Socioeconomic Factors Affect Disparities in Access to Liver Transplant for Hepatocellular Cancer

Objective. The incidence/death rate of hepatocellular cancer (HCC) is increasing in America, and it is unclear if access to care contributes to this increase. Design/Patients. 575 HCC cases were reviewed for demographics, education, and tumor size. Main Outcome Measures. Endpoints to determine access to HCC care included whether an eligible patient underwent liver transplantation. Results. Transplant patients versus those not transplanted were younger (55.7 versus 61.8 yrs, ), males (89.3% versus 74.4%, ), and having completed high school (10.1% versus 1.2%, ). There were differences in transplant by ethnicity, insurance, and occupation. Transplant patients with HCC had higher median income via census classification ($54,383 versus $49,383, ) and self-reported income ($48,948 versus $38,800, ). Differences in access may be related to exclusion criteria for liver transplant, as Pacific Islanders were more likely to have tumor size larger than 5？cm compared to Whites and have BMI > 35 (20.7%) compared to Whites (6.4%) and Asians (4.7%). Conclusions. Ethnic differences in access to transplant are associated with socioeconomic status and factors that can disqualify patients (advanced disease/morbid obesity). Efforts to overcome educational barriers and screening for HCC could improve access to transplant. 1. Introduction Hepatocellular cancer is the fifth most common cancer worldwide and is the fifth leading cause of cancer death in males in the USA. Although cancer incidence in the USA is generally decreasing, HCC is one of a few cancers that is increasing in incidence and death rate [1, 2]. The best treatment for long-term disease-free survival with hepatocellular cancer is liver transplantation. Those who qualify for liver transplant must have localized disease, not amenable to surgical resection, and access to donor livers. Because of limited donor livers, criteria have been developed to transplant those patients with HCC who have the best prognosis. The recommended criteria include tumor characteristics—specifically Milan criteria with a single tumor less than 5？cm or 3 tumors all less than 3？cm and without evidence of vascular invasion or extrahepatic spread of tumor [3, 4]. There are also other criteria for liver transplant that relate to the presence of other medical comorbidities, psychosocial factors, and the ability to finance the transplant procedure. Some of the latter criteria vary from center to center, but all centers aim to transplant those patients who are a reasonable operative risk and who demonstrate adequate compliance, psychosocial