Han D, Zhang ZY, Deng JY, Du HB. Survival disparities among racial groups with hepatic malignant tumors. World J Gastrointest Oncol 2024; 16(7): 2999-3010 [PMID: 39072178 DOI: 10.4251/wjgo.v16.i7.2999]
Corresponding Author of This Article
Hong-Bo Du, MD, PhD, Doctor, Division of Gastroenterology, Dongzhimen Hospital, Beijing University of Chinese Medicine, No. 5 Haiyuncang, Dongcheng District, Beijing 100700, China. 20220941183@bucm.edu.cn
Research Domain of This Article
Oncology
Article-Type of This Article
Clinical and Translational Research
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Author contributions: Han D had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis; Zhang ZY and Deng JY provided data organization and statistical analysis; Du HB designed the study and critically revised the manuscript; All authors read and approved the final manuscript.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Hong-Bo Du, MD, PhD, Doctor, Division of Gastroenterology, Dongzhimen Hospital, Beijing University of Chinese Medicine, No. 5 Haiyuncang, Dongcheng District, Beijing 100700, China. 20220941183@bucm.edu.cn
Received: February 17, 2024 Revised: April 25, 2024 Accepted: May 15, 2024 Published online: July 15, 2024 Processing time: 146 Days and 3.1 Hours
Abstract
BACKGROUND
Investigating the impact of race on the clinicopathologic characteristics and prognosis of hepatic malignant tumors represents a complex and significant area of research. Notably, distinct differences exist among various racial groups in terms of the clinical manifestations, pathologic features, and prognosis of hepatic malignant tumors.
AIM
To explore the effect of race on clinicopathologic features and prognosis of hepatic malignancies.
METHODS
Data from patients with hepatic malignancies diagnosed between 2000 and 2019 were collected from the Surveillance, Epidemiology, and End Results database and statistically analyzed.
RESULTS
This study included 123558 patients with hepatic malignant tumors, among whom 21078 (17.06%) were Asian, 14810 (11.99%) were Black, and 87670 (70.95%) were white. The median survival times for patients with hepatic malignant tumors of different races were 12.56, 7.70, and 9.35 months for Asian patients, Black patients, and white patients, respectively. The 3-year survival rates for Asian, Black, and white patients were 29%, 19%, and 21%, respectively, and the 5-year survival rates were 22%, 13%, and 15%, respectively. The Kruskal-Wallis test indicated a significant difference in the survival time of patients with hepatic malignant tumors between different races (P < 0.001). Univariate analysis revealed gender disparities in the prognosis among different ethnic groups (Asian: P > 0.05; Black: P < 0.001; White: P < 0.05). Among Black patients, the prognosis was less affected by the degree of hepatic fibrosis than among Asian patients and white patients (Black patients: P < 0.05; Asian patients: P < 0.001; White patients: P < 0.001). Significant differences were observed in the median survival time among patients with hepatic neuroendocrine tumors and hepatoblastomas during pathologic staging between races. Tumor number was inversely related to the prognosis. Cox regression analyses revealed that T stage, M stage, surgery, chemotherapy, alpha-fetoprotein, and tumor size independently influenced prognosis. Age was a specific independent prognostic factor for white patients. Among the tumor stages, N stage is a self-reliant prognostic element specific to white patients. Conversely, radiotherapy and liver fibrosis were not self-reliant prognostic factors for Black patients. Income alone did not independently influence the prognosis of Asian patients.
CONCLUSION
The prognosis of hepatic malignant tumors is better among Asian patients than among Black patients. The prognosis of hepatic malignant tumors among white patients is affected by multiple factors, including age and N stage.
Core Tip: The study's findings suggest that patients with hepatic malignant tumors of Asian descent have a more favorable prognosis compared to those of African descent who face a worse prediction. The factors that impact the prognosis of hepatic malignant tumors vary among different races. Racial disparities are evident in liver cancer treatment and survival prognosis. The primary causes for these disparities include socioeconomic status, autoimmune factors, and geographic location. Understanding the influence of racial disparities on hepatic malignant tumors can enhance comprehension of its pathogenesis, facilitate the provision of tailored treatment and prognosis, and offer guidance for the management of patients.
