THE IMPACT OF SOCIAL RISK FACTORS ON THE PRESENTATION, TREATMENT AND SURVIVAL OF PATIENTS WITH HEPATOCELLULAR CARCINOMA AT AN URBAN, ACADEMIC SAFETY-NET HOSPITAL
Kelsey S. Romatoski*1, Manal Dia1, Marianna V. Papageorge1, Alison P. Woods1,2, Sophie H. Chung1, Avneesh Gupta3, Christina LeBedis3, Teviah Sachs1, Arpan Mohanty4
1General Surgery, Boston Medical Center, Boston, MA; 2Johns Hopkins University, Baltimore, MD; 3Boston Medical Center Department of Radiology, Boston, MA; 4Boston Medical Center, Boston, MA
Introduction: Social risk factors impact the diagnosis, management and survival of patients with hepatocellular carcinoma (HCC). This is relevant as the incidence of HCC increases nationally, particularly among non-white, immigrant patients, yet receipt of treatment and overall outcomes for HCC continue to have disparities based on race, ethnicity, and socioeconomic status. We evaluated the relationship between social determinants of health and presentation, treatment and survival of patients with HCC at an urban, safety-net hospital.
Methods: A single institution retrospective chart review of patients with all stages of HCC from January 2009 through May 2019 was conducted. Demographic, disease, and treatment characteristics were obtained. Chi-square and Wilcoxon tests were used for categorical and continuous variables, respectively. Univariate analysis was used to evaluate stage at presentation, receipt of intervention (resection, ablation, TACE), receipt of systemic therapy and median overall survival. Survival between stage at diagnosis was compared using Kaplan-Meier methods.
Results: 388 patients with HCC were identified; median age was 61 years and 83.2% were male. Patients had an overall similar sociodemographic distribution for presentation of early versus late disease. However, commercial insurance status resulted in diagnosis at earlier stage (24.7% early stage vs 13.3% late stage; p=0.014) while safety-net/no insurance was a significant risk factor for advanced presentation at diagnosis (9.9% early stage vs 17.6% late stage; p=0.014). Higher level of education (high school and above) was associated with increased intervention for all stages of disease (70.1% vs no education/unknown 29.9%; p=0.048) as was origin of mainland USA (60.3% vs other countries/unknown 39.7%; p=0.018). No sociodemographic differences were seen for receipt of treatment, intervention or systemic therapy, for patients with early stage disease. Patients with late stage disease who had a higher level of education were more likely to receive intervention (73.0% vs no education/unknown 27.0%; p = 0.049). Receipt versus lack of systemic therapy was associated with employment status (unemployed/unknown 40.3% vs 17.5%; retired 40.3% vs 65.0%, employed 19.4% vs 17.5%; p=0.002). Median survival was not impacted by any examined sociodemographic factors.
Conclusion: Despite clear evidence of disparities in the diagnosis and care of patients with HCC in the literature, our data show that an urban academic safety net hospital is able to mitigate the impact of social determinants of health for these patients. Urban safety-net hospitals with a focus on vulnerable patient populations are able to provide outcomes on par with those seen on the national level and should serve as a care system model to address disparities in HCC care.
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