UC Davis

Background and Aim: Hepatocellular carcinoma (HCC) is one of the most common types of cancer in the world. Its incidence and mortality rate are rising in the United States. HCC affects minority populations disproportionately with higher incidence observed among Asian/Pacific Islanders and Hispanics and higher mortality observed among Black/African Americans and Hispanics. Studies have found Black/African Americans and Hispanics to have lower likelihood in accessing treatment. Because of the rapid tumor doubling time, if left untreated, HCC can quickly lead to a fatal outcome. Longer time to treatment can impact outcomes among patient subgroups, but no studies have assessed racial/ethnic disparities in time to treatment and its effect on survival. Finally, among patients who are able to obtain life-saving surgical treatments, complications from HCC surgery are common. Many existing studies on postsurgical complications are hospital based with small populations. No prior studies assessed racial/ethnic disparities in postoperative complications after having ablation, hepatectomy, or transplantation using a large population-based database. The goal of this population-based study among HCC patients is to examine racial/ethnic disparities in obtaining surgical treatment, delay in getting surgical treatment, and surgical complications.

Methods: 16,375 HCC patients overall were identified from the California Cancer Registry for the period 2012–2017, with 21.3% (n= 3,494) patients identified as having undergone surgical treatments of ablation, resection, and transplantation. Multivariate logistic regression was used to examine racial/ethnic disparities in access to treatment, time to treatment, and complications from treatment. Multivariate Cox proportional hazards regression was used toevaluate racial/ethnic disparities in survival after considering surgical treatments, treatment delay, and surgical complications.

Results: Asian/Pacific Islanders and Black/African Americans were more likely, and Hispanics were less likely, to get surgical treatment relative to non-Hispanic Whites. A higher odds of surgical treatment was also observed among those with private insurance, with high neighborhood SES, and receiving treatment at high volume hospitals. Our study found Asian/Pacific Islanders to have lower likelihood of surgical treatment delay compared to non-Hispanic Whites. Patient neighborhood SES, patient distance from hospital, and hospital surgical volume were also associated with delays. No racial/ethnic differences were observed for neurological, cardiac, pulmonary, gastrointestinal, renal, and infectious types of postsurgical complications combined. However, Black/African Americans demonstrated a lower odds for gastrointestinal complications and Asian/Pacific Islanders demonstrated a lower odds for cardiac complications when compared to non-Hispanic Whites. Higher odds of complications were found among patients with comorbidities or living in low SES neighborhoods. In multivariable models considering access to surgical treatment, increased survival was observed for Asian/PIs and Hispanics, while no difference in survival was observed for Black/African Americans, compared to non-Hispanic Whites. When considering delay in surgical treatment, Asian/PIs, Hispanics, and non-Hispanic Whites undergoing hepatectomy and transplantation had better survival when compared to undergoing ablation. Similar survival results were obtained when considering postoperative surgical complications.

Conclusion: We found improved access to surgical treatment among Black/African Americans driven mainly by hepatectomy. Survival among Black/African Americans also improvedcompared to prior estimates. Interactions were observed between race/ethnicity and HCC treatment for both treatment delay and postoperative complications. In both cases, improved survival was observed for Asian/PIs, Hispanics and non-Hispanic Whites undergoing hepatectomy and transplantation compared to undergoing ablation. No such survival difference was observed for Black/African Americans. This calls for further studies to investigate and closely monitor racial/ethnic associations with possible factors such as private insurance and early-stage cancer both of which are associated with better survival. Our findings on postoperative complications underscore the need for disaggregation of complications. HCC is a challenging form of cancer with fatal consequences and racial/ethnic disparities related to HCC can have significant impact on accessing quality treatment and outcomes and necessitates ongoing research to attain equity.