Citation: Han D, Zhang ZY, Deng JY, Du HB. Survival disparities among racial groups with hepatic malignant tumors. World J Gastrointest Oncol 2024; 16(7): 2999-3010
Globally, liver cancer accounts for 4.7% of all new cancer cases according to the World Health Organization (WHO). Approximately 840000 new cases of liver cancer were estimated to have occurred in 2020. The incidence of liver cancer is higher in developing countries, particularly those in Southeast Asia, Sub-Saharan Africa, and the Western Pacific region. Liver cancer caused approximately 780000 deaths worldwide in 2020, accounting for 8.3% of all cancer-related deaths and ranking sixth in incidence[1]. The incidence of liver cancer among white people is 2.6 per 100000, while it is more than twice as high in Asian people (7.8 per 100000) and African Americans (4.2 per 100000)[2]. The clinical manifestations of liver cancer vary between races. Hepatocellular carcinoma (HCC) is the most common type of liver cancer in Asian populations. The primary causes of the disease are nonalcoholic fatty liver disease (NAFLD) and viral hepatitis infection. In contrast, NAFLD and alcohol-related liver cancer are more common in Western countries. Studies have shown that liver cancer patients in Asian populations generally have a worse prognosis due to late-stage disease, genetic variations, and other factors[2]. In contrast, liver cancer patients in Western countries have a better prognosis due to more advanced early diagnosis and treatment options.
The impact of race on liver cancer has yet to be fully elucidated. Treatment approaches and systems for malignant liver tumors are incomplete. Race has a significant influence on clinical characteristics, pathological traits and prognosis of liver cancer. Understanding the impact of race on liver cancer is crucial for comprehending the pathogenesis of the disease, delivering accurate personalized treatment and prognosis evaluations, and providing guidance for managing liver cancer patients. However, further large-scale and multicenter studies are necessary to explore the effect of race on liver cancer, thereby promoting promote early diagnosis and treatment of the disease. This study used the Surveillance, Epidemiology, and End Results (SEER) database to investigate the overall survival of individuals of different races with malignant liver tumors, analyzed the factors that influence prognosis, and developed a predictive model. This study provides clinical data to support the detection and treatment of malignant liver tumors and predict the overall survival (OS) rate for patients of different races.
MATERIALS AND METHODS
Patients
Patient data was collected using SEER Stat (version 8.4.0) software. The database was searched for individuals diagnosed with hepatic malignancy between 2000 and 2019. The following variables were extracted: Age, sex, pathology, tumor-node-metastasis (TNM) stage, treatment modality, alpha-fetoprotein (AFP), degree of fibrosis, tumor size, number of tumors, and economic income. The inclusion criteria for the study were hepatic malignant tumors diagnosed between 2000 and 2019. Pathological examination was necessary to confirm the diagnosis for all patients with complete clinical, pathological, and follow-up information. Exclusion criteria included non-primary hepatic tumors, hepatic benign tumors, and refusal of regular follow-up.
Study eligibility
The age groups were determined according to the United Nations WHO's most recent guidelines as of 2021. Young adults are classified as individuals below 44 years of age, middle-aged are 45 to 59-year-olds, young seniors are between 60 and 74 years of age, and those above 75 are considered elderly. The pathological categories were based on the 4th edition of the WHO's digestive tumor classification system[3]. Hepatic cholangiocarcinoma comprises intrahepatic and extrahepatic cholangiocarcinoma. Tumor staging was based on the sixth edition of American Joint Committee on Cancer[4]. The primary outcome of this study was overall survival, recorded from the date of diagnosis until the date of last follow-up or death. The endpoint was defined as death when conducting survival analysis in this study.
Statistical analysis
SPSS25.0 statistical analysis software was used for data analysis. Mean and standard deviation were used to present measurement data, median (range) was used to present follow-up time, and number of cases and percentage were used to present count data. The 3-year and 5-year cumulative overall survival for HCC in various ethnic groups was computed using the life table method. The survival analysis was conducted using the Kaplan-Meier method, and the LogRank test was used to evaluate the variability of each covariate. Technical term abbreviations are explained when first used to ensure a clear and logical flow of information. Additionally, conventional academic sections and formatting guidelines are followed, while maintaining a formal register and precise word choice with consistent technical terms. The text avoids biased and emotional language and expresses balanced positions on subjects through hedging. Any grammar, spelling, and punctuation errors have been corrected. The study used a Cox regression model for multifactorial analysis, measuring evaluation indexes of hazard ratios (HR) and 95%CI. To assess whether there were differences in survival time distributions among patients with hepatic malignant tumors of different ethnicities, a Kruskal-Wallis test was conducted. The null hypothesis (H0) was that there was no difference between groups. A statistically significant difference was defined as P < 0.05. Any missing or unknown data in certain variables were treated as censored data.
