Referral patterns and treatment choices for patients with hepatocellular carcinoma: A United States population-based study

Omar Hyder, Rebecca M. Dodson, Hari Nathan, Joseph Herman, David Cosgrove, Ihab Kamel, Jean-Francois Francois Geschwind, Timothy M. Pawlik

Research output: Contribution to journalArticlepeer-review

36 Scopus citations


Background Patterns of care of physician specialists may differ for patients with hepatocellular carcinoma (HCC). Reasons underlying variations are poorly understood. One source of variation may be disparate referral rates to specialists, leading to differences in cancer-directed treatments. Study Design Surveillance, Epidemiology, and End Results (SEER)-linked Medicare database was queried for patients with HCC, diagnosed between 1998 and 2007, who consulted 1 or more physicians after diagnosis. Visit and procedure records were abstracted from Medicare billing records. Factors associated with specialist consult and subsequent treatment were examined. Results There were 6,752 patients with HCC identified; 1,379 (20%) patients had early-stage disease. Median age was 73 years; the majority were male (66%), white (60%), and from the West region (56%). After diagnosis, referral to a specialist varied considerably (hepatology/gastroenterology, 60%; medical oncology, 62%; surgery, 56%; interventional radiology [IR], 33%; radiation oncology, 9%). Twenty-two percent of patients saw 1 specialist; 39% saw 3 or more specialists. Time between diagnosis and visitation with a specialist varied (surgery, 37 days vs IR, 55 days; p = 0.04). Factors associated with referral to a specialist included younger age (odds ratio [OR] 2.16), Asian race (OR 1.49), geographic region (Northeast OR 2.10), and presence of early-stage disease (OR 2.21) (all p < 0.05). Among patients with early-stage disease, 77% saw a surgeon, while 50% had a consultation with medical oncologist. Receipt of therapy among patients with early-stage disease varied (no therapy, 30%; surgery, 39%; IR, 9%; chemotherapy, 23%). Factors associated with receipt of therapy included younger age (OR 2.48) and early-stage disease (OR 2.20). Conclusions After HCC diagnosis, referral to a specialist varied considerably. Both clinical and nonclinical factors were associated with consultation. Disparities in referral to a specialist and subsequent therapy need to be better understood to ensure all HCC patients receive appropriate care.

Original languageEnglish (US)
Pages (from-to)896-906
Number of pages11
JournalJournal of the American College of Surgeons
Issue number5
StatePublished - Nov 2013


  • Abbreviations and Acronyms
  • HCC
  • HR
  • IR
  • OR
  • SES
  • TACE
  • TAE
  • bland embolization
  • hazard ratio
  • hepatocellular carcinoma
  • interventional radiology
  • odds ratio
  • socioeconomic status
  • transarterial chemoembolization

ASJC Scopus subject areas

  • Surgery


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