Abstract
Introduction: We reported that hepatocellular carcinoma (HCC) patients in the Harris County Hospital District (HCHD) have an overall survival (OS) of 3.4 months. This is the third largest public hospital district in the U.S. and a high percentage of HCC patients appear to survive less than 1 month (OS<1 mo). We sought to explore possible factors associated with this observed disparity in OS.
Methods: An IRB-approved review of the HCHD Tumor Registry was conducted. Insurance and payor status, race, treatment, clinicopathologic parameters were recorded, including liver function tests, alpha-fetoprotein (AFP), international normalized ratio (INR), Child-Pugh score and model for end-stage liver disease (MELD) score. Outcomes were compared using Kaplan-Meier survival analysis and log-rank tests. Chi-square, Student's t-test, univariate, multivariate logistic regression and Cox proportional hazards model statistical tests were also used (p<0.05).
Results: A total of 337 HCC patients (N= 272 men and N= 65 female) from 1998-2010 were identified. Only 4% of patients had medicare; whereas 96% relied upon county funding. OS<1mo was noted in 90 patients (26.7%). There were no racial or gender differences between those with an OS<1mo and OS>1 mo. In the OS<1mo group, 22% were Stage I-II, 39% were stage III and 39% were stage IV. In contrast in the OS>1 mo cohort, 38% were Stage I-II, 33% Stage III and 28% were stage IV. Only 6% (N=5) of OS<1mo patients received therapy for HCC, whereas 27% (N=91) patients in the OS>1 mo group received therapy (p=0.00). Both individual laboratory parameters associated with advanced liver disease (elevated bilirubin and decreased albumin) and composite score (Child-Pugh and MELD) were predictive of OS<1 mo. In addition, elevated AFP, elevated creatinine, stage, and lack of treatment were independent predictors of OS<1 mo. A Cox proportional hazards model demonstrated gender, AFP, bilirubin, INR, presence of ascites and stage were predictive of median survival.
Conclusions: Median stage-adjusted survival of medically underserved HCC patients seen in a large urban hospital remains lower than the national average. Although advanced stage and advanced liver disease likely preclude treatment in many patients, there are still a large proportion of patients who receive no treatment. Additional studies are necessary to determine the reasons for lack of treatment and survival disparities in this patient population such as lack of early detection, non-referral to surgeons by primary care physicians, lack of availability of advanced treatments such as transplantation, or a combination of these factors. Furthermore, accurate prediction of those patients unlikely to survive beyond one month may prevent futile use of limited resources.
Citation Information: Cancer Epidemiol Biomarkers Prev 2010;19(10 Suppl):B91.
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