Abstract

Background: While studies have associated social determinants of health (SDOH) with hepatocellular carcinoma (HCC) treatment delay of >3 months, there is limited data on SDOH impacting expedited treatment and subsequent outcomes. This study investigates whether components of SDOH are associated with progression-free survival for HCC within Milan criteria and their effect on time to initiate HCC treatment.

Methods: We conducted a retrospective cohort study of adults diagnosed with HCC within Milan criteria from 2010 to 2021 at an urban liver transplant center. Patients who were not treated or received initial curative surgery (transplant or resection) were excluded. Patients with expedited therapy (<45 days from diagnosis) were compared to those with non-expedited therapy (≥45 days). Demographic data was gathered via chart review. Patients were geospatially mapped by address and linked to a Federal Information Processing Standards (FIPS) code and SDOH data from the 2020 U.S. Census. Our primary outcome was progression free survival. Secondary outcomes included time from diagnosis to treatment. T-tests, chi-square tests, logistic and cox univariate regression analyses were performed.

Results: Of 1401 patients with HCC, 235 (17%) were included. Our sample had an average age of 63 years and consisted of 64% males, 52% Hispanics, and 85% T1 tumors by TNM staging (Table 1). There was a notable trend towards increased progression free survival for those treated in <45 days (p=0.094). A smaller proportion of non-White patients received expedited treatment compared to White patients (37% vs 58%, p=0.01). SDOH associated with delayed therapy included higher social vulnerability index (p=0.013), minority status (p=0.03), income below 150% poverty line (p=0.007), vulnerable housing/transportation (p=0.032), vulnerable socioeconomic status (p=0.027), educational level below high school (p=0.003), and limited English (p=0.033). Though larger tumors received more expedited therapy (p=0.019), tumor size≥2 cm was associated with rapid disease progression (p=0.015).

Conclusion: SDOH clearly impact time to HCC treatment initiation and cancer progression. Despite the expedited group’s larger tumor size and the faster progression of larger tumors, there was a trend towards improved progression-free survival for patients receiving expedited treatment before 45 days. These findings underscore the importance of early treatment and implementing interventions to mitigate SDOH disparities in care of patients burdened by HCC.