Article Abstract

Centers with more therapeutic modalities are associated with improved outcomes for patients with hepatocellular carcinoma

Authors: Julie M. Jiang, Nitin Ohri, Justin Tang, Renee Moadel, Jacob Cynamon, Andreas Kaubisch, Milan Kinkhabwala, Madhur K. Garg, Chandan Guha, Rafi Kabarriti


Background: Higher facility volume is correlated to better overall survival (OS), but there is little knowledge on the effect of facility treatment modality number on OS in hepatocellular carcinoma (HCC).
Methods: This is a retrospective analysis of data from the National Cancer Database (NCDB) from 2004–2014 on patients with non-metastatic HCC. Treatment modalities assessed were surgical resection, transplantation, ablation, radioembolization, stereotactic body radiation therapy (SBRT), single-agent chemotherapy, and multi-agent chemotherapy. Facilities were dichotomized at the median of the listed treatment modalities.
Results: There were a total of 112,512 patients with non-metastatic HCC. Of a total of 1,230 sites, 830 (67.5%) used four or fewer modalities. Average survival for patients treated at facilities using fewer modalities was 12.0 and 23.5 months for those treated at facilities with more modalities [hazard ratio (HR) =0.52, 95% confidence interval (CI): 0.51–0.53, P<0.001]. After adjusting for facility volume, liver function, tumor and patient characteristics and other prognostic factors in a multivariable Cox model, treatment at a multi-modality facility still provided a survival advantage (HR =0.60, 95% CI: 0.52–0.70, P<0.001). This benefit also persisted after propensity score matching. Sensitivity analysis varying the cut point from 2 to 6 modalities for dichotomization showed that the benefit persisted. Subgroup stratified analyses based on stage showed that the benefit in OS was highest for patients with stage I and II (P≤0.002) but was not significant for stage III or IVa.
Conclusions: Institutions that offered more treatment modalities had improved OS for patients with non-metastatic HCC, especially for those with stage I and II.