RESULTS
Basic information
The study included 123558 patients diagnosed with hepatic malignant tumors, of whom 21078 (17.06%) were Asian, 14810 (11.99%) were Black, and 87670 (70.95%) were white. The highest incidence of HCC was observed among males aged between 60 and 75 years across all races. It is worth noting that Black patients in this study generally had a lower socioeconomic status, which is correlated with a poorer prognosis (Tables 1 and 2).
Table 1 Demographic information on 123558 patients with hepatic malignant tumors, n (%).
Classification
Asian
Black people
White people
n
21078 (17.06)
14810 (11.99)
87670 (70.95)
Age (yr)
0-44
1245 (5.9)
679 (4.5)
2973 (3.3)
45-59
5751 (27.2)
5345 (36.0)
26301 (30.0)
60-75
8951 (42.4)
7099 (47.9)
37834 (43.1)
> 75
5131 (24.3)
1687 (11.3)
20562 (23.4)
Sex
Male
14963 (70.9)
11159 (75.3)
65115 (74.2)
Female
6115 (29.0)
3651 (24.6)
22555 (25.7)
Table 2 Clinicopathologic characteristics and univariate analysis of 123558 patients with hepatic malignant tumors, n (%).
Classification
Asian
Asian, median survival time (months)
Black people
Black people, median survival time (months)
White people
White people, median survival time (months)
Age (yr)
0-44
1245 (5.9)
13.0
679 (4.5)
9.0
2973 (3.3)
33.0
45-59
5751 (27.2)
12.0
5345 (36.0)
6.0
26301 (30.0)
10.0
60-75
8951 (42.4)
16.0
7099 (47.9)
8.0
37834 (43.1)
10.0
> 75
5131 (24.3)
7.0
1687 (11.3)
3.0
20562 (23.4)
4.0
P value (K-M univariate)
< 0.001
< 0.001
< 0.001
Sex
Male
14963 (70.9)
12.0
11159 (75.3)
6.0
65115 (74.2)
8.0
Female
6115 (29.0)
13.0
3651 (24.6)
9.0
22555 (25.7)
9.0
P value (K-M univariate)
> 0.05
< 0.001
< 0.05
Pathology
Hepatocellular carcinoma
19326 (91.6)
13.0
13213 (89.2)
7.0
75424 (86.0)
9.0
Cholangiocarcinoma of the liver
250 (1.1)
7.0
222 (1.4)
6.0
2201 (2.5)
6.0
Mixed hepatocellular carcinoma and cholangiocarcinoma
124 (0.5)
10.0
85 (0.5)
5.0
606 (0.6)
8.0
Neuroendocrine tumor
49 (0.2)
6.0
82 (0.5)
25.0
450 (0.5)
15.0
Hepatoblastoma
145 (0.6)
41.0
87 (0.5)
91.0
719 (0.8)
43.0
Others
315 (1.4)
8.0
163 (1.1)
3.0
1354 (1.5)
4.0
NA
869 (4.1)
958 (6.4)
6916 (7.8)
P value (K-M univariate)
< 0.001
< 0.001
< 0.001
T staging
T1
4963 (23.5)
33.0
3000 (20.2)
17.0
19024 (21.6)
18.0
T2
2302 (10.9)
29.0
1566 (10.5)
15.0
9722 (11.0)
18.0
T3
2943 (13.9)
4.0
2123 (14.3)
4.0
10180 (11.6)
4.0
T4
595 (2.8)
3.0
436 (2.9)
2.0
1807 (2.0)
3.0
NA
10275 (48.7)
7685 (51.8)
46937 (53.5)
P value (K-M univariate)
< 0.001
< 0.001
< 0.001
N staging
N0
9946 (47.1)
19.0
6642 (44.8)
9.0
37326 (42.5)
13.0
N1
665 (3.1)
3.0
724 (4.8)
3.0
3614 (4.1)
3.0
NA
10467 (49.6)
7444 (50.2)
46730 (53.3)
P value (K-M univariate)
< 0.001
< 0.001
< 0.001
M staging
M0
9612 (45.6)
22.0
6392 (43.1)
11.0
36729 (41.8)
14.0
M1
1791 (8.4)
2.0
1512 (10.2)
2.0
7651 (8.7)
2.0
NA
9675 (45.9)
6906 (46.6)
43290 (49.3)
P value (K-M univariate)
< 0.001
< 0.001
< 0.001
Surgical
Yes
6090 (28.8)
64.0
1589 (10.7)
55.0
18620 (21.2)
53.0
No
14988 (71.1)
6.0
11490 (77.5)
4.0
69050 (78.7)
5.0
NA
0
1731 (11.6)
0
P value (K-M univariate)
< 0.001
< 0.001
< 0.001
Radiotherapy
Yes
