Rural-Urban Geographical Disparities in Hepatocellular Carcinoma Incidence Among US Adults, 2004-2017

Neighborhood-level Social Determinants of Health and Waitlist Mortality for Liver Transplantation: The Liver Outcomes and Equity Index

BACKGROUND AND AIMS

To examine neighborhood-level disparities in waitlist mortality for adult liver transplantation (LT), we developed novel area-based social determinants of health (SDOH) index using a national transplant database.

METHODS

ZIP Codes of individuals listed for or received LT in the Scientific Registry of Transplant Recipients database between June 18, 2013, and May 18, 2019, were linked to 36 American Community Survey (ACS) variables across 5 SDOH domains for index development. A step-wise principal component analysis was used to construct the Liver Outcomes and Equity (LOEq) index. We then examined the association between LOEq quintiles (Q1 = worst and Q5 = best neighborhood SDOH) and waitlist mortality with competing risk regression among listed adults in the study period and acuity circle (AC) era.

RESULTS

The final LOEq index consisted of 13 ACS variables. Of 59 298 adults waitlisted for LT, 30% resided in LOEq Q5 compared with only 14% in Q1. Q1 neighborhoods with worse SDOH were disproportionately concentrated in transplant regions with low median Model for End-Stage Liver Disease at transplant (MMAT) and shorter wait times. Five years cumulative incidence of waitlist mortality was 33% in Q1 in high MMAT regions versus 16% in Q5 in low MMAT regions. Despite this allocation advantage, LOEq Q1-Q4 were independently associated with elevated risk of waitlist mortality compared with Q5, with highest increased hazard of waitlist deaths of 19% (95% CI, 11%-26%) in Q1. This disparity persisted in the AC era, with 24% (95% CI, 10%-40%) increased hazard of waitlist deaths for Q1 versus Q5.

CONCLUSIONS

Neighborhood SDOH independently predicts waitlist mortality in adult LT.

Poverty Traps and Mortality From Liver Diseases in the United States

INTRODUCTION

Poverty traps, locations with multigenerational poverty, result from structural and economic factors that can affect health of residents within these locations. The aim of this study was to define poverty traps within the contiguous United States and their impact on outcomes from liver diseases or cancers.

METHODS

A systematic census-tract level analysis was used to spatially define regions that encompassed poverty traps. Clusters of prevalent poverty and mortality from chronic liver diseases or liver cancers were identified. Temporal trends and the relationship between race and ethnicity, type of space and escape from poverty traps on disease mortality within hot spots were determined.

RESULTS

The proportion of census tracts enduring multigenerational poverty within counties was strongly associated with mortality from liver disease or cancer. There was a highly significant clustering of persistent poverty and increased mortality. Hot spots of high-mortality areas correlated with factors related to income, ethnicity, and access to health care. Location or noneconomic individual factors such as race and ethnicity were important determinants of disparities within hot spots. Distinct groups of poverty traps were defined. The highly characteristic demographics and disease outcomes within each of these groups underscored the need for location-specific interventions.

DISCUSSION

Poverty traps are a major and important spatially determined risk factor for mortality from liver diseases and cancers. Targeted location-specific interventions and economic development aimed at addressing the underlying causes of poverty and enhancing prosperity will be required to reduce mortality from liver diseases within poverty traps.

The Influence of Urbanization on the Patterns of Hepatocellular Carcinoma Mortality From 1999 to 2020

Background

Hepatocellular carcinoma (HCC) remains one of the leading causes of cancer-related fatalities despite early diagnosis and treatment progress, creating a significant public health issue in the United States. This investigation utilized death certificate data from the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) database to investigate HCC mortality patterns and death locations from 1999 to 2020. The objective was to analyze trends in HCC mortality across different population groups, considering the impact of urbanicity.

Methods

In this study, death certificate data obtained from the CDC WONDER database were utilized to investigate the trends in HCC mortality and location of death between 1999 and 2020. The annual percent change (APC) method was applied to estimate the average annual rate of change during the specified timeframe for the relevant health outcome. Furthermore, including data on the location of death and geographic areas allowed us to gain deeper insights into the patterns and characteristics of HCC and its impact on different regions.

Results

Between 1999 and 2020, there were 184,073 reported deaths attributed to HCC, and data on the location of death were available for all cases. Most deaths occurred during inpatient admissions (34.93%) or at home (41.19%). The study also found that the highest age-adjusted mortality rate (AAMR) for HCC was observed among male patients, particularly among those identified as Asian or Pacific Islander. Variations in AAMR were determined based on the level of urbanization or rurality of the area, with higher rates observed in more densely populated and urbanized regions. In contrast, less urbanized and populated areas experienced a profound increase in AAMR over the past two decades.

