Invited Commentary: Disparities in the Receipt of Recommended Curative Treatment for Patients with Early-Stage Hepatocellular Carcinoma

Background In early-stage hepatocellular carcinoma (HCC), the receipt of recommended care is critical for long-term survival. Unfortunately, not all patients decide to undergo therapy. We sought to identify factors associated with the decision to decline recommended intervention among patients with early-stage HCC. Methods The National Cancer Database was queried for patients diagnosed with clinical stages I and II HCC (2004–2017). Cohorts were created based on the receipt or decline of recommended interventions–hepatectomy, liver transplantation, and ablation. Multivariable logistic regression identified predictors for declining intervention, and propensity score analysis was used to calculate the respective odds. Survival analysis was performed using the Kaplan–Meier method. Results Of 20,863 patients, 856 (4.1%) declined intervention. Patients who were documented as having declined intervention were more often Black (vs. other: OR, 1.3; 95% CI, 1.1–1.6; p = 0.0038), had Medicaid or no insurance (vs. Private, Medicare, or other government insurance): OR, 1.9; 95% CI, 1.6–2.3; p < 0.0001), lived in a low-income area (vs. other: OR, 1.4; 95% CI, 1.2–1.7; p < 0.0001), and received treatment at a non-academic center (vs. academic: OR, 2.1; 95% CI, 1.9–2.5; p < 0.0001). Patients who declined recommended interventions had worse survival compared to those who received treatment (22.9 vs. 59.2 months; p < 0.0001, respectively). Conclusions Racial and socioeconomic disparities persist in the decision to undergo recommended treatment. Underutilization of treatment acts as a barrier to addressing racial and socioeconomic disparities in early-stage HCC outcomes.