1438 (6.8)
16.0
1264 (8.5)
13.0
7436 (8.4)
14.0
No
19640 (93.1)
11.0
13546 (91.4)
6.0
80234 (91.5)
8.0
P value (K-M univariate)
< 0.001
< 0.001
< 0.001
Chemotherapy
Yes
7267 (34.4)
20.0
4721 (31.8)
15.0
28633 (32.6)
17.0
No
13811 (65.5)
7.0
10089 (68.1)
4.0
59037 (67.3)
4.0
P value (K-M univariate)
< 0.001
< 0.001
< 0.001
AFP
Negative
2547 (12.0)
42.0
1233 (8.3)
26.0
11215 (12.7)
27.0
Positive
6239 (29.5)
12.0
5380 (36.3)
8.0
24710 (28.1)
9.0
NA
12292 (58.3)
8197 (55.3)
51745 (59.0)
P value (K-M univariate)
< 0.001
< 0.001
< 0.001
Liver fibrosis (Ishak)
0-4
876 (4.1)
46.0
436 (2.9)
21.0
1962 (2.2)
28.0
5-6
2219 (10.5)
28.0
1460 (9.8)
16.0
10096 (11.5)
19.0
NA
17983 (85.3)
12914 (87.1)
75612 (86.2)
P value (K-M univariate)
< 0.001
< 0.001
< 0.001
Tumor size
0-2.5 cm
1214 (5.7)
65.0
800 (5.4)
33.0
8441 (9.6)
36.0
2.5-5 cm
4043 (19.1)
35.0
2575 (17.3)
18.0
13228 (15.0)
18.0
5-10 cm
3246 (15.3)
9.0
2040 (13.7)
6.0
11794 (13.4)
6.0
> 10 cm
1940 (9.2)
4.0
1204 (8.1)
3.0
5654 (6.4)
4.0
NA
10635 (50.4)
8191 (55.3)
48553 (55.3)
P value (K-M univariate)
< 0.001
< 0.001
< 0.001
Number of tumors
1
18314 (86.8)
11.0
12632 (85.2)
6.0
72771 (83.0)
8.0
2
2360 (11.1)
25.0
1853 (12.5)
13.0
12166 (13.8)
13.0
≥ 3
404 (1.9)
34.0
325 (2.1)
22.0
2733 (3.1)
17.0
P value (K-M univariate)
< 0.001
< 0.001
< 0.001
Average annual income ($)
0-44999
316 (1.4)
6.0
2137 (14.4)
5.0
6387 (7.2)
6.0
45000-54999
1062 (5.0)
6.0
2293 (15.4)
6.0
13412 (15.2)
7.0
55000-64999
4486 (21.2)
10.0
3985 (26.9)
7.0
21389 (24.3)
8.0
65000-74999
4164 (19.7)
11.0
3146 (21.2)
7.0
21735 (24.7)
9.0
≥ 75000
11047 (52.4)
15.0
3249 (21.9)
9.0
24724 (28.2)
10.0
NA
3 (0.1)
0
23 (0.1)
P value (K-M univariate)
< 0.001
< 0.001
< 0.001
Clinicopathologic features of tumors
There is consistency in tumor TNM staging among different ethnic groups of patients with hepatic malignancies. The predominant pathological tissue type was HCC. The most promising pathological type for hepatic malignancies among the Asian, Black, and White patients was hepatoblastoma (41 months, 91 months, and 43 months), while the most unfavorable types were neuroendocrine tumors (6 months), mixed HCC and cholangiocarcinoma (5 months), and hepatoblastoid cell carcinoma (6 months) AFP levels can be used as a crucial variable for evaluating patient prognosis, and the prognosis of patients with negative AFP levels is substantially better than that of patients with a positive AFP level (Asian patients: 42 months vs 12 months, Black patients: 26 months vs 8 months, white patients: 27 months vs 9 months). The prognosis of all ethnic groups was significantly influenced by the number of liver tumors, with the best prognosis observed for those with three tumors, intermediate for those with two tumors, and the worst prognosis for those with just one tumor (34 months, 25 months, and 11 months for Asian patients; 22 months, 13 months, and 6 months for Black patients; and 17 months, 13 months, and 8 months for white patients, respectively). Most of the tumors were solitary, with sizes ranging from 2.5-5 cm (Table 2).
