Transarterial bland versus chemoembolization for hepatocellular carcinoma: rethinking a gold standard.
BACKGROUND
Transarterial chemoembolization (TACE) is the most common procedure for the treatment of hepatocellular carcinoma (HCC). However, HCC is generally considered chemoresistant and data demonstrating the superiority of TACE over bland embolization (TAE) are lacking.


METHODS
A nationwide, retrospective cohort study of HCC patients treated with first-line TACE or TAE within the Veterans Affairs health care system (2005-2012) was performed. The primary outcome was overall survival. Risk of death by treatment type (TACE or TAE) was evaluated using multivariate (adjusted for age, presence of cirrhosis, Barcelona Clinic Liver Cancer stage, and Charlson comorbidity score) and propensity score-adjusted Cox regression.


RESULTS
The cohort included 405 patients treated with first-line transarterial embolization. Among these patients, 32 (7.9%) underwent TAE. Most of the patients (76.8%) had intermediate or advanced stage at presentation. Similar proportions of patients (TACE 53.3% versus TAE 43.7%; P = 0.30) received more than one embolization procedure. There was no difference in median survival (20.1 versus 23.1 mo, respectively; log-rank P = 0.84). Compared to TACE, there was no difference in risk of death associated with TAE after multivariate (hazard ratio [HR] 0.92; 95% CI, 0.61-1.37) and propensity score adjustment (HR = 0.86; 95% CI = 0.58-1.29).


CONCLUSIONS
There is no clear benefit associated with chemotherapy infusion over bland embolization for HCC treatment. Given the rising incidence of HCC in the United States and considering the added costs associated with TACE compared to TAE, future work comparing these competing management strategies is needed.
Veteran Affairs HSR&D Center for Innovations in Quality, Effectiveness and Safety (IQUEST), Michael E DeBakey VA Medical Center, Houston, Texas; Michael E DeBakey Department of Surgery, Division of Surgical Oncology, Baylor College of Medicine, Houston, Texas. Electronic address: Nader.Massarweh@bcm.edu.
Nader N
NN
Massarweh
Veteran Affairs HSR&D Center for Innovations in Quality, Effectiveness and Safety (IQUEST), Michael E DeBakey VA Medical Center, Houston, Texas; Department of Medicine, Division of Health Services Research, Baylor College of Medicine, Houston, Texas.
Jessica A
JA
Davila
Veteran Affairs HSR&D Center for Innovations in Quality, Effectiveness and Safety (IQUEST), Michael E DeBakey VA Medical Center, Houston, Texas; Department of Medicine, Division of Health Services Research, Baylor College of Medicine, Houston, Texas; Department of Medicine, Division of Gastroenterology, Baylor College of Medicine, Houston, Texas.
Hashem B
HB
El-Serag
Veteran Affairs HSR&D Center for Innovations in Quality, Effectiveness and Safety (IQUEST), Michael E DeBakey VA Medical Center, Houston, Texas.
Zhigang
Z
Duan
Veteran Affairs HSR&D Center for Innovations in Quality, Effectiveness and Safety (IQUEST), Michael E DeBakey VA Medical Center, Houston, Texas.
Sarah
S
Temple
Veteran Affairs HSR&D Center for Innovations in Quality, Effectiveness and Safety (IQUEST), Michael E DeBakey VA Medical Center, Houston, Texas.
Sarah
S
May
Veteran Affairs HSR&D Center for Innovations in Quality, Effectiveness and Safety (IQUEST), Michael E DeBakey VA Medical Center, Houston, Texas; Department of Medicine, Division of Medical Oncology, Baylor College of Medicine, Houston, Texas.
Yvonne H
YH
Sada
Section of Hepatobiliary Tumors, Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida.
Daniel A
DA
Anaya
D000328:Adult; D000368:Aged; D000970:Antineoplastic Agents / Q000008:administration & dosage; D006528:Carcinoma, Hepatocellular / Q000401:mortality / Q000628:therapy*; D016461:Chemoembolization, Therapeutic; D004621:Embolization, Therapeutic / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008113:Liver Neoplasms / Q000401:mortality / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D016019:Survival Analysis; D016896:Treatment Outcome
D000970:Antineoplastic Agents
Hepatocellular carcinoma; Transarterial chemoembolization; Transarterial embolization