Background
Hepatocellular carcinoma (HCC) early-stage treatment options include potentially curative surgeries. Locoregional treatments are recommended for nonsurgical intermediate stage patients, and those awaiting liver transplant. Systemic therapy is generally recommended for advanced disease. Real-world HCC treatment pathways from initial locoregional treatments are not well understood. This study describes the sequence of first to fourth treatments in patients with HCC initially receiving locoregional treatment in England.
Methods
This work includes patient data collated by the National Disease Registration Service in England including the Systemic Anti-Cancer Therapy (SACT) dataset, the national Radiotherapy Data Set, and linkage to Hospital Episode Statistics. Patients diagnosed with HCC (ICD10 C220 and ICD10-O2 morphology 8170) between 01/01/2015 – 31/12/2020, aged ≥18 years, and treated with locoregional treatments as first treatment -30 to 365 days after HCC diagnosis were selected. Locoregional treatments comprised transarterial chemoembolization (TACE), transarterial embolization (TAE), selective internal radiation therapy (SIRT)/transarterial radioembolization (TARE), or stereotactic body radiation therapy (SBRT). Potentially curative surgery included ablation, resection and transplant. Follow-up ended 30/6/2022. An algorithm was developed to identify change in treatment between resection, ablation, transplant, SACT or additional locoregional treatment. A gap >12 months between identical locoregional treatments meant they were classified as separate treatments. Kaplan-Meier analysis of time to next treatment (TTNT) from start of prior treatment was performed.
Results
We identified 2900 patients with HCC who received locoregional treatment as their first treatment, of which 65.8% (n=1907) received TACE (figure 1). Median follow-up from diagnosis was 26.4 (interquartile-range (IQR):16.4–40.7) months. Half (n=1475, 50.9%) received a second treatment, 18.4% (n=535) received a third treatment, and 6.4% (n=187) received a fourth treatment within the study period. For second treatment, 39.1% (n=576) had potentially curative surgery, 33.2% (n=490) had additional locoregional treatment, and 27.7% (n=409) progressed to systemic treatment. The most common second treatments were ablation (n=268,18.2%), sorafenib (n=252,17.1%), TACE (n=244,16.5%) and transplant (n=210,14.2%). TACE (n=126, 23.6%) was the most frequent third treatment followed by ablation (n=91,17.0%) and sorafenib (n=69,12.9%). Ablation (n=30,16.0%), TACE (n=30,16.0%) and sorafenib (n=29,15.5%) remained the most frequent fourth treatments. Median TTNT was 11.9 (IQR:11.2–12.5), 13.5 (IQR:12.7–14.5), 9.8 (IQR:9.0–11.2) months from first, second and third treatment, respectively.