Treatment and prognosis
The prognosis for tumors treated with surgery is favorable for those with indications for prompt surgical intervention. Nonsurgical treatment options should be considered for patients who no longer meet the indications for surgery; in particular, chemotherapy has been proven to be more efficacious than radiotherapy. This study revealed that Asian patients had a median survival time of 12.56 months, Black patients had a median survival time of 7.70 months, and white patients had a median survival time of 9.35 months. The 1-year survival rates were 44%, 33%, and 36% for Asian, Black, and white patients, respectively. Similarly, the 3-year survival rates for Asian, Black, and white patients were 29%, 19%, and 21%, respectively, and the 5-year survival rates were 22%, 13%, and 15%, respectively (Table 2). Figure 1 shows that the prognosis for Black patients was worse, while the prognosis was better for Asian patients. With respect to age, white patients aged 0-44 years had the best prognosis, with a median survival time of 33 months, while Black patients aged > 75 years had the worst prognosis, with a median survival time of 3 months. In terms of sex, the most favorable prognosis was observed for Asian females, with a median survival time of 12 months, whereas Black males had the worst prognosis, with a median survival time of 6 months. For TNM staging, the T stage with the best prognosis was the T1 stage among Asian patients (median survival time: 33 months), while the worst prognosis was associated with the T4 stage among Black patients (median survival time: 2 months). For N stage, the best prognosis was observed for the N0 stage among Asian patients (median survival time: 19 months). This study revealed that racial differences had a significant impact on prognosis, with a median survival time of 19 months. Tumors without race differences had the worst prognosis, with a median survival time of 3 months. In terms of M stage, the M0 stage had the best prognosis among Asian patients, with a median survival time of 22 months. Without ethnic differences, the worst prognosis was 2 months. For optimal treatment, surgical intervention offers maximum benefits and a relatively good prognosis for tumors among Asian, Black, and white patients, with median survival times of 64 months, 55 months, and 53 months, respectively. Radiotherapy, on the other hand, has a relatively poor prognosis, with median survival times of 16 months, 13 months, and 14 months for Asian, Black, and white patients, respectively. A better prognosis is associated with a lower degree of liver fibrosis. The median survival time was significantly longer for Asian patients with fibrosis (0-4:46 months; 5-6:28 months) than for Black patients with fibrosis (0-4:21 months; 5-6:16 months) or white patients with fibrosis (0-4:28 months; 5-6:19 months). Smaller tumors also tend to be associated with better patient outcomes. The most favorable prognosis was observed among Asian patients with tumors ranging in size from 0-2.5 cm (median survival time: 65 months), while Black patients with tumors larger than 10 cm had the worst survival outcome (median survival time: 3 months). Regarding income level, a positive correlation was found between annual income and patient survival. Asian patients with an annual income above $75000 had the most favorable survival outcome (median survival time: 15 months), whereas Black patients with an annual income between $0-44999 had the worst survival outcome (median survival time: 5 months).
Figure 1 Overall prognosis of patients with hepatic malignant tumors in Asian, black people and white people, respectively.
A: Overall prognosis of Asian patients with hepatic malignancies; B: Overall prognosis of black people patients with hepatic malignancies; C: Overall prognosis of white people patients with hepatic malignancies.
Software analysis
Univariate analysis revealed prognostic differences based on sex among different ethnic groups. Prognostic differences were observed among Black patients (P < 0.001) and white patients (P < 0.05) but not among Asian race patients (P > 0.05). Sex had a significant effect on the prognosis of Black patients, while no statistically significant difference was observed in the prognosis of Asian patients. The impact of hepatic fibrosis on prognosis was lower in Black patients than in Asian and white patients (Black patients: P < 0.05; Asian patients: P < 0.001; white patients: P < 0.001). The prognosis varied significantly (P < 0.001) among different ethnic groups in association with all other factors (Table 2). There was a statistically significant difference in survival time between patients with hepatic neuroendocrine tumors and patients with hepatoblastomas based on their ethnic background (P < 0.001). The evaluation of prognosis can be crucial, as demonstrated by the significantly better prognosis of AFP-negative patients than of AFP-positive patients (P < 0.001). The prognosis also varied depending on the number of liver tumors and the ethnicity of the patients (P < 0.001).
