title: Assessment of non-surgical versus surgical therapy for localized hepatocellular carcinoma.
abstract: BACKGROUND
  Localized hepatocellular carcinoma (HCC) in patients with adequate liver function is typically treated with resection. Non-surgical modalities including trans-arterial embolization have emerged as options for intermediate/advanced HCC. Hypothesizing that non-surgical techniques have expanded to localized disease, we examined treatment patterns, factors associated with surgical therapy, and the impact of modality on survival.
  
  
  METHODS
  Non-cirrhotic, localized HCC patients were identified from the National Cancer Data Base (2003-2011). Trends were examined using average annual percent change (AAPC). Regression models were developed to determine factors associated with treatment and assess the association of modality with survival.
  
  
  RESULTS
  Of 10,187 patients (median tumor size: 3.7 cm), 6,387 (62.7%) underwent surgery and 3,800 (37.3%) non-surgical therapy. Surgery declined from 61.6% to 44.5% (AAPC, -3.7%; 95%CI, -4.9% to -2.6%, P < 0.001). Non-surgical therapies increased from 17.2% to 39.2% (AAPC 11.4%; 95%CI, 8.8-14.1%, P < 0.001). White race, higher income, and treatment in an academic center (OR = 1.37, 95%CI 1.13-1.66) were associated with surgery. Patients selected for non-surgical therapy had worse adjusted 5-year survival (HR=2.05, 95%CI 1.85-2.26).
  
  
  CONCLUSIONS
  Non-surgical therapy has become as common as surgery in the treatment of non-cirrhotic, localized HCC. Randomized studies are needed to compare the effectiveness of treatments for this disease.
authors.affiliation: Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois.|Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.|Northwestern Institute for Comparative Effectiveness Research in Oncology (NICER-Onc), Robert H. Lurie Comprehensive Cancer Center, Chicago, Illinois.
authors.forename: Sanjay
authors.initials: S
authors.lastname: Mohanty
authors.affiliation: Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois.|Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.|Northwestern Institute for Comparative Effectiveness Research in Oncology (NICER-Onc), Robert H. Lurie Comprehensive Cancer Center, Chicago, Illinois.
authors.forename: Ravi
authors.initials: R
authors.lastname: Rajaram
authors.affiliation: Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois.|Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.|Northwestern Institute for Comparative Effectiveness Research in Oncology (NICER-Onc), Robert H. Lurie Comprehensive Cancer Center, Chicago, Illinois.
authors.forename: Karl Y
authors.initials: KY
authors.lastname: Bilimoria
authors.affiliation: Department of Radiology, Section of Interventional Radiology, Robert H. Lurie Comprehensive Cancer Center, Northwestern Memorial Hospital, Chicago, Illinois.
authors.forename: Riad
authors.initials: R
authors.lastname: Salem
authors.affiliation: Departments of Surgery and Oncology, The Johns Hopkins Hospital, Baltimore, Maryland.
authors.forename: Timothy M
authors.initials: TM
authors.lastname: Pawlik
authors.affiliation: Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.|Northwestern Institute for Comparative Effectiveness Research in Oncology (NICER-Onc), Robert H. Lurie Comprehensive Cancer Center, Chicago, Illinois.
authors.forename: David J
authors.initials: DJ
authors.lastname: Bentrem
mesh_terms: D000328:Adult; D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000473:pathology / Q000601:surgery / Q000628:therapy*; D016208:Databases, Factual; D004621:Embolization, Therapeutic / Q000706:statistics & numerical data*; D005260:Female; D006498:Hepatectomy / Q000706:statistics & numerical data*; D006801:Humans; D008113:Liver Neoplasms / Q000473:pathology / Q000601:surgery / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D014481:United States / Q000453:epidemiology
keywords: hepatocellular carcinoma; therapy; treatment trends