Influence of Nonclinical Factors on Choice of Therapy for Early Hepatocellular Carcinoma

Initial therapy for early hepatocellular carcinoma (HCC) with well-compensated cirrhosis is controversial. While we previously reported on the effect of clinical factors and surgeon specialty on choice of therapy for early HCC, other nonclinical factors also may impact decision-making. Surgeons who treat HCC were invited to complete a web-based survey that included ten case scenarios. Choice of therapy-liver transplantation (LT), liver resection (LR), or radiofrequency ablation (RFA)-was analyzed using regression models. There were 336 responses for analysis. Most respondents were in academic centers (86 %) that offered LT (71 %). The median number of patients annually evaluated for HCC was 30. Both practice type and HCC case volume were associated with choice of therapy, but these associations were not independent of surgeon specialty. LT surgeons who did not also perform RFA were less likely than those LT surgeons who did offer RFA to choose RFA over LT (relative risk ratios (RRR) 0.38, P < 0.001). Non-LT surgeons were more likely than LT surgeons who also offered RFA to choose RFA over LT (RRR 2.24, P < 0.001). Surgeons who worked at hospitals where LT was performed were much more likely to choose LT over LR and RFA even if they did not personally perform LT (RRR 1.27 and RRR 3.33, P < 0.001). Surgeon- and institution-related factors impact choice of therapy for early HCC even after adjustment for differences in clinical presentation. These data suggest that choice of therapy for patients with early HCC varies across providers independent of case selection.