Influence of social determinants of health on timeliness to treatment for metastatic HCC and the impact of affordable care act

OBJECTIVE: To achieve progress in cancer treatment, socioeconomic disparities impacting the care need to be recognized and addressed. We hypothesized that social determinants of health may predict a delay in systemic therapy for metastatic hepatocellular carcinoma patients (HCC) and sought to examine the impact of the Affordable Care Act (ACA). PATIENTS AND METHODS: National Cancer Database (NCDB) was queried for patients with metastatic hepatocellular carcinoma diagnosed from 2004-2015 and considered for first line systemic therapy within 6 months (180 days) of diagnosis. Time to initiation (TTI) was defined as the time in days (d) from diagnosis of cancer to initiation of systemic therapy. Survival was measured in months (m) from the day of diagnosis. Multivariate analyses were performed using 2010 as a cut-off between pre-and post-ACA for analysis. RESULTS: 630 patients meeting the eligibility criteria. Median TTI in the group was 57d. The only factor associated with delayed TTI (defined as the fourth quartile of TTI) in a multivariate logistic regression was non-Hispanic Black (NHB) race Odds Ratio OR 1.94 (95% CI 1.0–3.3), p-value=0.052. The OR showed improvement with implementation of ACA – OR 3.6 (95% CI 1.4-9.4), p-value 0.008 during pre-ACA vs. 1.3 (0.5-3.1), p-value=0.6 post-ACA. There was a non-significant trend towards higher mortality among NHB vs. NHW (HR 1.2, 95% CI 1.0-1.6) and lower mortality for those insured vs. uninsured (HR 0.8, 95% CI 0.5-1.1). CONCLUSIONS: Race appears to impact timeliness to therapy in metastatic HCC patients and was positively impacted by ACA. Continued research to monitor disparities in care and identify underlying mechanisms to mitigate them are warranted.