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Purpose: To compare utilization and effectiveness of radiofrequency ablation (RFA) and surgical resection for hepatocellular carcinoma (HCC).Methods: The 2004-2015 United States National Cancer Database was queried for HCC patients treated by RFA and surgical resection. Patients were 1:1 propensity score matched. Duration of hospital stay, unplanned readmission rates, and overall survival (OS) were compared in the matched cohort via multivariable regression models.Results: Eighteen thousand two hundred ninety-six patients were included (RFA, n = 8211; surgical resection, n = 10,085). RFA was more likely in young male whites with high degree of hepatic fibrosis, high bilirubin levels, high INR, and multifocal HCC; resection was more likely in those with private insurance, high income, high cancer grade and stage, and larger HCC. RFA rates varied between 32.3% (East South Central) and 58.5% (New England). Post-treatment outcomes were superior for RFA versus resection regarding duration of hospital stay (median 1 vs. 5d, p < 0.001), 30-day unplanned hospital readmission rates (3.1% vs. 4.5%, p < 0.001), and 30-/90-day mortality (0% vs. 4.6%/8%, p < 0.001). Overall survival was comparable for RFA and resection for severe hepatic fibrosis/cirrhosis (5-year OS 37.3% vs. 39.4%, p = 0.07), for patients > 65 years old (5-year OS 21.9% vs. 26.5%, p = 0.47), and for HCC < 15 mm (5-year OS 49.7% vs. 52.3%, p = 0.78). OS in the full cohort was superior for surgical resection (5-year OS 29.9% vs. 45.7%, p < 0.01).Conclusion: RFA for HCC shows substantial variation by geography, socioeconomic factors, liver function, and tumor extent. RFA offers superior post-treatment outcomes versus surgical resection and may be an alternative for older patients with cirrhosis and/or small HCC.Key Points: • Duration of hospital stay, unplanned readmissions, and 30-/90-day mortality are lower for RFA versus surgical resection. • RFA and surgical resection show similar survival in severe hepatic fibrosis. • In HCC < 15 mm, RFA and surgical resection yield similar survival. [ABSTRACT FROM AUTHOR]

Aim: To investigate determinants of receiving cancer-directed therapies and their potential survival impact in nonresected hepatocellular carcinoma (HCC) Materials & methods: Nonsurgically resected HCC patients between 2000 and 2010 were stratified by American Joint Committee on Cancer staging and the type of therapy. Predictors of receiving therapy were identified and implication on survival was evaluated.Results: Out of 9239 patients included, those receiving any therapy demonstrated prolonged overall survival with following median overall survival (months): ablation (30.8), Yttrium-90 (15.6), transcatheter arterial chemoembolization (15.5), Sorafenib (5.6), versus no cancer-directed therapy (3.7; p-values <0.001). Overall, 36% of patients received cancer-directed therapy including 47% with stage I/II. Favorable sociodemographic factors predicted receipt of percutaneous locoregional therapies (p-values <0.05).Discussion& Conclusion: There appears to be significant disparity in care of nonresected HCC patients with significant underutilization of cancer-directed therapies. [ABSTRACT FROM AUTHOR]

Aim: To investigate outcomes in unresectable hepatocellular carcinoma (HCC) patients stratified by sociodemographic and clinical factors in a population study.Materials& Methods: Surveillance, Epidemiology and End Results (SEER) database was used to identify patients diagnosed in 2000-2011. Overall survival (OS) was stratified using patient sociodemographic characteristics and American Joint Commission on Cancer (AJCC) staging. Log-rank test and Cox proportional hazard models were used to identify prognostic factors of OS.Results: In patients with AJCC stage I and II unresectable HCC, prolonged OS was correlated with being married, younger age, ethnicity, geographic location, living in large urban areas, being insured and higher income and education levels.Conclusion: In AJCC stage I and II unresectable HCC patients with favorable sociodemographic factors, prolonged OS maybe in part related to better access to cancer-directed therapy. [ABSTRACT FROM AUTHOR]

