Background: Disparities in hepatocellular carcinoma (HCC) have been partly attributed to low socioeconomic status among minorities. We investigated associations between race, socioeconomic characteristics, geographic characteristics and survival in HCC patients in Florida.
Methods: Using the Florida Cancer Data System (FCDS), we analyzed HCC cases diagnosed between 1/1/2004 and 12/31/2013. To ascertain population-level socioeconomic characteristics, we linked FCDS to the 2010–2014 US Census American Community Survey and the 2013 Florida Behavioral Risk Factor Surveillance System. We also estimated patient distance to liver transplant and academic cancer centers. Using Cox proportional hazards, we modeled the association between race and survival.
Results: Of 10,852 patients, 13.1% were Black, 67.1% White, 15.7% Hispanic, and 3.2% Asian. At diagnosis, Blacks were younger with more extensive disease, p <0.001. Transplants were performed in 9.3% of Hispanics, 7.5% of Whites, 5.8% of Asians and 4.2% of Blacks, p <0.001. Median survival was longest in Hispanics and shortest in Blacks, p<0.001 When adjusted for gender, age, payer, SEER stage, surgery type, and receipt of treatment, Blacks had a 17% increased risk of death [hazard ratio (HR) 1.17, 95% confidence interval (CI) 1.07–1.29] and Whites a 9% increased risk of death [HR 1.09, 95% CI 1.02–1.17] compared to Hispanics. As a group, Hispanics lived closest to any transplant or academic cancer center, p <0.001. Neighborhood poverty level was highest where Hispanic patients lived, p <0.001.
Conclusion: Though socioeconomic differences may contribute to disparities, Hispanics survived longer than Blacks and Whites in Florida despite living in the most socioeconomically depressed neighborhoods. Increased access to transplant likely contributed to improved survival. Additional research is needed to identify which individual socioeconomic and geographic determinants contribute most to disparities.
Keywords: racial disparities, hepatocellular carcinoma, geographic disparities
Over the past three decades, the incidence of hepatocellular carcinoma (HCC) has risen dramatically in the United States (US).1 In 2012, nearly 25,000 new cases were diagnosed.2 The Surveillance, Epidemiology, and End Results (SEER) Program estimates that over 42,000 persons will be diagnosed with liver cancer/intrahepatic bile duct cancer in 2019;3 approximately 75% of those cases represent HCC.4 Although HCC ranks 13th in the number of new cancers each year in the US, it is the 5th leading cause of cancer death3 and the fastest-growing cause of cancer-related death among men.5
Increases in HCC incidence vary by race; incidence rose faster among Blacks and Hispanics than non-Hispanic Whites2,6 with HCC risk highest in Hispanics.2,7 Significant racial disparities in HCC surveillance8 may contribute to the observation that Blacks more often present with late-stage cancer compared to other races.9–11 Adjusted for stage at presentation and severity of liver disease, Blacks are least likely to receive treatment for HCC and have the lowest survival.9,10,12,13 The etiology of chronic liver disease (CLD) causing HCC differs by race, which may confer increased risk for HCC.14,15 However, there is little evidence that HCC survival differences are driven primarily by race as a biological factor. Rather, sociodemographic implications of race such as area socioeconomic deprivation, lack of insurance and/or access to specialized care, including transplant, are major determinants of survival.13,16
Geographic differences in disease etiology and practice patterns may influence HCC incidence and survival.2,16,17 Through retrospective analysis of our local registry combined with chart review, we identified significant racial differences in HCC survival.9 In the study described herein, we aimed to evaluate whether the same trends observed locally would be present throughout the state. Florida is the third-most populous state with the fourth-highest number of HCC cases.2 The rich diversity of Florida’s population, enhanced by a large immigrant population, allows for the evaluation of multiple determinants of survival. Few studies have investigated how geography18 or neighborhood socioeconomic status (SES), which vary significantly by race, influence HCC survival on a population level. This study explores the association between race, geography, individual- and neighborhood-level socioeconomic factors and in that context, evaluates how race impacts HCC survival.
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