Socioeconomic disparities in access to and outcomes of liver transplantation (LT) for hepatocellular carcinoma (HCC).

Abstract

e16337 Background: HCC is a leading indication for liver transplantation (LT) and a major contributor to cancer-related mortality worldwide. Access to LT is often shaped by social determinants of health, including insurance status, employment, and geographic region, which can impact waitlist duration and post-transplant survival. Methods: We retrospectively analyzed 20,492 adult patients with HCC listed for LT in the United Network for Organ Sharing (UNOS) database. Socioeconomic variables assessed at registration included highest education level, employment status, and primary payer type (public vs. private insurance). We used multivariable logistic regression, adjusted for clinical covariates, to examine associations between these factors and (1) waitlist duration and (2) post-transplant survival. Results: Patients with public insurance had longer median wait times (7.9 vs. 7.2 months, p < 0.01) and shorter post-transplant survival (37.3 vs. 44.9 months, p < 0.01) compared with those with private insurance. Male sex was independently associated with worse survival (HR 1.15, 95% CI 1.06–1.25, p < 0.01). Compared with White patients, African American patients had an increased risk of mortality (HR 1.19, 95% CI 1.07–1.33, p < 0.01), while Hispanic (HR 0.90, 95% CI 0.82–0.99, p = 0.03) and Asian (HR 0.69, 95% CI 0.59–0.81, p < 0.01) patients exhibited lower risks. Employment was protective factor of survival(HR 0.73, 95% CI 0.68–0.79, p < 0.01). Education level was not significantly associated with survival. Regional differences in median wait times were significant (p < 0.01), ranging from 8.9 months in the northeast region to 6.8 months in the south region. In patients undergoing two or more LTs, there was no significant difference in survival by sex (p = 0.59). Among males, employment rates decreased after the first LT (34.0% vs. 19.8%; p < 0.001), while among females, employment rates increased (22.0% vs. 85.1%; p < 0.001). Conclusions: Socioeconomic factors—particularly insurance status, employment, race/ethnicity, and region—continue to drive disparities in both access and survival outcome to LT for HCC. Targeted approaches, such as patient navigation services, expanded financial support, and systemic policy reforms, are critical to closing these gaps and improving patient outcomes.