classification. Semin Liver Dis 1999;19:329338.

  • 21.

    Health Resources & Services Administration. Area Health Resources Files. Accessed July 28, 2020. Available at: http://data.hrsa.gov/topics/health-workforce/ahrf

  • 22.

    Yu M, Tatalovich Z, Gibson JT, . Using a composite index of socioeconomic status to investigate health disparities while protecting the confidentiality of cancer registry data. Cancer Causes Control 2014;25:8192.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 23.

    Yost K, Perkins C, Cohen R, . Socioeconomic status and breast cancer incidence in California for different race/ethnic groups. Cancer Causes Control 2001;12:703711.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24.

    Krieger N, Chen JT, Waterman PD, . Geocoding and monitoring of US socioeconomic inequalities in mortality and cancer incidence: does the choice of area-based measure and geographic level matter? The Public Health Disparities Geocoding Project. Am J Epidemiol 2002;156:471482.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25.

    Klabunde CN, Potosky AL, Legler JM, . Development of a comorbidity index using physician claims data. J Clin Epidemiol 2000;53:12581267.

  • 26.

    Ulahannan SV, Duffy AG, McNeel TS, . Earlier presentation and application of curative treatments in hepatocellular carcinoma. Hepatology 2014;60:16371644.

  • 27.

    Davila JA, Morgan RO, Richardson PA, . Use of surveillance for hepatocellular carcinoma among patients with cirrhosis in the United States. Hepatology 2010;52:132141.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28.

    Bruix J, Sherman M. Management of hepatocellular carcinoma: an update. Hepatology 2010;53:10201022.

  • 29.

    Shebl FM, Capo-Ramos DE, Graubard BI, . Socioeconomic status and hepatocellular carcinoma in the United States. Cancer Epidemiol Biomarkers Prev 2012;21:13301335.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30.

    Chang ET, Yang J, Alfaro-Velcamp T, . Disparities in liver cancer incidence by nativity, acculturation, and socioeconomic status in California Hispanics and Asians. Cancer Epidemiol Biomarkers Prev 2010;19:31063118.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31.

    Cullaro G, Rubin JB, Mehta N, . Differential impact of age among liver transplant candidates with and without hepatocellular carcinoma. Liver Transpl 2020;26:349358.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32.

    NC Medicaid Division of Health Benefits. Eligibility for Medicaid or Health Choice. Accessed July 28, 2020. Available at: http://medicaid.ncdhhs.gov/beneficiaries/get-started/eligibility-medicaid-or-health-choice

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