Increased morbidity and mortality of hepatocellular carcinoma patients in lower cost of living areas

Disparities in outcomes and access to therapy options in hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) disproportionately impacts racial and ethnic minorities and patients with lower socioeconomic status. These social determinants of health (SDH) lead to disparities in access to care and outcomes. We aim to understand the relationship between SDH and survival and locoregional treatment options in HCC.

METHODS

Using the National Cancer Database, we evaluated survival and access locoregional treatments including non-transplant surgery, liver transplant (LT), and liver-directed radiation therapy (LDRT) in patients with HCC diagnosed between 2004 and 2017. Variables including clinical stage, age, sex, race, income, rurality, year of diagnosis, facility type (FT), Charlson-Deyo score (CD), and insurance were evaluated. Cox proportional hazards multivariable regression and dominance analyses were used for analyses.

RESULTS

In total, 140 340 patients were included. Worse survival was seen with advanced stage, older age, Black race, rurality, public insurance, treatment at a nonacademic center, and lower income. The top predictors for survival included stage, age, and income. Completion of non-transplant surgery was best predicted by stage, FT, and insurance type, whereas LT was predicted by age, year of diagnosis, and CD score. LDRT utilization was most associated with year of diagnosis, FT, and CD score.

CONCLUSION

For patients with HCC, survival was predicted primarily by stage, age, and income. The primary sociodemographic factors associated with access to surgical treatments, in addition to FT, were insurance and income, highlighting the financial burdens of health care. Work is needed to address disparities in access to care, including improved insurance access, addressing financial inequities and financial toxicities of treatments, and equalizing care opportunities in community centers.

Assessing the impact of socioeconomic status on incidental lung nodules at an urban safety net hospital

INTRODUCTION

Lower socioeconomic status has been identified as an emerging risk factor for health disparities, including lung cancer outcomes. Most research investigating these outcomes includes patients from formal lung cancer screening programs. There is a paucity of studies assessing the relationship between socioeconomic status and incidental lung nodules. This study aimed to investigate the association between socioeconomic status and the size of incidental lung nodules on initial presentation at an urban safety net hospital, which did not have a formal lung cancer screening program or incidental lung nodule program.

METHODS

A retrospective chart review was conducted on patients with incidental lung nodules on CT chest imaging who were referred from primary care to a pulmonology clinic at a safety net hospital. Patients with incomplete nodule characteristics information were excluded. Data on demographics, comorbidities, smoking history, insurance type, immigration status, and geographical factors were collected. Less commonly studied determinants such as crime index, cost of living, and air quality index were also assessed. Logistic regression analysis was performed to assess relationships between nodule size and socioeconomic determinants.

RESULTS

Out of 3,490 patients with chest CT scans, 268 patients with ILNs were included in the study. 84.7% of patients represented racial or ethnic minorities, and most patients (67.8%) had federal insurance. Patients with non-commercial insurance were more likely to have larger, inherently higher-risk nodules (> 8 mm) compared to those with commercial insurance (OR 2.18, p 0.01). Patients from areas with higher unemployment rates were also less likely (OR 0.75, p 0.04) to have smaller nodules (< 6 mm). Patients representing racial or ethnic minorities were also more likely to have nodules > 8 mm (OR 1.6, p 0.24), and less likely to have nodules < 6 mm (OR 0.6, p 0.32), however, these relationships were not statistically significant.

CONCLUSION

This study found that lower socioeconomic status, indicated by having non-commercial insurance, was associated with larger incidental lung nodule size on initial presentation. While it is established that socioeconomic status is associated with disparities in lung cancer screening, these findings suggest that inequalities may also be present in those with incidental lung nodules. Further research is needed to understand the underlying mechanisms and develop interventions to address these disparities in incidental lung nodule evaluation and improve outcomes.

Racial, ethnic, and socioeconomic disparities impact post-liver transplant survival in patients with hepatocellular carcinoma

INTRODUCTION AND OBJECTIVES

Liver transplantation can be a curative treatment for patients with hepatocellular carcinoma (HCC); however, the morbidity and mortality associated with HCC varies by socioeconomic status and race and ethnicity. Policies like Share 35 were implemented to ensure equitable access to organ transplants; however, their impacts are unclear. We aimed to characterize differences in post-liver transplant (LT) survival among patients with HCC, when considering race and ethnicity, income, and insurance type, and understand if these associations were impacted by Share 35.

MATERIALS AND METHODS

We conducted a retrospective cohort study of 30,610 adult LT recipients with HCC. Data were obtained from the UNOS database. Survival analysis was carried out using Kaplan-Meier curves, and multivariate Cox regression analysis was used to calculate hazard ratios.

