Liver cancer survival in Australia differs depending on centre

Cancer care

By Siobhan Calafiore

30 Jun 2024

Patients treated for early-stage hepatocellular carcinoma (HCC) at liver transplant centres are 29% less likely to die than peers at non-transplant centres, according to an Australian study highlighting systematic differences in care.

The real-world cohort study, conducted at two liver cancer referral centres with an integrated liver transplant program and eight non-transplant HCC referral centres, involved 887 patients with stage Barcelona Clinic Liver Cancer (BCLC) 0 or A disease.

Patients were first diagnosed between January 2016 and December 2020, with 433 and 454 patients at centres with and without transplant programs, respectively.

Findings published in Cancers [link here], showed that there were slight differences in liver disease aetiology between the groups, with patients from non-transplant centres more likely to have HBV and alcohol as a cause of their liver disease.

Both groups consisted of mainly male patients.

Patients from transplant centres were significantly younger than those from non-transplant centres (mean age 64 vs 66) and had a significantly lower median platelet count (117 vs 137), suggesting more significant portal hypertension.

Similarly, liver transplant centre patients were more likely to have more severe disease and greater numbers of multinodular disease and large single tumours.

Of the 887 patients overall, 4.7% underwent transplantation during follow-up, with the majority doing so after a recurrence after a documented complete response.

“Importantly, the time to transplant from initial diagnosis was not significantly different between the two groups, suggesting that where liver transplant was required, patients being referred from an non-transplant centre were not subjected to significant delays,” said the authors, led by gastroenterologists at Alfred Health, Melbourne.

Reassuring result

Management at large volume centres with transplant programs did not significantly predict allocation to resection (adjusted OR 0.75) – a “reassuring” result, the researchers said, as access to resection, a HCC quality indicator, was not centre-dependent.

However, in patients not receiving resection, those at a centre with a transplant program were managed significantly differently to patients at a centre without a transplant program, including being five times less likely to receive upfront ablation (adjusted OR 0.19), even after adjusting for tumour burden, as well as for age, gender, liver disease aetiology, liver disease severity and medical comorbidities.

Transplant centres also had significantly higher proportions of patients undergoing transarterial chemoembolisation (TACE) for every tumour burden category, including those with a single tumour measuring 2cm or less, the team noted.

“Further work is needed to determine whether a treatment approach with upfront ablation or initial TACE followed by ablation significantly affects outcomes, particularly if there is a delay between initial TACE and subsequent ablation therapy, as was the case for the majority of patients in our study,” they wrote.

Other analyses indicated that management at a transplant centre was associated with a reduced risk of all-cause mortality (adjusted HR 0.71) during follow-up.

Further, a competing-risks regression analysis, which included liver transplant as a competing event, demonstrated a similar reduction in risk (adjusted HR 0.70) for the liver transplant centre group, suggesting that the reduced risk of death could not be fully explained by higher rates of transplantation.

The researchers said their findings were the first published data regarding variations in treatment approach between the two types of centres in Australia.

“Further work is needed to prospectively evaluate the differences in treatment strategy, access to transplantation, and long-term survival outcomes, both within and across centres, in order to identify opportunities for quality improvement,” they concluded.

The research received funding from Ipsen, Eisai, and AstraZeneca.

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