Modality-Specific and Multilevel Barriers to Curative Treatment for Early-Stage Hepatocellular Carcinoma

Background: Patients with early-stage hepatocellular carcinoma (HCC) are eligible for potentially curative treatments, yet these therapies are underused in clinical practice. Methods: We conducted a retrospective cohort study of patients with treatment-naïve, early-stage HCC (within Milan Criteria) seen between January 2010 and July 2021 at two U.S. health systems. Barriers to curative treatment were identified through review of medical records. We used univariable and multivariable logistic regression to identify factors associated with curative treatment receipt. Results: Among 629 eligible patients with early-stage HCC (median age 60 years; 72.3% male), 396 (63.0%) received curative treatment. In multivariable analysis, evaluation at a tertiary care center was associated with higher odds of curative treatment (OR 2.95, 95%CI 1.98-4.47). In contrast, having Medicaid (OR 0.27, 95%CI 0.14-0.53), being enrolled in a county-based subsidy program (OR 0.31, 95%CI 0.16-0.58), or being uninsured (OR 0.24, 95%CI 0.11-0.50) were associated with lower odds of curative treatment compared to private insurance. Other factors inversely associated with curative treatment included multifocal disease (OR 0.49, 95%CI 0.31-0.75), increasing tumor size (continuous: OR 0.73, 95%CI 0.60-0.88), and worse liver function (Child Pugh B vs A: OR 0.27, 95%CI 0.18-0.40; Child Pugh C vs A: OR 0.13, 95%CI 0.07-0.24). Common barriers to liver transplantation included lack of insurance, medical comorbidities, and psychosocial challenges. Common barriers to resection and ablation included comorbidities and unfavorable tumor location, respectively. Conclusion: Underuse of curative treatment for early-stage HCC is mediated by tumor-specific, clinical and system-level factors, underscoring a need for multi-level interventions to address identified barriers.