Disparities in stage at diagnosis for hepatocellular carcinoma according to race and ethnicity, neighborhood socioeconomic status, and insurance status; a population-based study in California, 2001-2020

Abstract

Stage at diagnosis is a key determinant of survival for patients with hepatocellular carcinoma (HCC). No study has concurrently assessed the impact of race, ethnicity, neighborhood socioeconomic status (nSES), and insurance status on stage of HCC diagnosis. We examined stage at diagnosis among 45,695 individuals with primary HCC from 2001-2020 with data from the California Cancer Registry. Multivariable, multinomial logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) of regional and distant stage at diagnosis (compared to localized) according to joint race/ethnicity, nSES, and insurance type; adjusted for age, sex, year of diagnosis, comorbidities, marital status and clustering by census tract. Race/ethnicity, nSES, and insurance type were independently associated with HCC stage in multivariable models. Compared to the NH White group, the NH Black group had higher odds of later stage compared to local stage diagnosis (OR distant=1.13, 95% CI=1.01, 1.26). Those with public or no insurance compared to private insurance had higher odds of later stage diagnosis (OR public insurance/distant stage=1.37, 95% CI=1.27, 1.49; OR no insurance/distant stage=2.78, 95% CI=2.37, 3.26). Lower nSES was associated with higher odds of late stage diagnosis (OR lowest compared to highest SES quintile/distant stage=1.46, 95% CI=1.32, 1.61). Stratified analyses highlight racial/ethnic groups for which underinsurance and/or low nSES increased the odds of distant stage diagnosis. Targeted, multilevel interventions would facilitate diagnosis of HCC at earlier stages and thus increase HCC survival for vulnerable groups defined by race, ethnicity, nSES, and insurance type.