title: Racial disparities in treatment and survival of patients with hepatocellular carcinoma in the United States.
abstract: BACKGROUND
  While the incidence and mortality of hepatocellular carcinoma (HCC) continue to increase across the United States (US), disparities may exist relative to treatment modality and survival. The objective of the present study was to determine the factors associated with racial differences in survival among patients with HCC in the US.
  
  
  METHODS
  The Surveillance, Epidemiology, and End Results (SEER) database was used to identify patients with HCC between 1998 and 2012 in the US. Multivariable logistic regression analysis was performed to examine associations between type of therapy and race, while a multivariable Cox proportional hazards model was built to determine the effect of race on survival.
  
  
  RESULTS
  A total of 58,186 patients with HCC were identified. Over two-thirds of patients were white (n=39,223, 67.4%), while 18.3% were Asian (n=10,665), 13.1% black (n=7,620) and 1.2% native American (n=678). In comparison to other racial groups, Asian patients with HCC tended to be older [white vs. black vs. native American vs. Asian: median age: 63 years, interquartile range (IQR), 55-73 vs. 59 years, IQR, 53-66 vs. 59 years, IQR, 53-69 vs. 64 years, IQR, 55-73, P<0.001] and were diagnosed with larger tumors (white vs. black vs. native American vs. Asian: median tumor size: 4.8 cm, IQR, 3.0-8.0 vs. 5.1 cm, IQR, 3.1-8.7 vs. 4.8 cm, IQR, 3.0-7.3 vs. 5.5 cm, IQR, 3.1-9.0, P<0.001). Asian patients were also less likely to present with concomitant cirrhosis (white vs. black vs. native American vs. Asian: 81.8% vs. 77.7% vs. 83.2% vs. 69.1%, P<0.001) while elevated levels of alpha-fetoprotein more were often noted among black patients (white vs. black vs. native American vs. Asian: 25.5% vs. 14.9% vs. 22.2% vs. 21.8%, P<0.001). Compared to other racial groups, Asian patients were most likely to receive any form of treatment (white vs. black vs. native American vs. Asian: 29.2% vs. 25.2% vs. 27.6% vs. 34.4%, P<0.001). In particular, after controlling for potential confounders, Asian patients demonstrated the greatest odds of undergoing surgery (OR: 1.48, 95% CI, 1.13-1.95, P=0.01). The median overall survival (OS) was 11 months with the worst prognosis noted among black patients. After accounting for disease and patient factors, Asian patients demonstrated the lowest risk for death [hazard ratio (HR): 0.76, 95% CI, 0.66-0.87, P<0.001] while no differences were noted in the risk of death among other racial groups (all P>0.05).
  
  
  CONCLUSIONS
  Significant racial differences were noted in presentation, treatment and survival among patients with HCC. Further research is necessary to better understand socio-demographic and biological factors driving racial disparities in care. Future policies should aim to improve access to care among racial/ethnic minorities.
authors.affiliation: 1 Department of Surgery, Johns Hopkins Hospital, Maryland, USA ; 2 Department of Hepatobiliary Surgery, Sun Yat-sen University Cancer Center, Guangzhou 510275, China ; 3 State Key Laboratory of Oncology in South China, Guangzhou 510060, China.
authors.forename: Li
authors.initials: L
authors.lastname: Xu
authors.affiliation: 1 Department of Surgery, Johns Hopkins Hospital, Maryland, USA ; 2 Department of Hepatobiliary Surgery, Sun Yat-sen University Cancer Center, Guangzhou 510275, China ; 3 State Key Laboratory of Oncology in South China, Guangzhou 510060, China.
authors.forename: Yuhree
authors.initials: Y
authors.lastname: Kim
authors.affiliation: 1 Department of Surgery, Johns Hopkins Hospital, Maryland, USA ; 2 Department of Hepatobiliary Surgery, Sun Yat-sen University Cancer Center, Guangzhou 510275, China ; 3 State Key Laboratory of Oncology in South China, Guangzhou 510060, China.
authors.forename: Gaya
authors.initials: G
authors.lastname: Spolverato
authors.affiliation: 1 Department of Surgery, Johns Hopkins Hospital, Maryland, USA ; 2 Department of Hepatobiliary Surgery, Sun Yat-sen University Cancer Center, Guangzhou 510275, China ; 3 State Key Laboratory of Oncology in South China, Guangzhou 510060, China.
authors.forename: Faiz
authors.initials: F
authors.lastname: Gani
authors.affiliation: 1 Department of Surgery, Johns Hopkins Hospital, Maryland, USA ; 2 Department of Hepatobiliary Surgery, Sun Yat-sen University Cancer Center, Guangzhou 510275, China ; 3 State Key Laboratory of Oncology in South China, Guangzhou 510060, China.
authors.forename: Timothy M
authors.initials: TM
authors.lastname: Pawlik
keywords: Hepatocellular carcinoma (HCC); race; survival; therapy