Underutilization of therapy for hepatocellular carcinoma in the medicare population.

Background: The incidence of hepatocellular carcinoma (HCC) is increasing in the United States, and the care of these patients remains highly specialized and complex. Multiple treatment options are available for HCC but their use and effectiveness remain unknown.

Methods: Using Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data, 8730 patients who were diagnosed with HCC between 1991 and 2005 were identified. Therapy included surgical resection (8.7%), liver transplantation (1.4%), ablation (3.6%), or transarterial chemoembolization (16%). Patients who received no or palliative-only treatment were grouped together (NoTx; 70.3%). Patient, disease, and tumor factors were examined as determinants of therapy.

Results: HCC is increasing in the Medicare population. The median age at diagnosis was 75.1 years and 73.6% of patients were coded as white, 17.2% as Asian, 8.3% as black, and 0.9% as other race. The rate of therapy increased over time, but only 29.7% of patients overall underwent therapy. In patients with early stage HCC, only 43.1% underwent therapy. In the NoTx group, 49.4% did not have cirrhosis, 36.0% had tumors that measured <5 cm, and 39.8% were diagnosed with stage I or II disease when variables were complete. The use of therapy for all HCC patients increased over time, correlating with a commensurate increase in median survival. In multivariate regression analysis, patients who received any modality of treatment achieved significant benefit compared with the NoTx group (odds ratio, 0.41; 95% confidence interval, 0.39-0.43).

Conclusions: In the Medicare population, HCC patients who received therapy experienced a substantial survival advantage over their nonoperative peers (NoTx). Despite evidence that many patients had favorable biological characteristics, <30% of patients diagnosed with HCC received any treatment.