Abstract
THE SOCIAL DETERMINANTS OF ACCESS TO CURATIVE THERAPIES FOR HEPATOCELLULAR CARCINOMA: A PROSPECTIVE COHORT STUDY
Background: Hepatocellular carcinoma (HCC) is a leading cause of cancer-related death, with high morbidity and mortality among vulnerable populations. We hypothesized the social determinants of health (SDOH), downstream social risks, and health behaviors impact access to curative therapies.
Methods: Adult patients were prospectively enrolled from three hospitals in the Indianapolis area from 6/2019-11/2021.Sixteen individual and area-level SDOH within three access to care domains were collected using structured interviews and validated questionnaires (Panel A). Multinominal multivariable logistic regression was used to explore the associations between these SDOH and the outcomes of being alive without curative therapy, and having been transplanted/resected, or deceased at one year. Multivariable Cox survival analysis was used to explore time to death.
Results: Of 139 patients with well characterized HCC 14.4% were Black and 7.9% were Hispanic. Most were Childs Pugh Category A (61.9%) and hepatitis-C virus was the most common underlying liver disease (46.5%). Annual household incomes of <$15,000 were reported by 21.6% of participants, and 7.9% reported trouble with transportation to medical appointments. 47.1% of patients lacked knowledge of their underlying liver disease. Brief Health literacy (BRIEF) scores were significantly lower, indicating worse health literacy, among those who died during the study period compared to those who were transplanted ((8.3 ± 3.8 vs. 10.5 ± 3.4) or still alive (10.7 ± 3.7) (p=0.013) (Panel B).
On average the cohort was followed 483 days; 31.6% (n=44) underwent transplant/resection and 19.4% (n-27) were deceased at follow-up. Multivariable multinomial logistic regression analysis showed that higher health literacy was associated with a greater odds of being transplanted/resected compared to deceased (OR 1.206 95% CI 1.047-1.389, p=0.009) and higher odds of being alive without transplant compared to deceased (OR 1.213 95% CI 1.065-1.381, p=0.004). Recent alcohol use was associated with lower odds of being transplanted/resected compared to being alive (OR 0.243 95% CI 0.076-0.779, p=0.017). On multivariable survival analysis health literacy scores were associated with survival (HR 0.87, 95% CI 0.80-0.96).
Conclusion: Low health literacy and recent alcohol are strong determinants of receiving curative therapies for HCC and survival. These social risks are modifiable from within the health care system.