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Non-white patients less likely to receive curative HCC therapy
SAN DIEGO — Non-white patients with hepatocellular carcinoma were less likely to undergo curative therapy and more likely to experience therapeutic delays than white patients, according to findings presented at Digestive Disease Week 2016.
Olutola A. Yerokun, MD, of the Department of Internal Medicine at the University of Texas Southwestern, said that HCC incidence rates are rapidly increasing in the U.S. “This increase is related to increasing rates of cirrhosis caused by hepatitis C virus and non-alcoholic fatty liver disease,” she said. “There are notable racial/ethnic disparities in HCC. We have seen higher incidence rates in Asians, blacks and Hispanics than in non-Hispanic whites.”
The researchers aimed to determine whether these disparities are based on biological or care delivery factors, or both. “There are data explaining that these disparities exist, but no data about why these disparities exist,” she said.
The study included 200 non-white patients and 174 white patients. The cohort was 53% white, 20% black and 20% Hispanic. Eligible participants were diagnosed with HCC between June 1, 2012, and May 31, 2013, at four centers in the United States. Outcome measures included tumor staging, curative treatment and survival, according to Yerokun.
Results indicated that non-whites were less likely than white patients to be under hepatology care prior to HCC diagnosis, 50.5% vs. 27.8% (P < .001). Rates of HCV infection were 62% for non-whites and 52% for white patients (P = .04).
While there was no significant difference in overall receipt of treatment between white patients and non-white patients, white patients had a shorter duration between diagnosis and treatment (P = .04). Therapeutic delays of more than 3 months occurred in 56% of white patients and 68% of non-white patients.
“Both blacks and Hispanics were more likely to be seen at a safety net system vs. a tertiary care system,” Yerokun added. “Also, less than 30% of patients in both the black and Hispanic groups received curative treatment.”
Yerokun showed that 82% of white patients received care at a transplant center, compared with just 28% for non-whites (P < .001). Fourteen percent of non-whites received curative treatment, compared with 25% for whites.
“Race predicted curative treatment,” Yerokun said.
Multivariate analysis results indicated that white race carried a non-significant increase in survival compared with non-white race, according to Yerokun.
The researchers also conducted further analysis to determine differences in treatment and outcomes between black and Hispanic patients. HCV rates were 82.9% for black patients and 44.6% for Hispanics. Hispanics also had increased rates of Child Pugh C cirrhosis (31.1% vs. 11.8%) and Barcelona Clinic Liver Staging stage D tumors (32.5% vs. 14.5%).
Yerokun concluded that non-white patients experience lower rates of curative treatment and higher rates of treatment delay even when HCC stage at presentation is the same. “These process failures represent targets for interventions to reduce racial/ethnic disparities in HCC outcomes,” she said. – Rob Volansky
Reference:
Yerokun O. Abstract #40. Presented at: Digestive Disease Week; May 21-24, 2016; San Diego.
Disclosures: Yerokun reports no relevant financial disclosures.
Perspective
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HCC incidence is highest among Asian/Pacific Islanders, but it’s expected to increase among blacks and Hispanics in the years to come.
The overarching question is what is the relative contribution of biology versus health services factors such as treatment and screening are to disparities in outcomes. Risk factors can of course be considered as well. We should also talk about access to care and receipt of care. We know that insurance rates are lower among minorities and individuals with lower socioeconomic status. Even if you have insurance, screening participation and treatment participation rates may differ. This leads to a couple important questions. How big are the access and receipt of care differences? Does equal access result in equal outcomes, or do biologic differences still exert effects? Can interventions to promote guideline recommended screening and treatment be developed?
Yerokun and colleagues didn’t observe big differences in staging and presentation, but whites were more likely to receive curative intent treatment, even after adjusting for key clinical parameters. The evidence clearly suggests the potential for major differences in treatment by race or ethnicity.
A few mechanisms we can think about include differences in offering guideline appropriate treatment. Is there bias, hidden or otherwise? Is there an incomplete understanding of what patients need to understand to accept treatment? We need to go back to our health service centers and dig into what is going on. There also may be difference in acceptance of guideline-appropriate treatment. Patients may have fatalism or distrust of the system.
Access to care and participation in screening and treatment are the main causes of racial disparity. But these are also the most modifiable factors, which is cause for optimism.
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