The management of early-stage hepatocellular carcinoma (HCC) is complex, with multiple treatment strategies available. There is a paucity of literature regarding variations in the patterns of care and outcomes between transplant and non-transplant centres. We conducted this real-world multi-centre cohort study in two liver cancer referral centres with an integrated liver transplant program and an additional eight non-transplant HCC referral centres across Australia to identify variation in patterns of care and key survival outcomes. Patients with stage Barcelona Clinic Liver Cancer (BCLC) 0/A HCC, first diagnosed between 1 January 2016 and 31 December 2020, who were managed at a participating site, were included in the study. Patients were excluded if they had a history of prior HCC or if they received upfront liver transplantation. A total of 887 patients were included in the study, with 433 patients managed at a liver cancer centre with a transplant program (LTC) and 454 patients managed at a non-transplant centre (NTC). Management at an LTC did not significantly predict allocation to resection (adjusted OR 0.75, 95% CI 0.50 to 1.11,p= 0.148). However, in those not receiving resection, LTC and NTC patients were systematically managed differently, with LTC patients five times less likely to receive upfront ablation than NTC patients (adjusted OR 0.19, 95% CI 0.13 to 0.28,p< 0.001), even after adjusting for tumour burden, as well as for age, gender, liver disease aetiology, liver disease severity, and medical comorbidities. LTCs exhibited significantly higher proportions of patients undergoing TACE for every tumour burden category, including those with a single tumour measuring 2 cm or less (p< 0.001). Using multivariable Cox proportional hazards analysis, management at a transplant centre was associated with reduced all-cause mortality (adjusted HR 0.71, 95% CI 0.51 to 0.98,p= 0.036), and competing-risk regression analysis, considering liver transplant as a competing event, demonstrated a similar reduction in risk (adjusted HR 0.70, 95% CI 0.50 to 0.99,p= 0.041), suggesting that the reduced risk of death is not fully explained by higher rates of transplantation. Our study highlights systematic differences in HCC care between large volume liver transplant centres and other sites, which has not previously been well-described. Further work is needed to better define the reasons for differences in treatment allocation and to aim to minimise unwarranted treatment variation to maximise patient outcomes across Australia.
早期肝细胞癌（HCC）的治疗策略多样，管理较为复杂。目前关于移植中心与非移植中心在诊疗模式及预后方面差异的文献较为有限。为此，我们在澳大利亚开展了一项真实世界多中心队列研究，纳入两家设有肝移植项目的肝癌转诊中心及另外八家非移植肝癌转诊中心，旨在分析诊疗模式差异及关键生存结局。研究纳入2016年1月1日至2020年12月31日期间首次确诊、在参与中心接受治疗的巴塞罗那临床肝癌分期（BCLC）0/A期HCC患者，排除既往有HCC病史或直接接受肝移植的患者。最终共纳入887例患者，其中433例在设有移植项目的肝癌中心（LTC）接受治疗，454例在非移植中心（NTC）接受治疗。LTC管理并未显著预测患者接受切除术的可能性（校正OR 0.75，95% CI 0.50-1.11，p=0.148）。然而，在未接受切除术的患者中，LTC与NTC患者的治疗策略存在系统性差异：即使校正肿瘤负荷、年龄、性别、肝病病因、肝病严重程度及合并症后，LTC患者接受直接消融治疗的可能性仍比NTC患者低五倍（校正OR 0.19，95% CI 0.13-0.28，p<0.001）。在所有肿瘤负荷分层中（包括单发肿瘤直径≤2 cm的患者），LTC接受经动脉化疗栓塞术（TACE）的患者比例均显著更高（p<0.001）。多变量Cox比例风险模型分析显示，在移植中心接受治疗与全因死亡率降低相关（校正HR 0.71，95% CI 0.51-0.98，p=0.036）；将肝移植作为竞争事件的竞争风险回归分析同样显示风险降低（校正HR 0.70，95% CI 0.50-0.99，p=0.041），提示死亡风险降低不能完全由较高的移植率解释。本研究揭示了大型肝移植中心与其他机构在HCC诊疗中存在的系统性差异，这一现象此前尚未被充分描述。未来需进一步探究治疗分配差异的原因，并致力于减少不必要的治疗差异，以优化澳大利亚全国范围内的患者预后。
肿瘤(癌症)患者之家