Determinants of Improved Survival in Patients with Hepatocellular Carcinoma: A SEER-Medicare Analysis

Abstract

Background: Curative treatment of hepatocellular carcinoma (HCC) improves 5-year survival rates from 0-5% to 40-70%.1, 2 We aimed to study the: I) effect of routine non-HCC cancer screening tests (nHCS) on earlier cancer detection and survival; and II) impact of receiving recommended HCC treatment per the American Association for the Study of Liver Diseases guidelines, on adverse events (AE) and survival versus non-recommended therapies. Methods: This retrospective cohort study evaluates Medicare beneficiaries with HCC from 2004-2007 using SEER-Medicare registry. Outcomes ( Aim I) were stage at diagnosis (American Joint Commission on Cancer) dichotomized into non-late (Stages I-III) and late stage HCC (Stage IV); and mortality. The odds of late stage at diagnosis and hazard of death among >67 year old recipients of nHCS within 2 years before HCC diagnosis were determined by logistic and Cox proportional hazards regression, respectively, stratified by sex and adjusted for sociodemographic variables, year of diagnosis, HCC risk factors, and comorbidities. For Aim II, patients >66 years were stratified according to stage at diagnosis, tumor size/nodularity, and cirrhosis. Within each group, AE operationalized as non-treatment hospitalizations, and mortality, were compared among those receiving and not receiving recommended treatments. Risk of hospitalization and death (binary variables) within each person-day were explored via logistic regression and generalized estimating equations (correcting for correlation in hospitalization days). Results: Women receiving nHCS (Aim I) in the 2 years before HCC had higher odds of non-late after adjustment. An analysis dichotomizing stages into Early (I/II) and Late (III/IV) found no difference between the two groups. Men and women receiving nHCS had reduced mortality, independent of stage at diagnosis. (Aim II) There were higher hospitalization and lower mortality among Stages I/II patients receiving recommended versus non-recommended therapy; and the opposite effect in Stages III/IV. Conclusions: Medicare recipients receiving nHCS had reduced mortality, independent of earlier diagnosis, suggesting a need to follow routine cancer screening guidelines among HCC patients. Those receiving guideline-recommended therapy had reduced mortality but increased hospitalization in Stages I/II; with the opposite effect among Stages III/IV, suggesting that treating HCC patients according to guidelines improves survival, despite the cost of hospitalizations.