Is the number of TACE treatments in HCC patients associated with improved survival? A SEER-Medicare population analysis.
210 Background: We examine treatment patterns and associated survival outcomes of TACE at all stages of Hepatocellular Carcinoma in SEER Medicare. Methods: Medicare enrollees, 65 and older, with a diagnosis of a primary HCC between 2000-07 who received treatment were followed through end of 2009 using the Surveillance, Epidemiology and End-Results Program (SEER) and linked Medicare databases, with claims from Medicare parts A and B. Using Cox proportional hazards models, we assessed the impact on mortality, of each additional TACE, systemic chemotherapy, SIRT, external beam radiation therapy, ablation and surgical resection, controlling for cancer stage, general health status, underlying liver disease (alcohol related, Hepatitis B and C, moderate/severe liver dysfunction), and demographics. We assessed overall and HCC-related mortality for all, then for TACE-only treated patients, and stratified outcomes by stage. Results: Out of 3322 treated non-transplant HCC patients, 1094 got TACE, 74% were Caucasian, 6% African American, 66% male, and 45% were at stage 1/2, 17% at stage 3 and 14% at stage 4. Most (56%) received 1, 23% 2, 11% 3 and 10% 4 or more TACEs. In the adjusted models, both overall and HCC mortality reduction were associated with treatment with up to 2 TACEs (HR=0.68, P=<0.001 and HR=0.73, P=<0.001, respectively). A third TACE, but not a fourth, provided a further decrease in overall mortality (0.46, <0.001) and HCC mortality (.45, <0.001). When stratified by stage, the second TACE had a significant marginal effect within Stage 3, and only the first TACE had benefit within Stage 4. No effects were found for TACE in early HCC. In the adjusted models, liver conditions were not associated with HCC mortality among TACE treated patients only. Conclusions: TACE provides a survival benefit for elderly HCC patients in clinical practice. However, the survival benefit may decrease beyond 3 TACE treatments and varies by stage. Additional TACE treatments may be confounded if 4+ TACE treatments are utilized mainly to treat biologically aggressive disease related to extensive tumor burden, advanced disease or recurrences. Treatment selection bias cannot be excluded and should be further explored.