Social Determinants of Health Are Associated With Treatment Receipt and Mortality in Patients With Hepatocellular Carcinoma

BACKGROUND: The association between social determinants of health (SDOH) and clinical outcomes among patients with hepatocellular carcinoma (HCC) remains unclear. METHODS: We conducted a retrospective cohort study of patients with treatment-naïve HCC seen between September 2018 and July 2023 at 4 US health systems. Patients completed surveys assessing SDOH and health beliefs. We used multivariable logistic regression analysis to identify factors associated with treatment receipt and Fine-Gray subdistribution hazard analysis to identify factors associated with risk of death, with liver transplantation as a competing event. RESULTS: Among 770 eligible patients (55.1% with Barcelona Clinic Liver Cancer [BCLC] stage 0/A HCC), 73.2% received HCC treatment, of whom 46.8% received curative therapy. Treatment receipt was inversely associated with alcohol-associated liver disease (ALD) etiology (adjusted odds ratio [aOR], 0.52; 95% CI, 0.28-0.98), Child-Pugh class B (aOR, 0.45; 95% CI, 0.27-0.75), medical mistrust (aOR, 0.61; 95% CI, 0.38-0.98), and patient-reported discrimination (aOR, 0.80; 95% CI, 0.76-0.83). After adjusting for tumor stage and type of HCC treatment, Child-Pugh class B cirrhosis was associated with a higher risk of mortality (subdistribution hazard ratio [sHR], 1.41; 95% CI, 1.05-1.89), whereas patient-reported discrimination was associated with a lower risk of mortality (sHR, 0.96; 95% CI, 0.94-0.99). Among follow-up survey respondents (n=475), those who reported barriers to treatment had lower treatment receipt (aOR, 0.79; 95% CI, 0.65-0.93), whereas those who reported better patient-provider communication had lower mortality (sHR, 0.95; 95% CI, 0.92-0.99). CONCLUSIONS: Patient-reported medical mistrust, experienced discrimination, and barriers to treatment are associated with treatment receipt and survival, underscoring the importance of addressing SDOH and health beliefs to improve outcomes in patients with HCC.