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: email@example.com
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