Association of Provider Specialty and Multidisciplinary Care With Hepatocellular Carcinoma Treatment and Mortality

Abstract

Background & aims: Little is known about provider and health system factors that affect receipt of active therapy and outcomes of patients with hepatocellular carcinoma (HCC). We investigated patient, provider, and health system factors associated with receipt of active HCC therapy and overall survival.

Methods: We performed a national, retrospective cohort study of all patients diagnosed with HCC from January 1, 2008 through December 31, 2010 (n = 3988) and followed through December 31 2014 who received care through the Veterans Administration (128 centers). Outcomes were receipt of active HCC therapy (liver transplantation, resection, local ablation, transarterial therapy, or sorafenib) and overall survival.

Results: In adjusted analyses, receiving care at an academically affiliated Veterans Administration hospital (odds ratio [OR], 1.97; 95% confidence interval [CI], 1.60-2.41) or a multi-specialist evaluation (OR, 1.60; 95% CI, 1.15-2.21), but not review by a multidisciplinary tumor board (OR, 1.19; 95% CI, 0.98-1.46), was associated with a higher likelihood of receiving active HCC therapy. In time-varying Cox proportional hazards models, liver transplantation (hazard ratio [HR], 0.22; 95% CI, 0.16-0.31), liver resection (HR, 0.38; 95% CI, 0.28-0.52), ablative therapy (HR, 0.63; 95% CI, 0.52-0.76), and transarterial therapy (HR, 0.83; 95% CI, 0.74-0.92) were associated with reduced mortality. Subspecialist care by hepatologists (HR, 0.70; 95% CI, 0.63-0.78), medical oncologists (HR, 0.82; 95% CI, 0.74-0.91), or surgeons (HR, 0.79; 95% CI, 0.71-0.89) within 30 days of HCC diagnosis, and review by a multidisciplinary tumor board (HR, 0.83; 95% CI, 0.77-0.90), were associated with reduced mortality.

Conclusions: In a retrospective cohort study of almost 4000 patients with HCC cared for at VA centers, geographic, provider, and system differences in receipt of active HCC therapy are associated with patient survival. Multidisciplinary methods of care delivery for HCC should be prospectively evaluated and standardized to improve access to HCC therapy and optimize outcomes.

Keywords: Liver Cancer; Population; Quality; Risk Factor.

Figure 1

First HCC-directed therapy received. Percentage of veterans receiving hepatic resection, liver transplantation, ablative therapies (radio-frequency, microwave, or cryo-ablation), transarterial therapies (bland, chemo- or radio-embolization), hospice care, and no active therapy as first intervention stratified by BCLC stage.

Figure 2

Unadjusted median survival stratified by BCLC stage. Kaplan-Meier survival analysis of 5-year overall survival shown.

Figure 3

Correlation between receipt of active HCC therapy and overall survival at the regional level. Spearman correlation of the proportion of patients receiving active HCC therapy (defined as resection, transplantation, ablation, transarterial therapy, or sorafenib) (“Proportion treated”) and median overall survival (OS) in months grouped by Veterans Integrated Service Network region. The diameter of each circle is proportional to the number of HCC cases in each Veterans Integrated Service Network.