Purpose: To assess the cost effectiveness of microwave ablation (MWA) and stereotactic body radiotherapy (SBRT) for patients with inoperable stage I non-small cell lung cancer (NSCLC)., Materials and Methods: A literature search was performed in MEDLINE with broad search clusters. A decision-analytic model was constructed over a 5-year period. The model incorporated treatment-related complications and long-term recurrence. All clinical parameters were derived from the literature with preference to long-term prospective trials. A healthcare payers' perspective was adopted. Outcomes were measured in quality-adjusted life years (QALYs) extracted from prior studies and U.S. dollars from Medicare reimbursements and prior studies. Base case calculations, probabilistic sensitivity analysis with 10,000 Monte Carlo simulations, and multiple 1- and 2-way sensitivity analyses were performed., Results: MWA yielded a health benefit of 2.31 QALYs at a cost of $195,331, whereas SBRT yielded a health benefit of 2.33 QALYs at a cost of $225,271. The incremental cost-effectiveness ratio was $1,480,597/QALY, indicating that MWA is the more cost-effective strategy. The conclusion remains unchanged in probabilistic sensitivity analysis with MWA being the optimal cost strategy in 99.84% simulations. One-way sensitivity analyses revealed that MWA remains cost effective when its annual recurrence risk is <18.4% averaged over 5 years, when the SBRT annual recurrence risk is >1.44% averaged over 5 years, or when MWA is at least $7,500 cheaper than SBRT., Conclusions: MWA appears to be more cost effective than SBRT for patients with inoperable stage I NSCLC., (Copyright © 2022. Published by Elsevier Inc.)

Objective: To evaluate the utilization and outcomes of PD-1-directed immunotherapy (PD-1 IMT) for advanced hepatocellular carcinoma. Methods: Patients with advanced hepatocellular carcinoma receiving systemic therapy and PD-1 IMT (nivolumab/pembrolizumab) were included from the Flatiron database. Overall survival (OS) was evaluated using multivariable Cox models with the following subgroup analyses: patients with data on clinical performance and liver function and patients receiving tyrosine kinase inhibitors. Results: n = 1770 patients were included (PD-1 IMT 19.3%). Overall, PD-1 IMT was associated with longer OS (hazard ratio [HR]: 0.57). This effect was robust across both subgroup analyses with HR: 0.72 (subgroup 1) and HR: 0.57 (subgroup 2). Conclusions: PD-1 IMT is increasingly used in clinical practice and associated with an OS benefit.

Background: This study sought to assess microsatellite and KRAS status, prevalence, and impact on outcome in stage IV colorectal cancer (CRC)., Materials and Methods: The 2010 to 2016 US National Cancer Database was queried for adult patients with stage IV CRC. Prevalence of microsatellite status (microsatellite instability-high [MSI-H] or microsatellite stable [MSS]) and KRAS status (KRAS mutation or wild-type) of the primary CRC was assessed. Overall survival (OS) was evaluated using multivariable Cox proportional hazards models in patients with complete data on both microsatellite and KRAS status and information on follow-up., Results: Information on microsatellite and KRAS status was available for 10,844 and 25,712 patients, respectively, and OS data were available for 5,904 patients. The overall prevalence of MSI-H status and KRAS mutation was 3.1% and 42.4%, respectively. Prevalence of MSI-H ranged between 1.6% (rectosigmoid junction) and 5.2% (transverse colon), and between 34.7% (sigmoid colon) and 58.2% (cecum) for KRAS mutation. MSI-H rates were highest in East North Central US states (4.1%), and KRAS mutation rates were highest in West South Central US states (44.1%). Multivariable analyses revealed longer OS for patients with KRAS wild-type versus mutation status (hazard ratio [HR], 0.91; 95% CI, 0.85-0.97; P=.004), those with MSS versus MSI-H status (HR, 0.75; 95% CI, 0.62-0.9; P=.003), and those with left-sided versus right-sided CRC (multivariable HR, 0.65; 95% CI, 0.6-0.7; P<.001). The effect of KRAS mutation further varied with CRC site and microsatellite status (P=.002 for interaction)., Conclusions: Depending on the primary site and US geography, stage IV CRC shows distinct mutational behavior. KRAS mutation, MSI-H, and primary CRC sidedness independently affect OS and interact with distinct prognostic profiles. Generically classifying adenocarcinomas at different sites as CRC might deprecate this diversity.

