Does where you live matter?: State-level variation in liver cancer mortality.

Abstract

e16344 Background: In the United States, liver cancer is among the most lethal cancers, highlighting the need for improved systems of care. Survival for patients with liver cancer may vary by state of residence, and factors related to this difference remain unexplored. The objective of this study was to assess differences in mortality for liver cancer by state and examine factors associated with any observed variation in mortality. Methods: Age-adjusted liver cancer incidence and mortality rates for 2022 were obtained for 50 U.S. states and the District of Columbia from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER). Liver cancer was defined using ICD-10 codes and included hepatocellular carcinoma and intrahepatic cholangiocarcinoma. For each state, the mortality to incidence ratio (MIR) was calculated as age-adjusted mortality divided by incidence. The state with the lowest MIR was designated as the top-performer and used as a benchmark. Delta MIR (dMIR) was defined as the difference between a state’s MIR and the benchmark. Variation in cancer mortality relative to incidence was visually depicted using heatmaps. Factors associated with mortality variation were examined using Spearman correlation analyses of 12 publicly available, state-level economic and health system indicators, such as healthcare expenditure per capita, insurance coverage and life expectancy. Weighted linear regression analyses were subsequently performed using inverse-variance weights from dMIR standard errors. Results: The median dMIR was 0.142, with wide state-level variation ranging from 0.005 to 0.501, representing an approximately 96-fold difference between the lowest and highest dMIR. New York demonstrated the best performance with the lowest MIR and served as the benchmark. Maine, Utah and Minnesota ranked as the next top 3 performers. In contrast, the highest dMIR values, indicating the greatest excess mortality, were observed in North Dakota (0.400), Rhode Island (0.403), and South Dakota (0.501), ranking these as the worst performing states for liver cancers. Univariate analysis showed that higher dMIR (worse performance) was significantly associated with higher percentage of minority population (p = 0.009) and fewer cancer centers (p = 0.025). In multivariable analysis, higher dMIR was significantly associated with lower health expenditure per capita (p = 0.046), lower life expectancy (p = 0.006) and higher percentage of minority population (p = 0.046). Conclusions: Liver cancer mortality outcomes vary substantially across states, with some states outperforming others. dMIR can be used as a benchmarking tool to explain geographic disparity and guide targeted cancer control efforts and policy interventions to improve mortality outcomes. Our study suggests that lower investment in public health infrastructure is associated with higher relative mortality for liver cancer.