Black Patients With HCC, Those Living in High-Poverty Neighborhoods Have Higher Odds of Experiencing Treatment Delays

Nikita Sandeep Wagle, PhD

Data from an analysis presented during the 2022 International Liver Cancer Association Conference revealed that nearly 1 in 7 patients with hepatocellular carcinoma (HCC) experience treatment delays, with higher odds observed in Black patients and those living in high poverty neighborhoods. Notably, treatment delays were linked with worse survival in these patients.

In a multivariable analysis, Black patients (odds ratio [OR], 1.91; 95% CI, 1.20-3.05) and those residing in moderate (OR, 1.30; 95% CI, 1.08-1.57) or high (OR, 1.53; 95% CI, 1.24-1.89) poverty neighborhoods had a higher likelihood of experienced treatment delays than those who were White or those who were living in low poverty neighborhoods, respectively.

Data from the 5-month landmark univariable analysis done in 6644 patients demonstrated worse survival in those who experienced treatment delays (HR, 1.13; 95% CI, 1.04-1.23); this was also observed in a 5-month landmark multivariable analysis (HR, 1.15; 95% CI, 1.05-1.25). Moreover, sensitivity analyses that utilized 6-, 7-, 8-, and 9-month landmarks continued to show that delayed treatment was associated with worse overall survival (OS) in these patients.

“Treatment delays are associated with worse survival, highlighting a need for interventions to improve time to treatment,” lead study author Nikita Sandeep Wagle, PhD, of Population Informatics Laboratory, Department of Health Policy & Management, School of Public Health, Texas A&M University, and colleagues, wrote in a poster on the findings.

Although HCC represents the third leading cause of cancer-related death on a global scale, failures have been observed spanning the care continuum for this population, including underuse of surveillance and curative treatments.

Delays in treatment that lead to potential stage migration has been reported for other cancers, but less information exists for this disease. Moreover, the impact of these delays on outcomes has not been well characterized in large racially and socioeconomically diverse patient populations with HCC.

In this study, investigators sought to determine the prevalence and disparities that exist in patients with HCC and treatment delays, and to examine the link between such delays and OS in a large population-based sample of patients with the disease residing in the United States.

Investigators leveraged the Surveillance, Epidemiology, and End Results – Medicare database to identify patients who were diagnosed with HCC between 2001 and 2015.

If patients were not continuously enrolled in Medicare part A and B during the study period, enrolled in health maintenance organizations, diagnosed with other cancers within 1 year before HCC diagnosis, died within 30 days following diagnosis, had missing sociodemographic characteristics that could not be imputed, or they did not receive treatment for HCC, they were excluded from the study.

The primary outcome for the study was presence of treatment delay which was examined as a dichotomous variable. Delayed treatment was defined as the time from diagnosis to first treatment having exceeded 3 months.

To determine factors linked with treatment delay, investigators performed multivariable logistic regression analysis. To characterize the link between delayed treatment and OS, they leveraged Cox proportional hazards regression analysis with a 5-month landmark and accounted for immortal time bias. Here, those with the disease who received treatment within 3 months were classified as having received timely treatment; those who received therapy between 4 and 5 months of their diagnosis were noted as having received delayed treatment. Those who received therapy beyond 5 months of a diagnosis were excluded.

A total of 13,874 patients with HCC were identified; 60.9% (n = 8,450) of these patients received treatment within 1 year of their diagnosis. The median time from diagnosis to first treatment received was 1 month (interquartile range, 1-3).

Treatment delays were noted in 14.3% (n = 1205) of patients. Notably, the proportion of those who experienced these delays were found to vary by therapy, with the highest proportion observed in those who underwent liver transplantation (21.6%) and the lowest proportion noted in those treated with resection (6.8%). Moreover, 16.8% of patients who received embolization had delayed treatment, as did 15.2% of those who received ablation, 14.2% of those who received radiation, and 13.3% of those who received systemic chemotherapy.

Additional data from the sensitivity analysis indicated that in the 5-month landmark, which utilized a sample size of 6644 patients, the hazard ratio (HR) for delayed treatment in those with first HCC treatment was 1.07 (95% CI, 0.98-1.17). In the 6-month landmark analysis (n = 6487), the HR for delayed treatment in those without first HCC treatment was 1.14 (95% CI, 1.05-1.23); with first HCC treatment, the HR was 1.06 (95% CI, 0.98-1.16).

In the 7-month landmark analysis, which had a sample size of 6328 patients, the HRs for delayed treatment in the groups without first HCC treatment and with first treatment were 1.17 (95% CI, 1.08-1.27) and 1.10 (95% CI, 1.01-1.19), respectively. In the 8-month landmark analysis (n = 6133), these HRs were 1.20 (95% CI, 1.11-1.30) and 1.11 (95% CI, 1.03-1.21), respectively; these HRs were 1.19 (95% CI, 1.10-1.29) and 1.10 (95% CI, 1.02-1.20), respectively, for the 9-month landmark analysis (n = 5947).

The study was funded by the National Institutes of Health, the Population Informatics Lab, and the Texas Virtual Data Library at Texas A&M University.

Reference

Wagle NS, Park S, Washburn D, et al. Racial, ethnic, and socioeconomic disparities in treatment delay among patients with hepatocellular carcinoma in the United States. Presented at: 2022 International Liver Cancer Association Conference; September 1-4, 2022; Madrid, Spain. Poster 35