Cox regression analysis revealed that T-stage, M-stage, surgery, radiotherapy, chemotherapy, AFP, liver fibrosis and tumor size were independent predictors of the survival outcomes among Asian patients (P < 0.05; Table 3); T-stage, M-stage, surgery, chemotherapy, AFP, tumor size and income were independent predictors of survival outcome among Black patients (P < 0.05; Table 4); and age, T-stage, N-stage, M-stage, surgery, radiotherapy, chemotherapy, AFP, liver fibrosis, tumor size and income were independent predictors of survival outcome among white patients (P < 0.05; Table 5). Age was an independent influencing factor specific to the survival outcomes of white patients (P < 0.05). Among tumor stages, N stage was an independent influencing factor specific to the survival outcomes of white patients (P < 0.05). Among the treatment modalities, only radiotherapy was not an independent influencing factor for the survival outcome of Black patients (P > 0.05). Liver fibrosis did not have an independent influence on prognosis for Black patients (P > 0.05). Income was not an independent prognostic factor for Asian patients (P > 0.05).
Table 3 Cox regression analysis of Asian with hepatic malignant tumors.
Classification
B
SE
Z
P value
HR (95%CI)
T
1
Ref.
2
0.229
0.081
2.807
0.005
1.26 (1.07, 1.47)
3
0.944
0.103
9.126
< 0.001
2.57 (2.1, 3.15)
4
1.688
0.161
10.464
< 0.001
5.41 (3.94, 7.42)
M
0.738
0.130
5.692
< 0.001
2.09 (1.62, 2.7)
Surgical
-1.204
0.083
-14.509
< 0.001
0.3 (0.26, 0.35)
Radiotherapy
-0.366
0.117
-3.137
0.002
0.69 (0.55, 0.87)
Chemotherapy
-0.616
0.069
-8.867
< 0.001
0.54 (0.47, 0.62)
AFP
0.298
0.075
3.996
< 0.001
1.35 (1.16, 1.56)
Liver fibrosis
0.172
0.079
2.171
0.03
1.19 (1.02, 1.39)
Tumor size
0-2.5 cm
Ref.
2.5-5 cm
0.398
0.105
3.810
< 0.001
1.49 (1.21, 1.83)
5-10 cm
0.644
0.128
5.046
< 0.001
1.9 (1.48, 2.45)
> 10 cm
0.975
0.149
6.526
< 0.001
2.65 (1.98, 3.55)
Table 4 Cox regression analysis of black people with hepatic malignant tumors.
Classification
B
SE
Z
P value
HR (95%CI)
T
1
Ref.
2
0.402
0.108
3.706
< 0.001
1.49 (1.21, 1.85)
3
0.389
0.150
2.594
0.009
1.47 (1.1, 1.98)
4
1.152
0.234
4.926
< 0.001
3.16 (2, 5.01)
M
0.784
0.145
5.404
< 0.001
2.19 (1.65, 2.91)
Surgical
1.344
0.135
9.983
< 0.001
3.84 (2.95, 4.99)
Chemotherapy
0.606
0.090
6.692
< 0.001
1.83 (1.53, 2.19)
AFP
0.373
0.124
3.024
0.002
1.45 (1.14, 1.85)
Tumor size
0-2.5 cm
Ref.
2.5-5 cm
0.52
0.139
3.734
< 0.001
1.68 (1.28, 2.21)
5-10 cm
0.788
0.180
4.366
< 0.001
2.2 (1.54, 3.13)
> 10 cm
1.498
0.210
7.150
< 0.001
4.47 (2.97, 6.75)
Average annual income ($)
0-44999
Ref.
45000-54999
-0.236
0.164
-1.440
0.15
0.79 (0.57, 1.09)
55000-64999
-0.416
0.143
-2.911
0.004
0.66 (0.5, 0.87)
65000-74999
-0.342
0.172
-1.985
0.047
0.71 (0.51, 1)
≥ 75000
-0.54
0.148
-3.651
< 0.001
0.58 (0.44, 0.78)
Table 5 Cox regression analysis of white people with hepatic malignant tumors.
Classification
B
SE
Z
P value
HR (95%CI)
Age (yr)
0-44
Ref.
45-59
0.49
0.141
3.482
< 0.001
1.63 (1.24, 2.15)
60-74
0.556
0.140
3.974
< 0.001
1.74 (1.33, 2.29)
≥ 75
0.876
0.144
6.065
< 0.001
2.4 (1.81, 3.19)
T
1
Ref.
