Effectiveness of Initial Transarterial Chemoembolization for Hepatocellular Carcinoma Among Medicare Beneficiaries.
Effectiveness of Initial Transarterial Chemoembolization for Hepatocellular Carcinoma Among Medicare Beneficiaries.
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DOI：
10.6004/jnccn.2015.0135
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发表时间：
2015-09
期刊：
影响因子：
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通讯作者：
Lund J
中科院分区：
文献类型：
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作者：
Sanoff HK;Chang Y;Stavas JM;Stürmer T;Lund J
经动脉化疗栓塞术（TACE）的最佳管理，中期肝细胞癌（HCC）的标准方法，需要临床和技术专业知识。我们试图评价TACE在广泛的医疗环境中是否保持其有效性。随着钇90放射性栓塞（Y 90）的使用越来越多，我们探讨了Y 90与TACE相比的有效性。从监测流行病学和最终结果（SEER）-医疗保险联系中确定了2004-2009年诊断的HCC患者，最初接受TACE或Y 90治疗。关键协变量包括诊断前AFP筛查、肝硬化并发症和肿瘤范围。使用多变量考克斯比例风险评价治疗、患者和医疗保健系统因素对总生存期（OS）的影响。提供了分层OS估计值。使用倾向评分（PS）加权比较Y 90与TACE的有效性。在1，528例动脉内栓塞中，577例记录了同期化疗（例如TACE）。TACE后的中位OS为21个月（95% CI 18-23），Y 90后为9个月（95% CI 1-41）。提供了按分期、AFP筛查和肝脏合并症分层的精确生存估计值。肝外扩散或血管浸润患者TACE后90天死亡率为21-25%。在PS加权分析中，Y 90与较差生存率相关，aHR 1.39（95% CI 1.02-1.90）。TACE的有效性可推广到在各种治疗环境中接受护理的Medicare患者。然而，晚期疾病患者的早期治疗后死亡率很高。我们没有发现Y 90与TACE相比结局改善的证据。该大型队列的生存率估计值可用于为考虑姑息性TACE的患者提供预后信息。
Optimal administration of transarterial chemoembolization (TACE), the standard approach for intermediate stage hepatocellular carcinoma (HCC), requires clinical and technical expertise. We sought to evaluate if TACE retains its effectiveness when administered across a broad range of healthcare settings. With increasing use of yttrium90 radioembolization (Y90), we explored the effectiveness of Y90 compared with TACE. HCC patients diagnosed from 2004–2009 treated initially with TACE or Y90 were identified from the Surveillance Epidemiology and End-Results (SEER)-Medicare linkage. Key covariates included prediagnosis AFP screening, complications of cirrhosis, and tumor extent. Effect of treatment, patient, and healthcare system factors on overall survival (OS) was evaluated using multivariable Cox proportional hazards. Stratified OS estimates are provided. Propensity score (PS) weighting was used to compare effectiveness of Y90 to TACE. Of 1,528 with intra-arterial embolization, 577 had documentation of concurrent chemotherapy (e.g. TACE). Median OS was 21 months (95% CI 18–23) following TACE, 9 months (95% CI 1–41) following Y90. Refined survival estimates stratified by stage, AFP screening, and liver comorbidity are presented. Ninety day mortality after TACE was 21–25% in patients with extrahepatic spread or vascular invasion. In the PS-weighted analysis, Y90 was associated with inferior survival, aHR 1.39 (95% CI 1.02–1.90). The effectiveness of TACE is generalizable to Medicare patients receiving care in a variety of treatment settings. However, early post-treatment mortality is high in patients with advanced disease. We found no evidence for improved outcomes with Y90 compared with TACE. Survival estimates from this large cohort can be used to provide prognostic information to patients considering palliative TACE.