Lee Rachel M, Gamboa Adriana C, Turgeon Michael K, Yopp Adam, Ryon Emily L, Kronenfeld Joshua P, Goel Neha, Wang Annie, Lee Ann Y, Luu Sommer, Hsu Cary, Silberfein Eric, Maithel Shishir K, Russell Maria C
1371 Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA.
Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical School, Dallas, TX, USA.
Am Surg. 2020 Jul;86(7):865-872. doi: 10.1177/0003134820939934. Epub 2020 Jul 28.
Hepatitis C virus (HCV) has historically been the most common cause of cirrhosis and hepatocellular carcinoma (HCC) in the United States. With improved HCV treatment, cirrhosis secondary to other etiologies is increasing. Given this changing epidemiology, our aim was to determine the impact of cirrhosis etiology on overall survival (OS) in patients with HCC.
All patients with cirrhosis and primary HCC from the US Safety Net Collaborative (2012-2014) database were included. Patients were grouped into "safety net" and "academic" based on where they received their care. The primary outcome was the OS.
1479 patients were included. The average age was 60 years and 78% (n = 1156) were male. 56% (n = 649) received care at academic and 44% (n = 649) at safety net hospitals. The median model for end-stage liver disease (MELD) was 10 (IQR 8-16). Median OS was 23 months. Etiology of cirrhosis was viral hepatitis 56% (n = 612), alcohol abuse 14% (n = 152), alcohol and hepatitis 23% (n = 251), and other 7% (n = 85). Patients with alcohol-related cirrhosis (alcohol alone or with hepatitis) were younger (59 vs 62 years), more likely to be male (86% vs 75%), treated at a safety net facility (45% vs 35%), uninsured (17% vs 13%), and had a higher MELD (median 12 vs 10) (all < .003). They were less likely to have been screened for HCC within 1 year of diagnosis (20% vs 29%) and to receive treatment (69% vs 81%), and more likely to present with stage IV disease (21% vs 15%) (all < .001). Patients with alcohol-related cirrhosis had decreased OS (5-year OS 24% vs 40%, < .001), which persisted in a subset analysis of both academic and safety net populations.
Although not significant on MVA, alcohol-related cirrhosis is associated with all factors that correlate with decreased survival from HCC. Efforts must focus on this vulnerable patient population to optimize screening, treatment, and outcomes.
在美国，丙型肝炎病毒（HCV）历来是肝硬化和肝细胞癌（HCC）最常见的病因。随着丙型肝炎治疗的改善，其他病因导致的肝硬化正在增加。鉴于这种流行病学的变化，我们的目的是确定肝硬化病因对HCC患者总生存期（OS）的影响。
纳入美国安全网协作组织（2012 - 2014年）数据库中所有患有肝硬化和原发性HCC的患者。根据患者接受治疗的地点，将其分为“安全网”组和“学术”组。主要结局指标是总生存期。
共纳入1479例患者。平均年龄为60岁，78%（n = 1156）为男性。56%（n = 649）在学术医院接受治疗，44%（n = 649）在安全网医院接受治疗。终末期肝病模型（MELD）中位数为10（四分位间距8 - 16）。中位总生存期为23个月。肝硬化病因中，病毒性肝炎占56%（n = 612），酒精滥用占14%（n = 152），酒精性肝炎占23%（n = 251），其他占7%（n = 85）。酒精相关肝硬化患者（单纯酒精性或合并肝炎）更年轻（59岁对62岁），男性比例更高（86%对75%），在安全网机构接受治疗（45%对35%），未参保（17%对13%），MELD更高（中位数12对10）（所有P <.003）。他们在诊断后1年内接受HCC筛查的可能性较小（20%对29%），接受治疗的可能性较小（69%对81%），出现IV期疾病的可能性更大（21%对15%）（所有P <.001）。酒精相关肝硬化患者的总生存期降低（5年总生存率24%对40%，P <.001），在学术组和安全网组的亚组分析中均持续存在。
尽管在多变量分析中不显著，但酒精相关肝硬化与所有与HCC生存率降低相关的因素有关。必须关注这一脆弱患者群体，以优化筛查、治疗和结局。
