Transarterial Radioembolization Versus Systemic Treatment for Hepatocellular Carcinoma with Macrovascular Invasion: Analysis of the U.S. National Cancer Database

Joseph C. Ahn; Marie Lauzon; Michael Luu; Marc L. Friedman; Kambiz Kosari; Nicholas Nissen; Shelly C. Lu; Lewis R. Roberts; Amit G. Singal; Ju Dong Yang

doi:10.2967/jnumed.121.261954

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FIGURE 1.
Proportion of patients who received TARE vs. systemic treatment for HCC with MVI between 2010 and 2017.
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FIGURE 2.
OS estimates of patients treated with TARE vs. systemic treatment before propensity score matching and after propensity score matching (B).
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FIGURE 3.
Comparison of survival in various subgroup of patients treated with TARE vs. systemic treatment. HSD = high school degree.

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TABLE 1

Clinical Features of Patients Before and After Propensity Score Matching, Part 1

	Before propensity score matching				After propensity score matching
Characteristic	All (n = 5,369)	Systemic (n = 3,915)	TARE (n = 1,454)	P	All (n = 1,136)	Systemic (n = 568)	TARE (n = 568)	P
Demographics
Age (y)	63.0 ± 9.73	62.6 ± 9.84	64.2 ± 9.33	<0.001	63.9 ± 9.13	63.7 ± 9.49	64.1 ± 8.75	0.420
Sex				0.720				0.880
Male	4,331 (80.7%)	3,153 (80.5%)	1,178 (81.0%)		917 (80.7%)	460 (81.0%)	457 (80.5%)
Female	1,038 (19.3%)	762 (19.5%)	276 (19.0%)		219 (19.3%)	108 (19.0%)	111 (19.5%)
Race				<0.001				0.587
White	3,347 (64.0%)	2,356 (61.8%)	991 (70.0%)		781 (68.8%)	385 (67.8%)	396 (69.7%)
Hispanic	536 (10.2%)	426 (11.2%)	110 (7.77%)		87 (7.66%)	47 (8.27%)	40 (7.04%)
Black	851 (16.3%)	660 (17.3%)	191 (13.5%)		168 (14.8%)	81 (14.3%)	87 (15.3%)
Asian + others	496 (9.48%)	373 (9.78%)	123 (8.69%)		100 (8.80%)	55 (9.68%)	45 (7.92%)
Socioeconomic factors
Insurance status				<0.001				0.933
Uninsured	285 (5.42%)	247 (6.46%)	38 (2.65%)		39 (3.43%)	21 (3.70%)	18 (3.17%)
Private	1,815 (34.5%)	1,319 (34.5%)	496 (34.5%)		392 (34.5%)	197 (34.7%)	195 (34.3%)
Medicaid/Medicare	3,072 (58.4%)	2,209 (57.8%)	863 (60.1%)		683 (60.1%)	340 (59.9%)	343 (60.4%)
Other	88 (1.67%)	49 (1.28%)	39 (2.72%)		22 (1.94%)	10 (1.76%)	12 (2.11%)
Median income				0.025				0.716
<$40,227	1,168 (23.7%)	882 (24.5%)	286 (21.6%)		246 (21.7%)	125 (22.0%)	121 (21.3%)
$40,227–$50,353	1,103 (22.4%)	825 (22.9%)	278 (21.0%)		268 (23.6%)	135 (23.8%)	133 (23.4%)
$50,354–$63,332	1,113 (22.6%)	790 (21.9%)	323 (24.4%)		279 (24.6%)	145 (25.5%)	134 (23.6%)
$63,333+	1,540 (31.3%)	1,103 (30.6%)	437 (33.0%)		343 (30.2%)	163 (28.7%)	180 (31.7%)
Without high school diploma				0.003				0.099
≥17.6%	1,345 (27.3%)	1,023 (28.4%)	322 (24.3%)		269 (23.7%)	152 (26.8%)	117 (20.6%)
10.9%–17.5%	1,360 (27.6%)	1,007 (27.9%)	353 (26.6%)		310 (27.3%)	152 (26.8%)	158 (27.8%)
6.3%–10.8%	1,305 (26.5%)	934 (25.9%)	371 (28.0%)		338 (29.8%)	162 (28.5%)	176 (31.0%)
<6.3%	922 (18.7%)	641 (17.8%)	281 (21.2%)		219 (19.3%)	102 (18.0%)	117 (20.6%)
Urban/rural				0.373				0.885
Metro	4,554 (87.1%)	3,338 (87.5%)	1,216 (86.1%)		974 (85.7%)	489 (86.1%)	485 (85.4%)
Urban	600 (11.5%)	424 (11.1%)	176 (12.5%)		142 (12.5%)	70 (12.3%)	72 (12.7%)
Rural	73 (1.40%)	52 (1.36%)	21 (1.49%)		20 (1.76%)	9 (1.58%)	11 (1.94%)