2
0.242
0.038
6.365
< 0.001
1.27 (1.18, 1.37)
3
0.571
0.051
11.179
< 0.001
1.77 (1.6, 1.96)
4
0.535
0.110
4.873
< 0.001
1.71 (1.38, 2.12)
N
0.407
0.068
6.003
< 0.001
1.5 (1.32, 1.72)
M
0.598
0.061
9.813
< 0.001
1.82 (1.61, 2.05)
Surgical
-1.184
0.041
-28.579
< 0.001
0.31 (0.28, 0.33)
Radiotherapy
0.378
0.054
7.012
< 0.001
1.46 (1.31, 1.62)
Chemotherapy
0.651
0.034
19.351
< 0.001
1.92 (1.8, 2.05)
AFP
0.273
0.035
7.785
< 0.001
1.31 (1.23, 1.41)
Liver fibrosis
0.273
0.048
5.669
< 0.001
1.31 (1.2, 1.44)
Tumor size
0-2.5 cm
Ref.
2-5 cm
0.397
0.040
9.878
< 0.001
1.49 (1.37, 1.61)
5-10 cm
0.679
0.054
12.494
< 0.001
1.97 (1.77, 2.19)
> 10 cm
0.935
0.071
13.108
< 0.001
2.55 (2.22, 2.93)
Average annual income ($)
0-44999
Ref.
45000-54999
-0.048
0.072
-0.668
0.504
0.95 (0.83, 1.1)
55000-64999
-0.235
0.068
-3.447
0.001
0.79 (0.69, 0.9)
65000-74999
-0.181
0.070
-2.571
0.01
0.83 (0.73, 0.96)
≥ 75000
-0.221
0.068
-3.252
0.001
0.8 (0.7, 0.92)
The Kruskal-Wallis analysis yielded a result of H = 187.396, P < 0.001, which led to the rejection of H0 based on the test criterion of α = 0.05. This finding implies that there is a difference in the overall survival of patients with hepatic malignant tumors across various ethnic groups. A two-by-two comparison revealed a significant difference in survival between the Asian race and Black patients groups (adjusted P < 0.001). Patient survival varied significantly between the Asian race and white patients groups (adjusted P < 0.001) and between the Black patients and white patients groups (adjusted P < 0.001; Figure 2).
Figure 2 Displays the statistical results of the Kruskal-Wallis test, with 1, 2, and 3 indicating the color of Asian, black people, and white people, respectively.
A: Subgroup comparison is presented. Kruskal-Wallis test found that the survival statistic H-value for the three groups was 187.396 with a P value of less than 0.001, which is a significant difference; B: Illustrates pairwise comparisons of different races; C: Provides additional details regarding the comparison between the races, including the Test statistic and SD values. The statistical values reported include test statistic, SE, standard text statistic, Sig (P value), and Adj Sig (Adjusted P value) (adjusted P < 0.001).
DISCUSSION
HCC is a type of cancer found worldwide[5,6]. Despite significant advancements in screening and early detection, the prognosis for HCC patients remains poor, with only 23% and 5% of patients surviving past one and five years, respectively[7]. Studies conducted internationally have shown that male and female patients diagnosed with hepatic malignant tumors between 2006 and 2012 had comparable 5-year survival rates of 21%. White patients had a survival rate of 20%, while Black patients had a lower rate of 16%, and Asian patients had a higher rate of 27%[8]. However, there were differences in survival rates among different racial groups. Notably, there are significant racial differences in the acceptance of curative treatment for liver cancer patients. Overseas studies have shown that Black patients are less likely to receive curative treatment, while Asian patients are more likely to receive treatment than white patients[9]. Additionally, Asian Indians have been found to exhibit the lowest liver cancer mortality rates, with a standardized mortality ratio of 0.63 (95%CI: 0.55-0.72) for men and 0.86 (95%CI: 0.66-1.06) for women. Korean men have been found to have lower liver cancer mortality rates and higher survival rates than white and Black patients[10]. Significant differences in race-based survival rates were observed, with Black patients exhibiting significantly higher mortality rates than white patients, Hispanic patients, and most other Asian ethnic groups[11,12]. A study revealed that Black patients receiving a liver transplant had shorter survival rates than white patients, while Asian/Pacific Islander patients had longer survival rates. The difference in survival rates may be due to variations in the amount of immunosuppression, as suggested by previous research[11]. It has been demonstrated that among liver cancer patients, Pakistani males and females, as well as Chinese males, have higher survival rates than white patients. Alterio et al[13] support these findings, stating that Indian/Pakistani and Chinese cohorts had higher survival rates than white patients, whereas Black patients had lower survival rates[14-17]. Our study confirmed the existence of varied prognoses among HCC patients of different races. The median survival times for individuals of different races were 12.56, 7.70, and 9.35 months for Asian, Black, and white patients, respectively. The corresponding 3-year survival rates for Asian, Black, and white patients were 29%, 19%, and 21%, respectively, and the 5-year survival rates were 22%, 13%, and 15%, respectively. Notably, the Black patients in this study reported lower economic income, which was associated with a worse prognosis. These findings underscore the critical role of economic factors in shaping the poor outcomes observed in Black patients suffering from HCC[18].
