Department of Surgical Oncology, Unit 1484, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
Surgical and Perioperative Care, Atlanta VA Health Care System, Decatur, GA, USA.
Ann Surg Oncol. 2023 Nov;30(12):7309-7318. doi: 10.1245/s10434-023-14132-9. Epub 2023 Sep 7.
Low socioeconomic status (SES) patients with early-stage hepatocellular carcinoma (HCC) receive procedural treatments less often and have shorter survival. Little is known about the extent to which these survival disparities result from treatment-related disparities versus other causal pathways. We aimed to estimate the proportion of SES-based survival disparities that are mediated by treatment- and facility-related factors among patients with stage I-II HCC.
We analyzed patients aged 18-75 years diagnosed with stage I-II HCC in 2008-2016 using the National Cancer Database. Inverse odds weighting mediation analysis was used to calculate the proportion mediated by three mediators: procedure type, facility volume, and facility procedural interventions offered. Intersectional analyses were performed to determine whether treatment disparities played a larger role in survival disparities among Black and Hispanic patients.
Among 46,003 patients, 15.0% had low SES, 71.6% had middle SES, and 13.4% had high SES. Five-year overall survival was 46.9%, 39.9%, and 35.7% among high, middle, and low SES patients, respectively. Procedure type mediated 45.9% (95% confidence interval [CI] 31.1-60.7%) and 36.7% (95% CI 25.7-47.7%) of overall survival disparities for low and middle SES patients, respectively, which was more than was mediated by the two facility-level mediators. Procedure type mediated a larger proportion of survival disparities among low-middle SES Black (46.6-48.2%) and Hispanic patients (92.9-93.7%) than in White patients (29.5-29.7%).
SES-based disparities in use of procedural interventions mediate a large proportion of survival disparities, particularly among Black and Hispanic patients. Initiatives aimed at attenuating these treatment disparities should be pursued.
患有早期肝细胞癌（HCC）的社会经济地位（SES）较低的患者接受治疗的频率较低，且生存期较短。对于这些生存差异在多大程度上是由于治疗相关差异还是其他因果途径造成的，人们知之甚少。我们旨在估计在 I 期-II 期 HCC 患者中，SES 相关生存差异中有多少是由与治疗和设施相关的因素介导的。
我们使用国家癌症数据库分析了 2008 年至 2016 年期间诊断为 I 期-II 期 HCC 的年龄在 18-75 岁的患者。采用逆概率加权中介分析来计算三种中介变量（手术类型、设施数量和提供的设施手术干预）介导的比例。进行交叉分析以确定治疗差异在黑人和西班牙裔患者的生存差异中是否发挥更大作用。
在 46003 名患者中，15.0%为低 SES，71.6%为中 SES，13.4%为高 SES。高、中、低 SES 患者的 5 年总生存率分别为 46.9%、39.9%和 35.7%。手术类型分别介导了低 SES 和中 SES 患者总体生存差异的 45.9%（95%置信区间[CI]31.1-60.7%）和 36.7%（95% CI 25.7-47.7%），这超过了两个设施水平中介变量的介导作用。手术类型在低 SES 和中 SES 的黑人和西班牙裔患者（46.6-48.2%和 92.9-93.7%）中介导的生存差异比例大于白种人患者（29.5-29.7%）。
SES 相关的手术干预使用差异很大程度上介导了生存差异，尤其是在黑人和西班牙裔患者中。应采取措施减少这些治疗差异。
