Social and clinical determinants of liver transplant evaluation in hepatocellular carcinoma: A multicenter cohort study
Monica Tincopa, Lana Bridi, Irine Vodkin, Mignote Yilma, Kali Zhou, Allison Kwong, Jasleen Singh, Neil Mehta, Alexander Kuo, Ryutaro Hirose, Steven A. Wisel, Justin A. Steggerda, Chris Freise, Veeral AjmeraBackground:
Liver transplantation (LT) is curative for hepatocellular carcinoma (HCC) but requires timely referral. Comprehensive data on factors impacting LT referral and outcomes for HCC are limited. We evaluated social, system, and clinical factors associated with listing, LT, mortality, HCC stage at referral, and time from HCC diagnosis to referral.
Methods:
The California Liver Network is a consortium of 6 LT centers comprising >75% of adult LTs in California. Demographic, clinical, psychosocial, and social determinants of health and outcome data were collected for adults referred for LT. Multivariable regression identified factors associated with outcomes.
Results:
Of 9987 adults referred, 1573 (15.7%) had HCC. Median age was 63.3 years; 73% males, 40% Hispanic, and 26.1% Medicaid insurance. Median MELD was 12.7 (IQR 8–16), and median time from HCC diagnosis to LT referral was 124 days (IQR 32–410). In all, 10% were T1 and 70.5% were T2 at referral. Alpha-fetoprotein (AFP) (OR 0.99), HCC stage, Medicaid insurance (OR 0.55), LT site, and marital status (OR 1.90) were associated with listing. Transplantation was associated with HCC stage (OR 0.42) and LT site. Mortality was associated with MELD (OR 1.02), hypertension (OR 1.44), dialysis (OR 2.48), hepatic encephalopathy (OR 1.54), and portal vein thrombosis (OR 1.44). Referral at more advanced HCC stage was associated with male sex (OR 1.55), AFP (OR 1.01), Medicaid insurance (OR 1.40), primary language (OR 0.70), and prior HCC treatment type. Longer time to referral was associated with HCV/alcohol liver disease and prior HCC treatment type.
Conclusions:
In this multicenter study of adults with HCC, Medicaid insurance, LT site, HCC treatment history, and psychosocial factors were key determinants of HCC care cascade progression, identifying targets to improve LT access.