Racial/ethnic and Socioeconomic Disparities in Survival of People with Liver Cancer

		SUMMARY: Although overall survival of people with hepatocellular carcinoma have increased over time, disparities according to race/ethnicity and economic status persist, according to a U.S. study published in the January 25, 2010 advance online edition of the journal Cancer. Black patients had the shortest survival both overall and among liver transplant recipients; Asians lived longest overall, while Hispanics lived longest after liver transplantation.

By Liz Highleyman

Over years or decades, chronic hepatitis B or C can progress to advanced liver disease including cirrhosis and hepatocellular carcinoma (HCC), a type of primary liver cancer. Other causes of liver damage, including heavy alcohol use and fatty liver disease can also lead to these conditions.

Avo Artinyan from the City of Hope Comprehensive Cancer Center near Los Angeles and colleagues looked at outcomes among patients with HCC stratified according to race and ethnicity, hypothesizing that differences in survival might result from inequities in access to care and response to therapy, as suggested by previous research.

The investigators identified 20,920 HCC patients from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database who had localized liver tumors, as well as 4735 individuals who underwent liver transplantation due to HCC from the United Network for Organ Sharing (UNOS) database.

Results

	Survival of patients with HCC significantly improved over time for all racial, ethnic, and income groups (P < 0.001).
	Patients diagnosed during 2000-2004 had 4-fold higher survival rate than those diagnosed during the 1970s (hazard ratio [HR] 0.2), with 5-year survival rates increasing from 2% to 15%.
	However, blacks had the worst long-term survival, with an unadjusted 5-year survival rate of about 6% (P < 0.001).
	People with middle- and high-income levels had significantly better survival compared with low-income individuals (HR 0.89 and 0.95, respectively; P < 0.03 for both).
	Across race/ethnicity groups, patients who underwent either tumor resection or liver transplantation had a significantly higher likelihood of survival that those not receiving either type of surgery (HR 0.27).
	Patients who underwent tumor ablation (destruction) likewise had a significantly higher survival rate than those not receiving such treatment (HR 0.40).
	In a multivariate analysis adjusting for factors including type of treatment received, black race remained predictive of poor overall survival (HR 1.15, or 15% higher risk of death; P < 0.001).
	People of Asian descent had the best overall survival (HR 0.87; P < 0.001).
	Among patients who underwent liver transplantation, blacks again had the worst graft (donor liver) survival and overall survival (median 30.5 and 39.7 months, respectively; P < 0.001).
	Among transplant recipients, Hispanic patients had the best graft survival and overall survival (83.4 and 86.6 months, respectively; P < 0.001).
	In a multivariate analysis of transplant recipients, race/ethnicity was again significantly associated with survival.

Based on these findings, the study authors concluded, "Significant racial and ethnic disparities in the outcome of patients with HCC persist despite the receipt of comparable treatment."

Therefore, they elaborated, "our study demonstrates that survival disparities by race and ethnicity cannot be explained by access issues alone, and other factors need to be considered."

"[F]urther investigations are warranted to identify the reasons for the stark disparity in outcomes between black patients and Hispanic patients after liver transplantation for HCC," they recommended.

Division of Oncologic Surgery, City of Hope Comprehensive Cancer Center, Department of Population Sciences, City of Hope, Duarte, CA; Center for Cancer Prevention and Treatment, St. Joseph Hospital, Orange, CA; Division of Transplantation, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA.

2/16/10

Reference
A Artinyan, B Mailey, N Sanchez-Luege, and others. Race, ethnicity, and socioeconomic status influence the survival of patients with hepatocellular carcinoma in the United States. Cancer (Abstract). January 25, 2010 (Epub ahead of print).