Examining disparities in the receipt of curative treatment for hepatocellular cancer (HCC): A multicenter retrospective study from 2016-2023.
Authors: Aldecoa Kim Abbegail Tan , Macaraeg Chef Stan Lucena , Vojjala Nikhil , Cherry Garrett , Clark Ryan , Deeb Dana , Dietz Grey , Fernandez Annelise , Khullar Alpa , Lawson Landon , rodriguez Juarbe Coralys , Sharma Aparna , Sims Dcota , Krishnamoorthy Geetha , Azar Ibrahim , Goodman Judie R. , Arsene Camelia 
Published: May 2024

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Background: Prior studies suggested disparities in hepatocellular cancer (HCC) treatment and outcomes based on region, race, and socioeconomic status. After the implementation of the Affordable Care Act, including Michigan’s Medicaid Expansion in 2014, there’s increased interest in how these changes affect HCC care. The study examines factors influencing curative treatment receipt and existing disparities, as a step toward intervention strategies. Methods: This is a retrospective study of HCC patients at 6 community-based (4 university-affiliated) hospitals, in Michigan from Jan 2016-Sep 2023. Patients without imaging or histologic confirmation were excluded. Factors associated with receiving curative treatment were determined using both univariate and multivariable logistic regressions. Analysis was done using SPSS 28, with a p-value<0.05 indicating statistical significance. Results: Of 680 HCC patients screened, 347 were analyzed. The mean age was 70 years, and 71% were male. 78.3% were White and 16.9% Black. 53.9% had private insurance and 35% had government insurance. Primary HCC etiologies were alcohol and hepatitis C virus (HCV) infection; 74.4% had cirrhosis. Barcelona Clinic Liver Cancer (BCLC) stages varied: A (10.6%), B (28.2%), C (36.4%), and D (24.8%). 59.4% underwent curative treatment (4.6% resection, 30.3% liver-directed, 13.3% systemic, 10.1% combination), while 38.3% had best supportive care. Univariate analysis identified many factors associated with receipt of curative treatment, including race (White>Black), insurance (private>government), earlier BCLC stages, ECOG 0/1/2, Child-Pugh A, lower MELD-Na score (mean=12), <400 alpha-fetoprotein levels, and better liver function (Bilirubin, INR, albumin). Tumor characteristics, such as smaller size, absence of metastasis, and absence of portal vein thrombosis, were also associated with receipt of curative treatment. Overall, the one-year survival rate was 64% for those who had curative treatment and 35% for best supportive care. All with p-value<0.05. Multivariable analysis showed Black patients (OR: 0.21, CI: 0.051-0.881) with larger tumors (OR:0.89, CI: 0.783-1.00) and lower albumin levels (OR:3.81, CI: 1.649-8.805) at presentation were less likely to receive curative treatment than White. Black patients were also diagnosed at a younger age (66.7 vs. 71.0 years, p=0.01), more advanced BCLC stages C/D (74% vs. 57%, p=0.04) on presentation, and HCV coinfection (58% vs. 32%, p<0.001) than White. Median survival for Black and White were 757 days and 823 days, respectively (p=0.89). Conclusions: Black patients with larger tumors and low albumin are less likely to receive curative treatment than White. HCV coinfection in the Black population suggests a focus area for early intervention. Further investigation of HCC disparities across various settings is warranted.