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Alcohol and Low Health Literacy
Hamper Access to Curative Therapy for HCC
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AASLD 2023, The Liver Meeting, November 10-14, 2023, Boston
Mark Mascolini
Ongoing alcohol use and low health literacy cut chances of getting curative therapy for hepatocellular carcinoma (HCC) in a 139-person prospective cohort study [1]. African American people in this Indianapolis population shouldered a heavier burden of social determinants of health (SDOH) like these than did people of other races.
Since 2015, noted Lauren Nephew and Indiana University colleagues, incidence and mortality of HCC infection have dropped in the United States. But blacks and American Indian/Alaska Natives have not enjoyed those salutary trends. In addition, HCC mortality rates differ from one locale to the next, depending on level of socioeconomic deprivation. Limited prospective data on the impact of SDOH, especially individual SDOH, on HCC impede understanding of the dynamics behind these variables.
To identify factors associated with getting a liver transplant or surgical resection for HCC-and being alive or dead without a transplant or resection-the researchers created a cumulative burden score incorporating 7 characteristics that had at least one univariable pairwise P < 0.2 when tested for impact on survival and curative therapy status: black race (not included when assessing cumulative burden score by race), income under $30,000 yearly, not married, Medicaid insurance, first (lowest) quartile of the BRIEF Health Literacy Score, education less than high school, and alcohol use in the last 90 days.
Among 207 eligible people with HCC, the researchers approached 164 to enter this study, of whom 139 agreed. Sixty-eight people were alive without a transplant, 44 had a transplant or surgical resection, and 27 died without a transplant. The study group averaged 64.0 years in age, 73.4% were men, 14.4% black, and 7.9% Hispanic. HCV infection in 46.5% of the study cohort led the list of underlying liver diseases, followed by nonalcoholic steatohepatitis (NASH) in 33.9% and alcoholic liver disease in 15.7%.
Follow-up continued for a median 386 days. Under half of the whole study group, 47.1%, had accurate knowledge of their liver disease. One in 5 cohort members, 21.6%, had an annual income below $15,000. A similar proportion, 20.9%, lived in a census tract more deprived than 93.5% of such tracts in the United States.
BRIEF Health Literacy Score averaged 8.3 in people who had died by the end of the study period, compared with 10.5 in people who got a liver transplant (P = 0.013). Among people alive without a transplant, almost one third, 30.9%, had used alcohol in the past 90 days, compared with 9.1% of people who got a liver transplant (P = 0.023). One bit of favorable news emerged: Median PROMIS instrumental social support T score stood at 64.9; that's 1.5 standard deviations better than age- and sex-adjusted national averages.
Cumulative burden score correlated inversely with the proportion of people getting a liver plant-the higher the cumulative score, the lower the proportion getting a transplant. Median cumulative burden score stood at 4.0 in blacks, 1.7 in whites, and 1.2 in people of other races (P < 0.001).
Multinomial logistic regression adjusted for BRIEF Health Literacy Score, alcohol use, alpha-fetoprotein tumor marker levels, income category, and race determined that higher health literacy boosted chances of getting a transplant versus dying (odds ratio [OR] 1.2, 95% confidence interval [CI] 1.03 to 1.39). Higher health literacy also favored being alive rather than dead (OR 1.2, 95% CI 1.04 to 1.38). Alcohol use in the past 90 days independently lowered chances of getting a transplant or resection versus being alive (OR 0.2, 95% CI 0.05 to 0.75). Multivariable Cox survival analysis singled out lower health literacy as the only SDOH associated with survival (hazard ratio 0.85, 95% CI 0.77 to 0.95, P = 0.004).
The Indiana investigators concluded that their urban HCC population carries a heavy SDOH load, and that load looks heavier in black people with HCC than in other races. Two individual SDOH-ongoing alcohol use and low health literacy-affect ability to access therapies that can cure HCC: liver transplant or surgical resection. The researchers stressed that the threatening social determinants they singled out "are modifiable from within health care systems and liver clinics."
Reference
1. Nephew LD, Rawl S, Carter A, et al. The social determinants of access to curative therapies for hepatocellular carcinoma: a prospective cohort study. AASLD 2023, The Liver Meeting, November 10-14, 2023, Boston.
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