Purpose: To assess use of stereotactic body radiotherapy (SBRT) for stage I renal cell carcinoma (RCC) and compare outcomes with thermal ablation and partial nephrectomy (PN)., Materials and Methods: The 2004-2015 National Cancer Database was investigated for histopathologically proven stage I RCC treated with PN, cryoablation, radiofrequency (RF) or microwave (MW) ablation, or SBRT. Patients were propensity score-matched to account for potential confounders, including patient age, sex, race, comorbidities, tumor size, histology, grade, tumor sequence, administration of systemic therapy, treatment in academic vs nonacademic centers, treatment location, and year of diagnosis. Overall survival (OS) was evaluated with Kaplan-Meier plots, log-rank tests, and Cox proportional hazards models., Results: A total of 91,965 patients were identified (SBRT, n = 174; PN, n = 82,913; cryoablation, n = 5,446; RF/MW ablation, n = 3,432). Stage I patients who received SBRT tended to be older women with few comorbidities treated at nonacademic centers in New England states. After propensity score matching, a cohort of 636 patients was obtained with well-balanced confounders between treatment groups. In the matched cohort, OS after SBRT was inferior to OS after PN and thermal ablation (PN vs SBRT, hazard ratio [HR] = 0.29, 95% confidence interval [CI] 0.19-0.46, P < .001; cryoablation vs SBRT, HR = 0.40, 95% CI 0.26-0.60, P < .001; RF/MW ablation vs SBRT, HR = 0.46, 95% CI 0.31-0.67, P < .001). Compared with PN, neither cryoablation nor RF/MW ablation showed significant difference in OS (cryoablation vs PN, HR = 1.35, 95% CI 0.80-2.28, P = .258; RF/MW ablation vs PN, HR = 0.64, 95% CI 0.95-2.55, P = .079)., Conclusions: Current SBRT protocols show lower OS compared with thermal ablation and PN, whereas thermal ablation and PN demonstrate comparable outcomes., (Copyright © 2019 SIR. Published by Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to evaluate socioeconomic discrepancies in current treatment approaches and survival trends among patients with intrahepatic cholangiocarcinoma (ICC)., Methods: The 2004-2015 National Cancer Database was retrospectively analyzed for histopathologically proven ICC. Treatment predictors were evaluated using multinomial logistic regression and overall survival via multivariable Cox models., Results: Overall, 12,837 ICC patients were included. Multiple factors influenced treatment allocation, including age, education, comorbidities, cancer stage, grade, treatment center, and US state region (multivariable p < 0.05). The highest surgery rates were observed in the Middle Atlantic (28.7%) and lowest rates were observed in the Mountain States (18.4%). Decreased ICC treatment likelihood was observed for male African Americans with Medicaid insurance and those with low income (multivariable p < 0.05). Socioeconomic treatment discrepancies translated into decreased overall survival for patients of male sex (vs. female; hazard ratio [HR] 1.21, 95% confidence interval [CI] 1.16-1.26, p < 0.001), with low income (< $37,999 vs. ≥ $63,000 annually; HR 1.07, 95% CI 1.01-1.14, p = 0.032), and with Medicaid insurance (vs. private insurance; HR 1.13, 95% CI 1.04-1.23, p = 0.006). Both surgical and non-surgical ICC management showed increased survival compared with no treatment, with the longest survival for surgery (5-year overall survival for surgery, 33.5%; interventional oncology, 11.8%; radiation oncology/chemotherapy, 4.4%; no treatment, 3.3%). Among non-surgically treated patients, interventional oncology yielded the longest survival versus radiation oncology/chemotherapy (HR 0.73, 95% CI 0.65-0.82, p < 0.001)., Conclusions: ICC treatment allocation and outcome demonstrated a marked variation depending on socioeconomic status, demography, cancer factors, and US geography. Healthcare providers should address these discrepancies by providing surgery and interventional oncology as first-line treatment to all eligible patients, with special attention to the vulnerable populations identified in this study.

Purpose: To analyze the cost-effectiveness of radioembolization in the treatment of intrahepatic cholangiocarcinoma (ICC) using the Surveillance, Epidemiology, and End Results (SEER) Medicare cancer database., Materials and Methods: Cost as measured by total treatment-related reimbursement in patients diagnosed with ICC who received chemotherapy alone or chemotherapy and yttrium-90 radioembolization was assessed in the SEER Medicare cancer database (1999-2012). Survival analysis was performed, and incremental cost-effectiveness ratios were generated., Results: The study included 585 patients. Average age at diagnosis was 71 years (standard deviation: 9.9), and 52% of patients were male. Twelve percent of patients received chemotherapy with radioembolization (n = 72), and 88% of patients (n = 513) received only chemotherapy. Median survival was 1043 days (95% confidence interval [CI]: 894-1244) for chemotherapy plus radioembolization and 811 days (95% CI: 705-925) for chemotherapy alone (P = .02). Patients who received combination therapy were slightly younger (71 vs 69 years, P = .03). No significant differences were observed between treatment groups in age at treatment, sex, race, or city size. Multivariable analysis showed a hazard ratio for progression for combination therapy versus chemotherapy alone of 0.76 (95% CI: 0.59-0.97, P = .029). The incremental cost-effectiveness ratio, a measure of cost of each added year of life, was $50,058.65 per year (quartiles: $11,454.63, $52,763.28)., Conclusions: Combination therapy of ICC with chemotherapy and radioembolization is associated with higher median survival and can be a cost-effective treatment, with a median cost of $50,058.65 per additional year of survival., (Copyright © 2018 SIR. Published by Elsevier Inc. All rights reserved.)

