Dissecting Disease, Race, Ethnicity, And Socioeconomic Factors For Hepatocellular Carcinoma: An Analysis From The United States Safety Net Collaborative

Abstract

Presenter: Rachel Lee MD, MSPH | Emory University Background: Racial/ethnic and socioeconomic disparities are assumed to negatively affect treatment and outcomes for hepatocellular carcinoma (HCC). Our aim was to investigate the interaction of racial/ethnic and socioeconomic factors with stage of disease and type of treatment facility in receipt of treatment and overall survival (OS) of patients with HCC. Methods: We included all patients with primary HCC in the US Safety-Net Collaborative database(2012-2014), which is comprised of five highly select, geographically diverse safety-net hospitals (SNH) and their corresponding quaternary-referral center. Patients were categorized into “safety-net” or “academic” based on where they received treatment. Socioeconomic factors were determined at the zip-code level and included median income, and percent of adults who graduated from high-school. Primary outcomes were receipt of treatment and OS. Results: 1832pts were included. Average age was 61yrs and 77%(n=1405) were male. 57%(n=1039) were treated at academic and 43%(n=793) at safety-net hospitals. Patients treated at SNH were younger(59vs63yrs), less likely to be white(40vs65%), and more likely to be uninsured(27vs4%), have lower median income($43,001vs$52,598), and live in areas in which fewer adults graduated from high school(84vs76%)(all p<0.001). SNH patients were more likely to have a history of alcohol abuse(51vs40%) and to present with stage IV disease(25vs14%); they were less likely to have been previously radiographically screened(17vs27%) or to receive treatment (65vs83%)(all p<0.001). SNH patients had decreased 5-year OS compared to their academic counterparts (24vs37%,p<0.001). On MV Cox regression, neither race/ethnicity, median income, nor care provided at a SNH were directly associated with decreased OS (all p>0.05). Independent predictors of decreased OS included having no insurance(HR 1.34), less educational attainment (HR 1.59) higher MELD score(HR 1.07), higher stage at diagnosis(II:HR 1.34, III:HR 2.87, IV:HR 3.23), and not receiving treatment (HR 3.94)(all p<0.05). Factors associated with not receiving treatment on MV analysis included history of alcohol abuse(HR 0.682), increasing MELD(HR 0.874), and higher stage at diagnosis(III: HR 0.234, IV: HR 0.210). Although these characteristics were more common in patients treated at SNH, race/ethnicity, socioeconomic status as measured by income and education, and treatment at a SNH were not associated with receipt of treatment. Of patients who actually received treatment, there were no racial/ethnic or socioeconomic disparities in survival. Instead, survival was dictated by MELD, treatment modality, and stage at presentation. Patients who were screened were more likely to present with stage I disease(62vs39%) and to receive treatment(86vs72%, all p<0.001), both important factors associated with improved survival. Conclusion: The interplay of race/ethnicity, socioeconomic factors, disease biology, and the condition of the host liver is complex as it relates to treatment and outcomes of patients with HCC. While there is overlap amongst all these factors, there is no intrinsic or direct association of race/ethnicity, socioeconomic status, or being treated at select safety-net hospitals with worse outcomes. Poor liver function, no insurance, and advanced stage of presentation are the main determinants of not receiving treatment and decreased survival. Efforts directed towards education, government aid, and screening programs for vulnerable and at-risk patients who receive their care at safety-net hospitals are needed.