Health literacy and cumulative social disadvantage are associated with survival and transplant in patients with hepatocellular carcinoma: a prospective study.

Objective: To investigate how individual social determinants of health (SDOH) and cumulative social disadvantage (CSD) affect survival and receipt of liver transplant (LT) in patients with hepatocellular carcinoma (HCC).
Methods: We enrolled 139 adult patients from two Indianapolis hospital systems between June 2019 and April 2022. Structured questionnaires collected SDOH and social risk factor data. We compared SDOH and CSD by race, gender and disease aetiology, assigning one point per adverse SDOH. Multivariable competing risk survival analysis assessed associations between SDOH, CSD, survival and LT receipt.
Results: Black patients experienced higher CSD than white patients in the cohort (5.4±2.5 vs 3.2±2.1, p<0.001). Black patients were significantly more likely to have household incomes <US$15 000 per year (52.6% vs 18.3%, p=0.003), to be insured by Medicaid (57.9% vs 33.0%, p=0.04), and to live in high Social Deprivation Index areas (68.4% vs 17.5%, p<0.001) than white patients. Patients with hepatitis C virus and alcohol-related liver disease had more adverse SDOH than those with metabolic dysfunction-associated steatotic liver disease, while there were no significant differences by gender. On multivariable analysis, a higher health literacy score was a significant predictor of survival (HR 2.54, 95% CI 1.19 to 5.43 CI, p=0.02) and higher CSD was associated with a lower probability of receipt of LT (HR 0.80, 95% CI 0.68 to 0.95, p=0.01).
Conclusions: There are significant racial and aetiology-related differences in SDOH burden. Low health literacy and high CSD are linked to worse outcomes in HCC patients. Health literacy screening and targeted interventions for those with high CSD could improve LT access and survival rates.
Competing Interests: Competing interests: NC has ongoing paid consulting activities (or had in preceding 12 months) with Madrigal, GSK, Ipsen, Pfizer, Merck and Zydus. These consulting activities are generally in the areas of non-alcoholic fatty liver disease and drug hepatotoxicity. NC receives research grant support from Exact Sciences and Zydus where his institution receives the funding. He has equity ownership in Avant Sante, a contract research organisation. Over the last decade, NC has served as a paid consultant to more than 35 pharmaceutical companies and these outside activities have regularly been disclosed to his institutional authorities. None of the aforementioned disclosures are related to the study. The other authors declare no relevant conflicts of interest.
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