Inequities in primary liver cancer in Europe: The State of Play

The liver cancer burden in Europe is increasing and to improve health outcomes equitably, it is crucial to investigate how social determinants of health (SDoH) affect liver cancer risk factors and access to care. This paper summarises the available evidence on the differential distribution of liver cancer risk factors, incidence, and health outcomes in the European Economic Area and the United Kingdom from an SDoH perspective. Vulnerable and marginalised populations have low socio-economic and educational backgrounds and are the most affected by liver cancer risk factors. Reasons for this include that access to hepatitis B virus vaccination varies, while viral hepatitis screening, harm reduction, and treatment access are limited. Additionally, alcohol-related liver disease remains prevalent among individuals with low education, insecure employment, economic instability, migrants, and deprived populations. Moreover, significant variation exists across Europe in the proportion of adults with steatotic liver disease, overweight/obesity, and diabetes, based on geographical area, gender, socio-economic, educational background, and density of ultra-processed foods outlets. Inequities in cirrhosis mortality rates have been reported, with the highest death rates among individuals living in socio-economically disadvantaged areas and those with lower educational levels. Furthermore, insufficient healthcare access for key populations with primary liver cancer is influenced by complex healthcare systems, stigmatisation, discrimination, low education, language barriers, and fear of disclosure. These challenges contribute to the liver cancer care pathway inequities. Future studies are needed to explore the different SDoH-interlinked effects on liver cancer incidence and outcomes in European countries. The ultimate goal is to develop evidence-based multilevel public health interventions that reduce the SDoH impact in precipitating and perpetuating a disproportionate liver cancer level among specific populations.