title: Effectiveness of Initial Transarterial Chemoembolization for Hepatocellular Carcinoma Among Medicare Beneficiaries.
abstract: BACKGROUND
  Optimal administration of transarterial chemoembolization (TACE), the standard approach for intermediate-stage hepatocellular carcinoma (HCC), requires clinical and technical expertise. We sought to evaluate whether TACE retains its effectiveness when administered across a broad range of health care settings. Furthermore, as the use of yttrium(90) (Y(90)) radioembolization has been increasing, we explored the comparative effectiveness of Y(90) as an alternative to TACE.
  
  
  METHODS
  Patients with HCC diagnosed from 2004 through 2009 treated initially with TACE or Y(90) were identified from the SEER-Medicare linkage. Key covariates included prediagnosis α-fetoprotein (AFP) screening, complications of cirrhosis, and tumor extent. Effect of treatment, patient, and health care system factors on overall survival (OS) was evaluated using multivariable Cox proportional hazards. Stratified OS estimates are provided. Propensity score (PS) weighting was used to compare effectiveness of Y(90) with TACE.
  
  
  RESULTS
  Of 1528 patients who underwent intra-arterial embolization, 577 received concurrent chemotherapy (eg, TACE). Median OS was 21 months (95% CI, 18-23) following TACE and 9 months (95% CI, 1-41) following Y(90). Refined survival estimates stratified by stage, AFP screening, and liver comorbidity are presented. The 90-day mortality rate after TACE was 21% to 25% in patients with extrahepatic spread or vascular invasion. In the PS-weighted analysis, Y(90) was associated with inferior survival, with an adjusted hazard ratio of 1.39 (95% CI, 1.02-1.90).
  
  
  CONCLUSIONS
  The effectiveness of TACE is generalizable to Medicare patients receiving care in a variety of treatment settings. However, early posttreatment mortality is high in patients with advanced disease. We found no evidence of improved outcomes with Y(90) compared with TACE. Survival estimates from this large cohort can be used to provide prognostic information to patients considering palliative TACE.
authors.affiliation: From UNC Lineberger Comprehensive Cancer Center and the Division of Hematology/Oncology, Division of Vascular-Interventional Radiology, and Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina. From UNC Lineberger Comprehensive Cancer Center and the Division of Hematology/Oncology, Division of Vascular-Interventional Radiology, and Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina.
authors.forename: Hanna K
authors.initials: HK
authors.lastname: Sanoff
authors.affiliation: From UNC Lineberger Comprehensive Cancer Center and the Division of Hematology/Oncology, Division of Vascular-Interventional Radiology, and Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina.
authors.forename: YunKyung
authors.initials: Y
authors.lastname: Chang
authors.affiliation: From UNC Lineberger Comprehensive Cancer Center and the Division of Hematology/Oncology, Division of Vascular-Interventional Radiology, and Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina.
authors.forename: Joseph M
authors.initials: JM
authors.lastname: Stavas
authors.affiliation: From UNC Lineberger Comprehensive Cancer Center and the Division of Hematology/Oncology, Division of Vascular-Interventional Radiology, and Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina. From UNC Lineberger Comprehensive Cancer Center and the Division of Hematology/Oncology, Division of Vascular-Interventional Radiology, and Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina.
authors.forename: Til
authors.initials: T
authors.lastname: Stürmer
authors.affiliation: From UNC Lineberger Comprehensive Cancer Center and the Division of Hematology/Oncology, Division of Vascular-Interventional Radiology, and Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina. From UNC Lineberger Comprehensive Cancer Center and the Division of Hematology/Oncology, Division of Vascular-Interventional Radiology, and Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Lund
mesh_terms: D000368:Aged; D000970:Antineoplastic Agents / Q000008:administration & dosage*; D006528:Carcinoma, Hepatocellular / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D016461:Chemoembolization, Therapeutic / Q000379:methods*; D005260:Female; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications; D008113:Liver Neoplasms / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D008297:Male; D006278:Medicare; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D009367:Neoplasm Staging; D057216:Propensity Score; D018426:SEER Program; D015996:Survival Rate; D047368:Tumor Burden; D014481:United States; D015021:Yttrium Radioisotopes / Q000008:administration & dosage*; D000509:alpha-Fetoproteins / Q000378:metabolism
chemical_list: D000970:Antineoplastic Agents; D015021:Yttrium Radioisotopes; D000509:alpha-Fetoproteins