Conclusion

The HCC-related AAMRs have worsened over time for most ethnic groups, except for Asian or Pacific Islanders, which showed a reduction in APC despite having the worst AAMR. Although rural and less densely populated areas have substantially increased AAMR over the past two decades, more urbanized areas continued to have higher AAMR rates.

Care for Vulnerable Populations with Chronic Liver Disease: A Safety-Net Perspective

Safety-net hospitals (SNHs) and facilities are the cornerstone of healthcare services for the medically underserved. The burden of chronic liver disease-including end-stage manifestations of cirrhosis and liver cancer-is high and rising among populations living in poverty who primarily seek and receive care in safety-net settings. For many reasons related to social determinants of health, these individuals often present with delayed diagnoses and disease presentations, resulting in higher liver-related mortality. With recent state-based policy changes such as Medicaid expansion that impact access to insurance and critical health services, an overview of the body of literature on SNH care for chronic liver disease is timely and informative for the liver disease community. In this narrative review, we discuss controversies in the definition of a SNH and summarize the known disparities in the cascade of the care and management of common liver-related conditions: (1) steatotic liver disease, (2) liver cancer, (3) chronic viral hepatitis, and (4) cirrhosis and liver transplantation. In addition, we review the specific impact of Medicaid expansion on safety-net systems and liver disease outcomes and highlight effective provider- and system-level interventions. Lastly, we address remaining gaps and challenges to optimizing care for vulnerable populations with chronic liver disease in safety-net settings.

Prevention of Hepatocellular Carcinoma (HCC). White Paper of the Texas Collaborative Center for Hepatocellular Cancer (TeCH) Multi-stakeholder Conference

BACKGROUND & AIMS

Texas has the highest age-adjusted incidence rate of hepatocellular carcinoma (HCC) in the United States. The Cancer Prevention and Research Institute of Texas has funded the Texas Collaborative Center for Hepatocellular Cancer (TeCH) to facilitate HCC research, education, and advocacy activities with the overall goal of reducing HCC mortality in Texas through coordination, collaboration, and advocacy.

METHODS

On September 17, 2022, TeCH co-sponsored a multi-stakeholder conference on HCC with the Baker Institute Center for Health and Biosciences. This conference was attended by HCC researchers, policy makers, payers, members from pharmaceutical industry and patient advocacy groups in and outside of Texas. This report summarizes the results of the conference.

RESULTS

The goal of this meeting was to identify different strategies for preventing HCC and evaluate their readiness for implementation.

CONCLUSIONS

We call for a statewide (1) viral hepatitis elimination program; (2) program to increase nonalcoholic steatohepatitis and obesity awareness; (3) research program to develop health care models that integrate alcohol associated liver disease treatment and treatment for alcohol use disorder; and (4) demonstration projects to evaluate the effectiveness of identifying and linking patient with advanced fibrosis and cirrhosis to clinical care.

Geographical disparities in hepatitis b virus related hepatocellular carcinoma mortality rates worldwide from 1990 to 2019

This study aims to evaluate global trends in hepatitis B virus-related hepatocellular carcinoma (HBV-HCC) related mortality over the past 30 years. Despite improvements in the treatment of both HBV and HCC, disparities in access to care and treatment persist, and these disparities may have affected HBV-HCC outcomes across certain global regions disproportionately. Using data from the Global Burden of Diseases, Injury, and Risk Factors Study (GBD) from 1990 to 2019, we evaluated overall mortality rates related to HBV-HCC. From 1990 to 2019, overall global HBV-HCC mortality rate decreased by 30.3%. While most world regions experienced declines in HBV-HCC mortality, several regions also experienced significant increases in mortality, including Australasia, Central Asia, and Eastern Europe. When stratified by age, all age groups demonstrated declines in HBV-HCC mortality from 1990 to 2019. Similar trends were observed for both men and women. When stratified by world regions, HBV-HCC mortality in 2019 was highest in East Asia, which was significantly higher than the region with the next highest HBV-HCC mortality, Southeast Asia. Significant disparities in HBV-HCC mortality are observed among global regions. We observed higher HBV-HCC mortality rates with older age, higher mortality in males, and highest mortality in East Asia. The clinical significance of these findings are to highlight those regions that need more targeted resources to improve HBV testing and treatment to reduce the long term consequences of untreated HBV, such as HCC.

