Adjuvant Transarterial Chemoembolization After Truly Curative Resection Does Not Improve Survival of Patients With Hepatocellular Carcinoma at High Risk of Recurrence: A Target Trial Emulation Study

ABSTRACT Background Consensus guidelines from China recommend adjuvant transarterial chemoembolization (TACE) for patients with hepatocellular carcinoma (HCC) who are at high risk of recurrence after curative resection. However, some of the clinical evidence behind this recommendation involves patients who underwent palliative resection. Methods The study design followed the target trial emulation framework with inverse probability of treatment weighting (IPTW) and propensity score matching (PSM) to minimize biases. This study compared recurrence‐free survival (RFS) and overall survival (OS) during follow‐up among patients who received TACE after truly curative resection, defined as absence of tumor staining during postoperative digital subtraction angiography (DSA); patients who received TACE after palliative resection; and patients who received only active surveillance after both kinds of resection. Results Patients who received TACE showed significantly higher RFS (HR 0.82, 95% CI 0.71–0.93) and OS (HR 0.81, 95% CI 0.67–0.98). However, adjuvant TACE after truly curative resection was associated with marginally, but not significantly, higher RFS (HR 0.92, 95% CI 0.80–1.08) and OS (HR 0.86, 95% CI 0.70–1.06) than active surveillance. The patients who underwent palliative resection, therapeutic TACE was associated with longer RFS (HR 0.70, 95% CI 0.56–0.87) and OS (HR 0.61, 95% CI 0.45–0.83) than active surveillance. These similar results with both types of survival were found after PSM and IPTW. Conclusions Adjuvant TACE may not improve survival of HCC patients at high risk of recurrence. Our work highlights the efficacy of DSA for detecting microscopic lesions and could help guide adjuvant treatment decisions after hepatic resection.