Studies have shown that the incidence of liver cancer is higher among Asian populations, such as those in China, Japan, and Korea, than among white and Black patients. This may be linked to the elevated prevalence of hepatitis B virus infection and cirrhosis[19,20]. Studies have demonstrated variations in the occurrence of mutations in genes associated with HCC within different ethnic groups. For instance, TP53 gene mutations are frequent in Asian populations, while CTNNB1 gene mutations are common in African populations. These mutations can influence tumor progression and prognosis[21]. In HCC tissues from Asian patients, the quantity of macrophages is elevated, and there is an increase in Chemerin protein expression[22]. Additionally, the level of the chemerin protein is positively correlated with the number of dendritic and natural killer cells[23]. This indicates the presence of active isoforms of these cells in HCC tissues from Chinese patients. In European patient HCC tissues, the level of the chemerin protein did not correlate with inflammation scores, indicating its inactivity. The study revealed that the survival period for Asian patients was longer than that for white patients. Previous studies have suggested that the level of chemerin could be a contributing factor to the discrepancy in prognosis between Asian patients and white patients.
It was determined through this research that hepatoblastoma has a better prognosis and longer survival rates among liver cancer patients across various ethnicities. Hepatoblastoma is frequently detected during infancy, as tumors can develop during fetal life, and early detection increases the probability of successful treatment and significantly influences prognosis[24]. Neuroendocrine tumors carry the most unfavorable prognosis among patients with hepatic malignancies, with a median survival time of only 6 months. The inferior prognosis of hepatic neuroendocrine tumors in Asian populations may be attributable to several factors. (1) Diagnostic delay: Individuals of Asian descent may be more likely to overlook symptoms of hepatic neuroendocrine tumors, resulting in delayed diagnosis and missed opportunities for early treatment. Additionally, certain tumor types and grades are more prevalent and are linked to a poorer prognosis in this population; (2) Genetic variations: The genomes of individuals of Asian descent differ from those of individuals of other races, possibly leading to a less effective treatment response for hepatic neuroendocrine tumors; and (3) Genetic factors: Some patients with hepatic neuroendocrine tumors may have a familial predisposition, and the risk of familial inheritance may be greater in those of Asian descent. In Asian populations, HCC frequently manifests as a single tumor with nodular growth, consisting of hepatocytes. In contrast, in Western countries, HCC generally manifests as multiple tumors or metastatic lesions, potentially involving various hepatocyte subtypes[25]. The study revealed that the rate of lymph node and distant metastasis in patients with malignant hepatic tumors was lower in the Asian population than in the white population. Additionally, the rate of tumor singularity was greater in Asian patients than in white patients.
There are limitations to this study. First, patients were solely selected from the database, which may not fully reflect global issues and could diminish the credibility of the statistical results. Second, some patients' clinical data were more incomplete than others, leading to possible bias in the data. Prospective, multicenter, large-scale trials are necessary to identify independent risk factors that affect the prognosis of patients with different ethnicities and to investigate the mechanisms contributing to their prognostic variations in the future.
CONCLUSION
The study's findings suggest that Asian patients with hepatic malignant tumors have more favorable survival outcomes than Black patients. The factors that impact the prognosis of hepatic malignant tumors vary among different races. Racial disparities are evident in hepatic malignant tumors treatment and survival prognosis. The primary causes of these disparities include socioeconomic status, autoimmune factors, and geographic location. Understanding the influence of racial disparities on hepatic malignant tumors can enhance the understanding of its pathogenesis, facilitate the provision of tailored treatment and prognosis, and offer guidance for the management of patients.
ACKNOWLEDGEMENTS
We are grateful to all patients and all relevant medical workers who participated in this study. The Surveillance, Epidemiology, and End Results (SEER) database was used for this study. The authors acknowledge the efforts of the SEER Program tumor registry in creating the database.
Footnotes
Provenance and peer review: Unsolicited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Oncology
Country of origin: China
Peer-review report’s classification
Scientific Quality: Grade C
Novelty: Grade C
Creativity or Innovation: Grade C
Scientific Significance: Grade C
P-Reviewer: Ueda H, Japan S-Editor: Li L L-Editor: A P-Editor: Zhang XD
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