An Open-Access, Interactive Decision-Support Tool to Facilitate Guideline-Driven Care for Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is increasing in incidence and is a leading cause of cancer-related mortality worldwide. Adherence to HCC surveillance guidelines and appropriate treatment triage of liver lesions may improve receipt of curative-intent treatment and improved survival. Late-stage HCC diagnosis reflects sub-optimal implementation of effective HCC surveillance, whereas inappropriate treatment triage or linkage to care accounts for the non-receipt of curative-intent in close to half of early-stage HCC in the USA. A free, open-access decision-support tool for liver lesions that incorporates current guideline recommendations in a user-friendly interface could improve appropriate and timely triage of patients to appropriate care. This review provides a summary of gaps and disparities in linkage to HCC care and introduces a free, internet-based, interactive decision-support tool for managing liver lesions. This tool has been developed by the HCC Steering Committee of the Chronic Liver Disease Foundation and is targeted toward clinicians across specialties who may encounter liver lesions during routine care or as part of dedicated HCC surveillance.

Hepatocellular Carcinoma-Related Mortality in the USA, 1999-2018

BACKGROUND AND AIMS

The burden of hepatocellular carcinoma (HCC) is increasing, and certain groups may be at higher risk.

METHODS

We analyzed trends in HCC-related mortality in the USA (1999-2018) using national death data. Age-adjusted trends in death rates (annual percentage change, APC) were calculated using joinpoint regression analysis.

RESULTS

HCC-related death rates increased by 2.1% (95% CI 1.9 to 2.3) annually. Hepatitis C (HCV)-related HCC death rates increased from 1999 to 2012 (8.9%, 95% CI 7.6 to 10.2) followed by a -1.3% (95% CI -3.5 to 0.9) decrease annually. For adults > 65 years, HCV-related HCC death rates increased (7.3% annually, 95% CI 6.5 to 8.1), especially for rural areas (11.1% annually, 95% CI 6.9 to 15.5) with high rates among African-Americans and Hispanics. Increases in non-HCV-related HCC death rates were larger: 13.5% annually (95% CI 3.6 to 24.3, 2005-2010) followed by 4.2% annually (95% CI 2.3 to 6.2, 2010-2018). Annual rates of increase were similar for men (6.8%, 95% CI 5.9 to 7.8) and women (7.0%, 95% CI 5.5 to 8.4) from 1999 to 2018. Rate of increase across races was Whites 8.3% (95% CI 7.2 to 9.4, 1999-2018), African-Americans 11.2% (95% CI -6.6 to 32.3, 2015-2018), and Hispanics 3.7% (95% CI 1.0 to 6.5, 2012-2018).

CONCLUSION

HCC-related mortality has increased, driven by increases in non-HCV-related mortality with important demographic and regional trends. In addition, HCV-HCC mortality remains high particularly in older persons and those in rural areas despite advances in HCV therapy. These data underscore the need for targeted approaches to mitigate the burden of HCC-related mortality similar to efforts for other cancers.

Quality measures in HCC care by the Practice Metrics Committee of the American Association for the Study of Liver Diseases

The burden of HCC is substantial. To address gaps in HCC care, the American Association for the Study of Liver Diseases (AASLD) Practice Metrics Committee (PMC) aimed to develop a standard set of process-based measures and patient-reported outcomes (PROs) along the HCC care continuum. We identified candidate process and outcomes measures for HCC care based on structured literature review. A 13-member panel with content expertise across the HCC care continuum evaluated candidate measures on importance and performance gap using a modified Delphi approach (two rounds of rating) to define the final set of measures. Candidate PROs based on a structured scoping review were ranked by 74 patients with HCC across 7 diverse institutions. Out of 135 measures, 29 measures made the final set. These covered surveillance (6 measures), diagnosis (6 measures), staging (2 measures), treatment (10 measures), and outcomes (5 measures). Examples included the use of ultrasound (± alpha-fetoprotein [AFP]) every 6 months, need for surveillance in high-risk populations, diagnostic testing for patients with a new AFP elevation, multidisciplinary liver tumor board (MLTB) review of Liver Imaging-Reporting and Data System 4 lesions, standard evaluation at diagnosis, treatment recommendations based on Barcelona Clinic Liver Cancer staging, MLTB discussion of treatment options, appropriate referral for evaluation of liver transplantation candidacy, and role of palliative therapy. PROs include those related to pain, anxiety, fear of treatment, and uncertainty about the best individual treatment and the future. The AASLD PMC has developed a set of explicit quality measures in HCC care to help bridge the gap between guideline recommendations and measurable processes and outcomes. Measurement and subsequent implementation of these metrics could be a central step in the improvement of patient care and outcomes in this high-risk population.