RESULTS

Men (HR: 0.90 (95% CI: 0.85-0.95)), private insurance (HR: 0.91 (95% CI: 0.87-0.92)), and income (HR: 0.87 (95% CI: 0.83-0.92)) corresponded with higher post-LT survival, when adjusted for over 20 demographic and clinical characteristics (Table 2). African American or Black individuals were associated with lower post-LT survival (HR: 1.20 (95% CI: 1.12-1.28)), whereas. Asian (HR: 0.79 (95% CI: 0.71-0.88)) or Hispanic (HR: 0.86 (95% CI: 0.81-0.92)) individuals were associated with higher survival as compared with White individuals (Table 2). Many of these patterns held in the pre-Share 35 and Share 35 periods.

CONCLUSIONS

Racial, ethnic, and socioeconomic disparities at time of transplant, such as private insurance and income, influence post-LT survival in patients with HCC. These patterns persist despite the passage of equitable access policies, such as Share 35.

Clinical Informatics Approaches to Understand and Address Cancer Disparities

OBJECTIVES

Disparities in cancer incidence and outcomes across race, ethnicity, gender, socioeconomic status, and geography are well-documented, but their etiologies are often poorly understood and multifactorial. Clinical informatics can provide tools to better understand and address these disparities by enabling high-throughput analysis of multiple types of data. Here, we review recent efforts in clinical informatics to study and measure disparities in cancer.

METHODS

We carried out a narrative review of clinical informatics studies related to cancer disparities and bias published from 2018-2021, with a focus on domains such as real-world data (RWD) analysis, natural language processing (NLP), radiomics, genomics, proteomics, metabolomics, and metagenomics.

RESULTS

Clinical informatics studies that investigated cancer disparities across race, ethnicity, gender, and age were identified. Most cancer disparities work within clinical informatics used RWD analysis, NLP, radiomics, and genomics. Emerging applications of clinical informatics to understand cancer disparities, including proteomics, metabolomics, and metagenomics, were less well represented in the literature but are promising future research avenues. Algorithmic bias was identified as an important consideration when developing and implementing cancer clinical informatics techniques, and efforts to address this bias were reviewed.

CONCLUSIONS

In recent years, clinical informatics has been used to probe a range of data sources to understand cancer disparities across different populations. As informatics tools become integrated into clinical decision-making, attention will need to be paid to ensure that algorithmic bias does not amplify existing disparities. In our increasingly interconnected medical systems, clinical informatics is poised to untap the full potential of multi-platform health data to address cancer disparities.

Current status of disparity in liver disease

Disparities have emerged as an important issue in many aspects of healthcare in developed countries and may be based on race, ethnicity, sex, geographical location, and socioeconomic status. For liver disease specifically, these potential disparities can affect access to care and outcome in viral hepatitis, chronic liver disease, and hepatocellular carcinoma. Shortages in hepatologists and medical providers versed in liver disease may amplify these disparities by compromising early detection of liver disease, surveillance for hepatocellular carcinoma, and prompt referral to subspecialists and transplant centers. In the United States, continued efforts have been made to address some of these disparities with better education of healthcare providers, use of telehealth to enhance access to specialists, reminders in electronic medical records, and modifying organ allocation systems for liver transplantation. This review will detail the current status of disparities in liver disease and describe current efforts to minimize these disparities.

The Pyroptosis-Related Long Noncoding RNA Signature Predicts Prognosis and Indicates Immunotherapeutic Efficiency in Hepatocellular Carcinoma

Pyroptosis was recently demonstrated to be an inflammatory form of gasdermin-regulated programmed cell death characterized by cellular lysis and the release of several proinflammatory factors and participates in tumorigenesis. However, the effects of pyroptosis-related long noncoding RNAs (lncRNAs) on hepatocellular carcinoma (HCC) have not yet been completely elucidated. Based on the regression coefficients of ZFPM2-AS1, KDM4A-AS1, LUCAT1, NRAV, CRYZL2P-SEC16B, AL031985.3, SNHG4, AL049840.5, AC008549.1, MKLN1-AS, AC099850.3, and LINC01224, HCC patients were classified into a low- or high-risk group. The high-risk score according to pyroptosis-related lncRNA signature was significantly associated with poor overall survival even after adjusting for age and clinical stage. Receiver operating characteristic curves and principal component analysis further supported the accuracy of the model. Our study revealed that a higher pyroptosis-related lncRNA risk score was significantly associated with tumor staging, pathological grade, and tumor-node-metastasis stages. The nomogram incorporating the pyroptosis-related lncRNA risk score and clinicopathological factors demonstrated good accuracy. Furthermore, we observed distinct tumor microenvironment cell infiltration characteristics between high- and low-risk tumors. Notably, based on the risk model, we found that the risk score is closely related to the expression of immune checkpoint genes, immune subtypes of tumors, and the sensitivity of HCC to chemotherapy drugs and immunotherapy. In conclusion, our novel risk score of pyroptosis-related lncRNA can serve as a promising prognostic biomarker for HCC patients and provide help for HCC patients to guide precision drug treatment and immunotherapy.