The role of income level in outcomes and treatment for patients with fibrolamellar hepatocellular carcinoma.
Authors: Patel Jaikin , Braaten Marco , Bine Christopher Reese , Silberstein Peter T. 
Published: September 2024

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Background:
Fibrolamellar hepatocellular carcinoma (FL-HCC) is a rare and aggressive type of hepatic cancer – comprising less than 1% of total liver malignancies – that commonly presents in younger patients. Treatment primarily consists of surgical resection with adjuvant chemotherapy, however, standardized protocols have not been well established due to its rarity. Previous studies have attempted to analyze potential risk factors for developing fibrolamellar hepatocellular carcinoma; however, the relationship between socioeconomic status and incidence rates have yet to be clearly elucidated. Using the National Cancer Database, we aim to uncover the relationship between FL-HCC and income level to better understand the role it plays on the outcomes of these patients.
Methods:
The National Cancer Database (NCDB) was used to identify patients diagnosed with fibrolamellar hepatocellular carcinoma from 2004 to 2019 using the histology code 8171. Socioeconomic and treatment variables were identified as assigned by the Commission on Cancer Accreditation program. Low income was categorized as <30,000, middle income between 30,000 - 45,999, and high income as >= 46,000. Survival data was computed using logrank testing and a Cox proportional hazards model. Data was analyzed using IBM SPSS Statistics for Windows, Version 27.0 software (IBM Corp., Armonk, NY) and statistical significance was set at α = 0.05.
Results:
Initial search revealed 418 patients to be included for analysis. 20% of patients were categorized as low-income, 52.6% of patients as middle-income, and 27.3% of patients as high-income. Low-income patients had a median survival of 18.07 months, compared with 32.62 months for middle income and 63.34 months for high income patients (p<0.05). Low-income patients were also more likely to be uninsured (8.2% vs. 6.8% for middle income and 2.5% for high income; p<0.001). Treatment differences between income groups were observed: only 42.6% of low-income patients were treated with surgery compared with 56.7% of middle-income patients and 66.0% of high-income patients (p<0.001). This discrepancy is explained by the fact that low-income patients were less likely to have surgery of the primary site performed because it was not included as part of their planned first course treatment compared with middle- and high-income patients (53.3% vs. 37.3% and 28.9%, respectively; p = 0.002). No differences existed between radiation, immunotherapy and chemotherapy treatments offered to these patients. Additionally, there were no differences in the grade of the tumor, staging, or evidence of metastasis at time of diagnosis amongst these patients.
Conclusions:
This analysis identifies the influence of income level on the treatments offered and outcomes of patients with fibrolamellar hepatocellular carcinoma. Surgery should ultimately be included when establishing guidelines pertaining to the treatment of FL-HCC, especially amongst low-income patients.