Diverging Incidence Trends for Hepatocellular Carcinoma in Rural and Urban Settings in the United States

In the United States, hepatocellular carcinoma (HCC) is the fastest growing cause of cancer-related deaths and was the 5th most common cause in 2020.¹ One in 5 Americans lives in a rural area,² yet little is known about temporal changes in HCC incidence by rural-urban residence. Area-specific data are critical to guide public health strategies and clinical interventions. Our study compared the overall and subgroup incidence trends for HCC across rural and urban communities in the United States over the past 20 years using the North American Association of Central Cancer Registries database, which covers 93% of the United States and well-represents the rural United States (North American Association of Central Cancer Registries 14.6% rural vs United States 14.8% rural).³.

Declining US Hepatocellular Carcinoma Rates, 2014-2017

Liver cancer is a prominent cause of cancer death in the United States.¹ Rates of hepatocellular carcinoma (HCC), the most common histologic subtype,² increased for decades,³ until recent years when rates flattened,⁴ and then potentially declined. Previously, we reported that US HCC rates in 2016 were 4% lower than 2015⁵; however, it was unclear from those data whether that finding reflected a true downward trend. Here, we examine HCC rates through 2017.

Ethnic Minorities and Low Socioeconomic Status Patients With Chronic Liver Disease Are at Greatest Risk of Being Uninsured

Background

Chronic liver disease (CLD) predominantly affects ethnic minorities and socially vulnerable populations, who have high prevalence of risk factors (e.g., suboptimal insurance coverage) predisposing to healthcare disparities. We evaluate prevalence and predictors of uninsured status among CLD adults, and secondarily, how this affects documented immunity or vaccination for hepatitis A virus (HAV) and hepatitis B virus (HBV).

Methods

Using 2011 - 2018 National Health and Nutrition Examination Survey data, self-reported insurance status was determined among adults with CLD. Prevalence of uninsured status was stratified by patient characteristics and evaluated using multivariable logistic regression models. Prevalence of self-reported completion of vaccination as well as laboratory value-based documented immunity to HAV and HBV was stratified by insurance status.

Results

Overall, 19.0% of adults with CLD reported having no insurance, which was highest among individuals of Hispanic ethnicity (33.5%), less than high school education (33.7%), and below poverty status (35.3%). On multivariable analyses, significantly lower odds of having any insurance coverage was observed in men, Hispanics, and individuals with lower education and lower household income. Prevalence of documented immunity or vaccination for HAV was low across all insurance categories, ranging from 46.5% to 54.0%. Prevalence of documented immunity or vaccination for HBV was similarly low across all insurance categories, ranging from 24.3% to 40.8%.

Conclusion

Prevalence of uninsured status among CLD was more than twice the US adult population, and lack of insurance particularly impacted Hispanics and individuals with low education and low household income. Low prevalence of documented immunity or vaccination for HAV and HBV across all insurance categories is concerning.

Prevalence and Correlates of SARS CoV-2 Among a Community-Based Sample Recruited Using Randomized Venue-Based Sampling. Essex County, NJ, 2020

Disparities in morbidity and mortality related to COVID-19 based on race and ethnicity have been documented in the USA. However, it is unclear if these disparities also exist at the exposure stage. To determine this, studies are needed to document the underlying burden of disease, potential disparities through serologic surveillance. Additionally, such studies can help identify where along the disease spectrum (e.g., exposure, infection, diagnosis, treatment, death) and with regard to the structural factors that necessitate public health and/or clinical interventions. Our objectives in this study were to estimate the true burden of SARS CoV-2 in the community of Essex County, NJ, an early and hard hit area, to determine the correlates of SARS CoV-2 prevalence and to determine if COVID-19 disparities seen by race/ethnicity were also reflected in SARS CoV-2 burden. We utilized venue-based-sampling (VBS) to sample members of the community in Essex County. Participants completed a short electronic survey and provided finger stick blood samples for testing. We sampled 924 residents of Essex County, New Jersey. Testing conducted in this study identified 83 (9.0%) participants as positive for SARS-CoV-2 antibodies. Importantly, our findings suggest that the true burden of SARS-Cov-2 and the pool of persons potentially spreading the virus are slightly more than six times than that suggested by PCR testing Notably, there were no significant differences in odds of testing positive for SARS CoV-2 antibodies in terms of race/ethnicity where we compared Black and Latinx participants to other race participants. Our study suggests that disparities in COVID-19 outcomes stem from potential upstream issues such as underlying conditions, access to testing, and access to care rather than disparities in exposure to the virus.