* Available in only 24% of patients.
Data are number followed by percentage in parentheses, except for MELD and tumor size (median followed by interquartile range) and age (mean ± SD).

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TABLE 2

Factors Predicting TARE Treatment Among Patients with T3BN0M0 HCC

Characteristic	Univariate		Multivariate
Characteristic	HR	P	HR	P
Age (10-y change)	1.194 (1.122–1.272)	<0.001	1.174 (1.091–1.267)	<0.001
Sex, male (reference)	(reference)		(reference)
Sex, female	0.969 (0.831–1.129)	0.691	0.957 (0.802–1.122)	0.607
Race, white (reference)	(reference)		(reference)
Race, Hispanic	0.615 (0.496–0.768)	<0.001	0.685 (0.536–0.883)	0.003
Black	0.688 (0.576–0.817)	<0.001	0.829 (0.675–1.013)	0.070
Race, Asian + others	0.796 (0.664–1.013)	0.034	0.735 (0.604–0.973)	0.012
Uninsured (reference)	(reference)		(reference)
Private insurance	2.362 (1.648–3.318)	<0.001	2.038 (1.376–2.950)	<0.001
Medicaid/Medicare insurance	2.470 (1.736–3.452)	<0.001	1.889 (1.276–2.716)	<0.001
Other insurance	5.004 (2.913–8.547)	<0.001	3.225 (1.730–5.869)	<0.001
Median income, <$40,227 (reference)	(reference)		(reference)
Median income, $40,227–$50,353	1.039 (0.850–1.221)	0.680	0.943 (0.742–1.144)	0.599
Median income, $50,354–$63,332	1.252 (1.061–1.511)	0.013	1.095 (0.889–1.394)	0.430
Median income, $63,333+	1.202 (1.025–1.429)	0.030	0.980 (0.761–1.258)	0.872
Without high school diploma, ≥17.6% (reference)	(reference)		(reference)
Without high school diploma, 10.9%–17.5%	1.100 (0.949–1.323)	0.262	0.976 (0.808–1.203)	0.811
Without high school diploma, 6.3%–10.8%	1.246 (1.057–1.471)	0.009	1.024 (0.815–1.264)	0.829
Without high school diploma, <6.3%	1.377 (1.151–1.652)	<0.001	1.181 (0.896–1.511)	0.212
Metro (reference)	(reference)		(reference)
Urban	1.125 (0.941–1.363)	0.212	1.161 (0.939–1.444)	0.174
Rural	1.085 (0.626–1.740)	0.753	1.134 (0.608–1.901)	0.663
Facility, academic (reference)	(reference)		(reference)
Facility, community cancer program	0.346 (0.231–0.534)	<0.001	0.424 (0.274–0.676)	<0.001
Facility, comprehensive community cancer program	0.762 (0.656–0.892)	<0.001	0.729 (0.612–0.864)	<0.001
Facility, integrated network	1.003 (0.826–1.196)	0.973	1.034 (0.845–1.274)	0.747
Region, Northeast (reference)	(reference)		(reference)
Region, Midwest	1.651 (1.390–2.017)	<0.001	1.640 (1.364–2.076)	<0.001
Region, South	1.110 (0.951–1.333)	0.225	1.268 (1.068–1.562)	0.014
Region, West	1.556 (1.287–1.906)	<0.001	1.740 (1.418–2.198)	<0.001
Charlson index, 0 or 1 (reference)	(reference)		(reference)
Charlson index, 2	1.087 (0.870–1.352)	0.457	1.117 (0.873–1.416)	0.371
Charlson index, 3	0.787 (0.662–0.934)	0.006	0.821 (0.676–0.984)	0.039
AFP, normal (reference)	(reference)		(reference)
AFP, elevated	0.992 (0.841–1.182)	0.928	1.123 (0.947–1.373)	0.223
MELD (10-unit change)	0.736 (0.660–0.785)	<0.001	0.756 (0.663–0.801)	<0.001
Tumor size	0.993 (0.983–1.002)	0.136	0.992 (0.982–1.001)	0.101

Data in parentheses are 95% CIs.

