December 28, 2010

Blacks Face Higher Death Risk from Early Liver Cancer

By John Gever, Senior Editor, MedPage Today
Published: December 21, 2010
Reviewed by Zalman S. Agus, MD; Emeritus Professor
University of Pennsylvania School of Medicine and
Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

African-Americans diagnosed with early-stage liver cancer face "persistently poor survival" relative to white patients, after accounting for other factors known to affect outcomes, researchers said.

Analyzing 12 years of data in the federal Surveillance, Epidemiology, and End Results (SEER) registry, researchers at the University of Michigan in Ann Arbor calculated a hazard ratio for death of 1.11 (95% CI 1.03 to 1.20) for black patients with stage I or II hepatocellular carcinoma (HCC) relative to white patients, after accounting for numerous factors, including the types of treatment provided.

"This finding is linked to two major issues that contribute to health-related disparities in minority populations," wrote Christopher Sonnenday, MD, MHS, and colleagues in the December issue of Archives of Surgery. "Black patients have poor access to treatment, and, even after obtaining treatment, they have relatively poor outcomes compared with white patients."

The study also showed that, after adjusting for the different treatment mixes seen among racial groups, survival rates were the same in Hispanic patients relative to whites, and were higher in Asian patients.

The latter finding, according to Sonnenday and colleagues, "may be explained by Asian patients tending to present with HCC resulting from chronic hepatitis B virus infection ... and by greater awareness of HCC owing to screening programs that target this population."

SEER data covering 13,244 cases of stage I or II HCC diagnosed from 1995 to 2006 were the basis for the findings. In addition to eventual outcomes, the data included tumor size at diagnosis, type of treatment provided, patients' race/ethnicity, age, and gender, and place of residence.

Patient-specific socioeconomic and educational data were not available, but the researchers made rough estimates using countywide averages for the patients' residences.

Sonnenday and colleagues found important differences in the types of treatment provided to the four racial-ethnic groups.

Overall, 32.8% of patients received "invasive therapy," defined as transplant, hepatectomy, or focused tumor ablation. In blacks and Hispanics, the figure was closer to 28%, while in whites it was 35%.

Adjusting for baseline tumor size, age, and the projected sociodemographic variables -- but not treatment type -- hazard ratios for death in the three nonwhite groups relative to whites were as follows:

• Blacks: 1.24 (95% CI 1.15 to 1.33)
• Hispanics: 1.08 (95% CI 1.01 to 1.15)
• Asian: 0.87 (95% CI 0.82 to 0.93)

Adding treatment type to the adjustments reduced these values in all three groups. In Hispanics, it declined to 0.97, which did not differ significantly from whites. In Asians, the fully adjusted hazard ratio was 0.84 (95% CI 0.79 to 0.89).

That the fully adjusted value for blacks of 1.11 remained significant was an indication that outcomes of aggressive treatment were not as good as in the other groups, Sonnenday and colleagues suggested.

They also considered the overall invasive-therapy rate of 32.8% to reflect "significant underuse of appropriate interventions for the most treatable stages of HCC."

But the racial differences in invasive therapy usage were also a concern, including a higher rate of hepatectomy in Asian patients and "a nearly twofold lower rate of liver transplant in blacks compared with white patients."

Sonnenday and colleagues described the latter as "clearly contingent on access to care," particularly in light of another recent study showing equal transplant rates in blacks and whites who get on waiting lists for the procedure.

A researcher at Johns Hopkins University in Baltimore concurred in an accompanying commentary that early-stage HCC patients are often undertreated.

Richard D. Schulik, MD, called the 32.8% figure for invasive therapy "alarming because stage I and II disease is typically treated with good outcomes."

But he warned that the study authors' other interpretations may not be valid.

They "assumed that patients ... had intrinsic differences that affected which therapy was selected for them," Schulick wrote.

"This assumption may not be as valid as the authors think because sometimes patients are treated according to how they enter the system for treatment."

Schulick wrote that in facilities that don't screen patients with a multidisciplinary team, the treatment choice may be heavily influenced by whether patients first see a surgical oncologist, a transplant surgeon, or an interventional radiologist.

He also emphasized the importance of study limitations listed by Sonnenday and colleagues, including the possibility that patients may have been inappropriately staged and the lack of patient-specific information on income, educational level, and other factors that were estimated crudely in the study.

The study was supported by the National Institutes of Health.

Study authors and Schulick declared they had no competing financial interests.

Primary source: Archives of Surgery
Source reference:
Mathur A, et al "Racial/ethnic disparities in access to care and survival for patients with early-stage hepatocellular carcinoma" Arch Surg 2010; 145: 1158-63.

Additional source: Archives of Surgery
Source reference:
Schulick R "Undertreatment of patients with early-stage hepatocellular carcinoma" Arch Surg 2010; 145: 1163-64.


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