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Racial and Geographic Disparities in the Utilization of Surgical Therapy for hepatocellular carcinoma
Christopher J. Sonnenday*1, Justin B. Dimick1, Richard D. Schulick2, Michael a. Choti2
1Department of Surgery, University of Michigan, Ann Arbor, MI; 2Department of Surgery, Johns Hopkins University, Baltimore, MD

Background: The incidence of hepatocellular carcinoma (HCC) continues to increase, a trend that will likely continue associated with the high prevalence of chronic hepatitis C infection. Improved options for therapy also promise to expand the number of patients eligible for surgical therapy, if properly utilized. This study sought to determine the recent patterns of utilization of surgical therapy for HCC from the Surveillance, Epidemiology, and End Results (SEER) national cancer registry.
Methods: Data were extracted for all patients with HCC submitted to the SEER 17 Public-Use database from 1998-2003. Socioeconomic data from the 2000 Census for the county of residence of each patient were linked to the SEER data. Patients with missing demographic or treatment data were excluded. Univariate and multivariate regression analysis were performed to measure the association of patient demographic and tumor covariates on the utilization of surgical therapy (ablation, hepatic resection, or transplantation) for HCC.
Results: A total of 14,902 patients with HCC were included in the analysis. Twenty percent of patients underwent surgical therapy (8.5% resection, 6.1% ablation, 4.9% transplant). On adjusted analysis, the utilization of surgical therapy increased 5% per year from 1998 to 2003. Significant variations in the utilization of surgical therapy exists by region of residence (range, 8% in rural Georgia to 31% in Alaska and Hawaii). On multivariate analysis, female sex, younger age, smaller tumor size, and having a solitary tumor were associated with increased utilization of surgical therapy. African-Americans were 25% less likely to receive surgical therapy than white patients (P=0.007), while Asian patients were 27% more likely to receive surgery (P=0.001). Factors associated with decreased probability of receiving surgical therapy included residence in counties with higher rates of unemployment and higher densities of residences with >1 person / room. Median household income and level of education were not associated with the utilization of surgical therapy for HCC on adjusted analysis.
Conclusions: Significant racial and regional disparities exist in the utilization of surgical therapy for HCC, despite adjustment for tumor factors, socioeconomic status, and level of education. Further investigation to understand the etiology of these profound differences is essential to ensure equitable provision of surgical therapies, which provide the only potentially curative treatments for HCC.

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