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TABLE 3

Factors Associated with OS Among Patients with T3BN0M0 HCC

Characteristic	Univariate		Multivariate
Characteristic	HR	P	HR	P
Age (10-y change)	1.022 (0.990–1.056)	0.184	1.035 (0.998–1.072)	0.063
Sex, male (reference)	(reference)		(reference)
Sex, female	0.925 (0.852–1.003)	0.060	0.912 (0.840–0.990)	0.029
Race, white (reference)	(reference)		(reference)
Race, Hispanic	0.830 (0.741–0.930)	0.001	0.850 (0.754–0.959)	0.008
Race, black	0.947 (0.865–1.036)	0.232	0.933 (0.846–1.029)	0.164
Race, Asian + others	0.887 (0.791–0.994)	0.040	0.894 (0.793–1.008)	0.066
Uninsured (reference)	(reference)		(reference)
Private insurance	0.909 (0.787–1.051)	0.198	0.920 (0.793–1.067)	0.269
Medicaid/Medicare insurance	0.970 (0.843–1.116)	0.672	0.956 (0.827–1.106)	0.547
Other insurance	0.877 (0.659–1.167)	0.368	0.912 (0.685–1.215)	0.530
Median income, <$40,227 (reference)	(reference)		(reference)
Median income, $40,227–$50,353	1.024 (0.927–1.131)	0.638	0.978 (0.878–1.089)	0.682
Median income, $50,354–$63,332	0.923 (0.836–1.018)	0.107	0.884 (0.790–0.989)	0.032
Median income, $63,333+	0.991 (0.907–1.083)	0.841	0.949 (0.839–1.073)	0.404
Without high school degree, ≥17.6% (reference)	(reference)		(reference)
Without high school degree, 10.9%–17.5%	1.086 (0.993–1.189)	0.072	1.082 (0.981–1.193)	0.114
Without high school degree, 6.3%–10.8%	1.098 (1.005–1.199)	0.038	1.117 (1.003–1.244)	0.044
Without high school degree, <6.3%	1.088 (0.985–1.202)	0.097	1.131 (0.988–1.294)	0.073
Metro (reference)	(reference)		(reference)
Urban	1.134 (1.025–1.255)	0.014	1.106 (0.992–1.233)	0.070
Rural	1.276 (0.982–1.657)	0.068	1.171 (0.892–1.537)	0.255
Facility, academic (reference)	(reference)		(reference)
Facility, community cancer program	1.552 (1.311–1.838)	<0.001	1.376 (1.159–1.634)	<0.001
Facility, comprehensive community cancer program	1.247 (1.149–1.352)	<0.001	1.234 (1.135–1.342)	<0.001
Facility, integrated network	1.164 (1.055–1.285)	0.003	1.153 (1.043–1.275)	0.005
Region, Northeast (reference)	(reference)		(reference)
Region, Midwest	1.179 (1.069–1.301)	<0.001	1.167 (1.055–1.292)	0.003
Region, South	1.013 (0.929–1.105)	0.763	0.963 (0.879–1.054)	0.414
Region, West	1.000 (0.900–1.111)	0.996	0.987 (0.883–1.102)	0.813
Charlson index 0 or 1 (reference)	(reference)		(reference)
Charlson index 2	0.994 (0.878–1.126)	0.928	0.979 (0.863–1.109)	0.735
Charlson index 3	1.082 (0.989–1.184)	0.087	1.073 (0.979–1.177)	0.131
AFP, normal (reference)	(reference)		(reference)
AFP, elevated	1.330 (1.202–1.473)	<0.001	1.356 (1.220–1.506)	<0.001
MELD score (10-unit change)	1.134 (1.084–1.186)	<0.001	1.113 (1.061–1.167)	<0.001
Treatment, systemic (reference)	(reference)		(reference)
Treatment, TARE	0.745 (0.691–0.803)	<0.001	0.739 (0.684–0.798)	<0.001