Few Liver Cancer Patients in US Get Treatment‏

Veronica Hackethal, MD

October 13, 2014

Rates of treatment for liver cancer in the United States are "disappointingly low," even among patients with early-stage liver cancer that is more easily cured, according to a meta-analysis published online on August 21 in Alimentary Pharmacology and Therapeutics.

"We found the low treatment rates among patients with early-stage tumors particularly concerning. Many of these patients currently fail to receive any treatment despite having curative treatment options that could afford long-term survival," senior author Amit Singal, MD, from the University of Texas, in Austin, said in a press release. "These findings highlight the urgent need for interventions such as multidisciplinary management clinics to optimize treatment of patients with primary liver cancer."

Liver cancer is the third-leading cause of cancer death worldwide, and the disease disproportionately affects minorities, especially Asian Americans and African Americans, according to background information in the article. Survival rates are worse among the elderly, African Americans, and people with low socioeconomic status. The increasing incidence of liver cancer in the United States is linked to the current epidemics of nonalcoholic fatty liver disease and hepatitis C virus.

The study was based on a a computer-assisted and manual literature review of Medline for English-only articles published from January 1989 to March 2013.

The researchers included 24 studies in the analysis. Pooled analyses revealed that only 53% of liver cancer patients receive any treatment, suggesting that almost 50% receive no treatment at all. Only about 22% receive curative treatment. Furthermore, about 59% of those with earlier-stage liver cancer receive curative treatment, meaning that more than one third of patients with early-stage disease may not receive treatment for a potentially curable cancer.

Treatment rates were lower among the elderly, nonwhites, and people with low socioceconomic status. People with private insurance had higher treatment rates than those without insurance or with Medicare/Medicaid.

Most studies did not look at reasons underlying the low rates of liver cancer treatment, which limited the analysis. Studies also varied widely in study design and in the reporting of important patient characteristics, such as age, sex, race/ethnicity, and socioeconomic status.

"When people at risk of liver cancer are identified, they are frequently not enrolled in programs of surveillance for early detection of liver cancer," Lewis Roberts, MB, ChB, PhD, professor of medicine at the Mayo Clinic, in Rochester, Minnesota, told Medscape Medical News when contacted for an outside opinion. "Consequently, most patients with liver cancer in the US are diagnosed at advanced stages when curative treatment is not feasible."

"Socioeconomic disparities are a major contributor to disparities in healthcare in the US," Dr Roberts pointed out. "Race is often a surrogate for low educational achievement, low income, or low wealth, all of which are unevenly distributed in the US and contribute significantly to decreased access to healthcare."

Other high-risk populations, such as immigrants from Asia, Africa, or Europe, where there are high rates of hepatitis B or C, need to be screened, Dr Roberts emphasized.

Recently there has been some movement toward increasing awareness about the need for better surveillance and treatment of liver cancer, especially among at-risk populations.

In 2012, the CDC recommended that all baby boomers be screened for hepatitis C. This was a "major step," Dr Roberts pointed out, because people born between 1945 and 1965 have a five-fold increased risk for hepatitis C.

Advocacy groups such as the National Viral Hepatitis Roundtable and the Liver Cancer Roundtable have stepped up their efforts to increase awareness of viral hepatitis. The WHO and the CDC have worked together to develop treatment and surveillance guidelines for hepatitis C, which were released in April 2014, and hepatitis B, which are expected to be released later this year.

"These guidelines should help to establish screening for hepatitis and early detection of liver cancer as the worldwide standard of care," Dr Roberts emphasized, "It is important for individuals to take ownership of their healthcare and partner with their healthcare providers to ensure that they have been tested for hepatitis B and/or hepatitis C if they have any of the risk factors."

The study was supported by a grant from the Center for Translational Medicine, NIH/NCATS, and an ACG Junior Faculty Development Award. Dr Singal reports being on the speakers' bureaus for Bayer and Onyx. Dr Roberts reports grant support from Wako Diagnostics, which produces the AFP-L3% and DCP tests, and from Gilead Sciences, which produces drug treatments for both hepatitis B and hepatitis C.

Aliment Pharmacol Ther. 2013;38:703-713. Abstract

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