Purpose To compare survival rates of thermal ablation and stereotactic radiation therapy (SRT) for stage 1 non-small cell lung cancer (NSCLC). Materials and Methods In this retrospective study, patients with stage 1 NSCLC treated by thermal ablation (TA) or SRT were identified in the 2004-2013 National Cancer Database. Patients who underwent TA and SRT were one-to-one propensity matched to undergo thermal ablation. Outcomes were overall survival and unplanned hospital readmission within 30 days after treatment. Results This study included 28 834 patients (TA, 1102 patients; SRT, 27 732 patients). Patients treated with TA had more comorbidities (Charlson comorbidity index of 1 vs ≥2, 32.8% [362 of 1102] vs 19.7% [217 of 1102], respectively) compared with SRT (Charlson comorbidity index of 1 vs ≥2, 26.9% [7448 of 27 732] vs 15.3% [4251 of 27 732], respectively; P , .001) and smaller tumor size (mean tumor size, TA vs SRT: 19 mm vs 22 mm, respectively; P , .001). In the propensity score-matched cohort with balanced distribution of potential confounders, there was no significant difference in overall survival between TA and SRT at a mean follow-up of 52.4 months (survival difference, P = .69). Overall survival rates were comparable between TA and SRT (1 year, 85.4% vs 86.3%, respectively, P = .76; 2 years, 65.2% vs 64.5%, respectively, P = .43; 3 years, 47.8% vs 45.9%, respectively, P = .32; 5 years, 24.6% vs 26.1%, respectively, P = .81). Unplanned hospital readmission rates were higher for patients who underwent TA versus those who underwent SRT (3.7% [40 of 1070] vs 0.2% [two of 1070], respectively; P , .001). Conclusion Regarding overall survival, thermal ablation was noninferior to stereotactic radiation therapy for primary treatment of stage 1 non-small cell lung cancer. © RSNA, 2018 Online supplemental material is available for this article. See also the editorial by Shyn in this issue.

Background: Primary liver cancer, including Hepatoblastoma (HB) and hepatocellular carcinoma (HCC), in pediatric populations is often fatal. The outcomes are poor despite universal health care access in pediatric patients., Aim: We investigated the sociodemographic factors affecting outcomes in pediatric patients with primary liver cancer., Materials and Methods: This is a large population database study of Surveillance, Epidemiology, and End Results cancer registry data from 1973 to 2011. HB and HCC were analyzed regarding age, sex, race, geographic area, and treatment-related information including survival., Results: In total, 998 patients, the median age at time of diagnosis was 1 year for HB [0-19; 95% confidence interval (CI), 1.5-1.9] and 14 years for HCC (0-19; 95% CI, 12.1-13.3) (P<0.001). Overall Survival (OS) in HB was 374 months (25% failures 19) versus HCC 21 months (25% failures 5; P<0.0001). In HCC, the fibrolamellar subgroup OS was 41 months (32-.) versus 16 months (11-21) in all others [hazard ratio (HR) 2.0; P=0.005]. Diagnosis between 2000 and 2011 (HB: 25% failures not reached; HCC: 38) versus diagnosis 1973 to 1999 (HB: 374; HCC: 12) had different survival (P=0.01; HR 1.9). For HB, OS in patients with age of diagnosis under 2, 25% failures was not reached versus 374 months over the age of 2 (HR 1.7; P<0.0007). African American children with HB had OS of 67 (17-.) versus all others (25% failures 21) and 48% of African American children were diagnosed after the age of 2 versus 34% of whites (HR 1.9; P=0.01)., Conclusions: Later diagnosis and decreased survival in African American children with HB warrants further research.