African Americans are less likely to receive curative treatment for hepatocellular carcinoma

Table 1 Demographics and clinical parameters in patients with hepatocellular carcinoma grouped by race

	Caucasian(n = 32428)		African-American(n = 9726)		Hispanic(n = 8988)		Other(n = 11462)		P value
	n	%	n	%	n	%	n	%
Age (yr)									< 0.001
≤ 64	17695	54.6	6980	71.8	5357	59.6	6609	57.7
65-79	10982	33.9	2287	23.5	2888	32.1	3762	32.8
≥ 80	3751	11.6	458	4.7	743	8.3	1090	9.5
Sex									0.880
Male	23845	73.5	7172	73.7	6572	73.1	8319	72.7
Female	8583	26.5	2554	26.3	2416	26.9	3122	27.3
Primary payer									< 0.001
Medicare	15765	48.9	3471	35.9	3645	40.6	4520	39.5
Medicaid	4155	12.9	2707	27.9	2206	24.5	2573	22.5
Private insurance	9497	29.4	2236	23.1	2020	22.5	3143	27.5
Other	2844	8.8	1267	13.1	1118	12.4	1202	10.5
Geographic region									< 0.001
Northeast	7726	23.8	2603	26.8	1829	20.4	2395	20.9
Midwest	5904	18.2	1785	18.4	536	5.9	3016	26.3
South	13086	40.4	4454	45.8	3126	34.8	2102	18.3
West	5712	17.6	883	9.1	3497	38.9	3950	34.5
Discharge year									0.917
2010	8180	25.2	2194	22.6	2223	24.7	3162	27.6
2011	8118	25.0	2457	25.3	2386	26.5	2980	26.0
2012	7910	24.4	2490	25.6	2170	24.1	2660	23.2
2013	8220	25.4	2585	26.6	2210	24.6	2660	23.2
Hepatitis C	5056	15.6	2497	25.7	1518	16.9	1737	15.2	< 0.001
Hepatitis B	610	1.9	598	6.2	236	2.6	1975	17.2	< 0.001
Alcohol	5566	17.2	1278	13.2	2023	22.5	1157	10.1	< 0.001
NASH	10802	33.3	3436	35.3	3601	40.1	4140	36.1	< 0.001
Primary sclerosing cholangitis	326	1.0	81	0.8	35	0.4	140	1.2	0.046
Primary biliary cirrhosis	131	0.4	0	0.0	10	0.1	34	0.3	-
Autoimmune	91	0.3	25	0.3	60	0.7	≤ 10	0.1	0.007
Other	14336	44.2	3818	39.3	2967	33.0	4566	39.9	< 0.001
Liver decompensation features									< .0010
Zero	18388	56.7	5690	58.5	4475	49.8	6827	59.6
One	8968	27.7	2756	28.3	2846	31.7	3092	27.0
Two	4074	12.6	1010	10.4	1340	14.9	1242	10.8
Three or greater	998	3.1	270	2.8	328	3.6	301	2.6
Metastasis									0.007
None	27328	84.3	7841	80.6	7497	83.4	9567	83.5
Single site	3945	12.2	1453	14.9	1092	12.2	1516	13.2
Two or more site	1155	3.6	433	4.5	399	4.4	379	3.3
Elixhauser comorbidity score									< 0.001
< 3	15593	48.1	4177	43.0	4255	47.3	6642	57.9
≥ 3	16835	51.9	5549	57.1	4733	52.7	4821	42.1
Treatment options									< 0.001
Transplant	1254	3.9	190	1.9	252	2.8	349	3.1
Resection	4306	13.3	823	8.5	728	8.1	1644	14.3
Ablation	2031	6.3	425	4.4	517	5.8	833	7.3
TACE	2419	7.5	754	7.8	836	9.3	939	8.2
Noninvasive treatment	22418	69.1	7534	77.5	6656	74.1	7697	67.2
In hospital mortality	2924	9.0	1120	11.5	928	10.3	1151	10.1	0.017

TACE: Transarterial chemoablation; NASH: Non-alcoholic steatohepatitis.

Table 2 Multivariate logistic regressions comparing outcomes of hepatocellular carcinoma by race

Outcome	Race	Adjusted odds ratio	95%CI
Metastatic Hepatocellular Carcinoma1	African-American	Reference
	Caucasian	0.82	0.71-0.94
	Hispanic	0.87	0.73-1.05
	Other/unknown	0.84	0.70-1.001
Liver Decompensation2	African-American	Reference
	Caucasian	1.16	1.03-1.30
	Hispanic	1.28	1.10-1.51
	Other/unknown	1.14	0.995-1.31
Inpatient Mortality3	African-American	Reference
	Caucasian	0.78	0.65-0.93
	Hispanic	0.82	0.66-1.03
	Other/unknown	0.86	0.69-1.07

¹Model is adjusted for age, sex, race, geographic region, hepatitis C, alcohol, non-alcoholic steatohepatitis (NASH), liver decompensation features, and Elixhauser comorbidity score;

²Model is adjusted for age, sex, race, geographic region, hepatitis C, alcohol, NASH, primary biliary cirrhosis, metastasis, and Elixhauser comorbidity score;

³Model is adjusted for age, sex, race, geographic region hepatitis C, hepatitis B, alcohol, NASH, liver decompensation features, metastasis, and treatment.

Table 3 Multinomial logistic regression to evaluate disparities in treatment for hepatocellular carcinoma based on payer^{1, 2}

Intervention	Race	Odds ratio	Confidence interval
Liver Transplant	African-American	Reference
	Caucasian	2.66	1.92-3.68
	Hispanic	2.18	1.40-3.39
	Other/unknown	2.41	1.62-3.61
Resection	African-American	Reference
	Caucasian	1.82	1.48-2.23
	Hispanic	1.24	0.94-1.64
	Other/unknown	1.79	1.39-2.32
Ablation	African-American	Reference
	Caucasian	1.77	1.36-2.30
	Hispanic	1.46	1.05-2.03
	Other/unknown	2.03	1.47-2.80
TACE	African-American	Reference
	Caucasian	1.15	0.93-1.41
	Hispanic	1.29	0.97-1.72
	Other/unknown	1.19	0.90-1.58

¹Noninvasive treatment is treated as the reference category; ²Model adjusts for age, gender, race, geographic region, hepatitis C, hepatitis B, alcohol, non-alcoholic steatohepatitis, liver decompensation features, and Elixhauser comorbidity score. TACE: Transarterial chemoablation.