Journal of Gastrointestinal Surgery

, Volume 23, Issue 5, pp 933–943 | Cite as

Surgical Delay Is Associated with Improved Survival in Hepatocellular Carcinoma: Results of the National Cancer Database

  • Kerui XuEmail author
  • Shinobu Watanabe-Galloway
  • Fedja A. Rochling
  • Paraskevi A. Farazi
  • K. M. Monirul Islam
  • Hongmei Wang
  • Jiangtao Luo
Original Article



Hepatocellular carcinoma (HCC) is one of the fastest growing causes of cancer-related death in the USA. Studies that investigated the impact of HCC therapeutic delays are limited to single centers, and no large-scale database research has been conducted. This study investigated the association of surgical delay and survival in HCC patients.


Patients underwent local tumor destruction and hepatic resection for stages I–III HCC were identified from the 2004 to 2013 Commission on Cancer’s National Cancer Database. Surgical delay was defined as > 60 days from the date of diagnosis to surgery. Generalized linear-mixed model assessed the demographic and clinical factors associated with delay, and frailty Cox proportional hazard analysis examined the prognostic factors for overall survival.


A total of 12,102 HCC patients met the eligibility criteria. Median wait time to surgery was 50 days (interquartile range, 29–86), and 4987 patients (41.2%) had surgical delay. Delayed patients demonstrated better 5-year survival for local tumor destruction (29.1 vs. 27.6%; P = .001) and resection (44.1 vs. 41.0%; P = .007). Risk-adjusted model indicated that delayed patients had a 7% decreased risk of death (HR, 0.93; 95% CI, 0.87–0.99; P = .027). Similar findings were also observed using other wait time cutoffs at 50, 70, 80, 90, and 100 days.


A plausible explanation of this finding may be case prioritization, in which patients with more severe and advanced disease who were at higher risk of death received earlier surgery, while patients with less-aggressive tumors were operated on later and received more comprehensive preoperative evaluation.


Hepatocellular carcinoma National Cancer Database Surgical delay Wait time Cancer survival 


Funding Source

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author Contributions

KX contributed to the study design, conceptualization, statistical analysis, and drafted the original paper. KMMI was responsible for data acquisition. SWG and FR also contributed to the study design and conceptualization, and JL assisted with statistical analysis. FR, PF, HW, and KMMI critically reviewed and edited the paper for important intellectual content. SWG supervised research activities.

Compliance with Ethical Standards

The data used in the study are derived from a de-identified NCDB file. The American College of Surgeons and the Commission on Cancer have not verified and are not responsible for the analytic or statistical methodology employed, or the conclusions drawn from these data by the investigator.

Ethics Committee Approval

The study was exempted from review by the University of Nebraska Medical Center Institutional Review Board.

Conflict of Interest

The authors declare that they have no conflict of interest.

Supplementary material

11605_2018_3925_MOESM1_ESM.docx (45 kb)
ESM 1 (DOCX 45 kb)


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Copyright information

© The Society for Surgery of the Alimentary Tract 2018

Authors and Affiliations

  1. 1.Wisconsin Surgical Outcomes Research Program, Department of SurgeryUniversity of Wisconsin-Madison School of Medicine and Public HealthMadisonUSA
  2. 2.Department of Epidemiology, College of Public HealthUniversity of Nebraska Medical CenterOmahaUSA
  3. 3.Division of Gastroenterology and Hepatology, Department of Internal Medicine, College of MedicineUniversity of Nebraska Medical CenterOmahaUSA
  4. 4.Department of Health Services Research and Administration, College of Public HealthUniversity of Nebraska Medical CenterOmahaUSA
  5. 5.Department of Biostatistics, College of Public HealthUniversity of Nebraska Medical CenterOmahaUSA

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