Socioeconomic And Survival Differences Among Minorities With Hepatocellular Carcinoma In Florida

Figures & data

Figure 1 Study flow diagram.

Abbreviations: ICD-10, International Classification of Disease; ICD-O-3, International Classification of Diseases for Oncology; NOS, not otherwise specified.

Table 1 Baseline Characteristics Of The Overall Sample And The Sample Stratified By Race

	Overall (n = 10852)	Stratified By Race
		Black	White	Hispanic	Asian	Other	p value^‡
		(n = 1420)	(n = 7282)	(n =1708)	(n = 346)	(n =96)
Male, n (%)^†	8388	1065	5782	1229	243	69	<0.001
	(77.4)	(75)	(79.5)	(72)	(70.2)	(73.4)
Age at Diagnosis, years Median (IQR)	63	59	63	64	63	63	<0.001
	(56-73)	(53-66)	(56-73)	(57-74)	(55-72)	(55.5-73)
Payer, n (%)
Medicaid	1285 (11.8)	301 (21.2)	679 (9.3)	255 (14.9)	43 (12.4)	7 (7.3)	<0.001
Private	2425 (22.4)	318 (22.4)	1627 (22.3)	355 (20.8)	94 (27.2)	31 (32.3)
Medicare	4999 (46.1)	464 (32.7)	3599 (49.4)	775 (45.4)	121 (35)	40 (41.7)
Uninsured	805 (7.4)	165 (11.6)	455 (6.3)	138 (8.1)	40 (11.6)	7 (7.3)
Military/Tricare	101 (0.9)	14 (1)	64 (0.9)	10 (0.6)	11 (3.2)	2 (2.1)
VA	196 (1.8)	34 (2.4)	137 (1.9)	24 (1.4)	0	1 (1)
IPHS	43 (0.4)	12 (0.9)	21 (0.3)	7 (0.4)	3 (0.9)	0
Insurance NOS	638 (5.9)	74 (5.2)	456 (6.3)	85 (5)	20 (5.8)	3 (3.1)
Unknown	360 (3.3)	38 (2.7)	244 (3.4)	59 (3.5)	14 (4.1)	5 (5.2)
Married, n (%)	5624 (51.8)	518 (36.5)	3916 (53.8)	903 (52.9)	245 (70.8)	42 (43.8)	<0.001
Current Tobacco, n (%)	2277 (21)	339 (23.9)	1628 (22.4)	255 (14.9)	42 (12.1)	13 (13.5)	<0.001
Tumor Size, mm Median (IQR)	49 (30-80)	54 (32-90)	47 (30-78)	48 (30-74)	60 (35-95)	42 (26-65)	<0.001
Tumor Grade, n (%)
Grade I (Well)	1909 (17.6)	218 (15.4)	1333 (18.3)	282 (16.5)	60 (17.3)	16 (16.7)	0.001
Grade II (Moderately)	1778 (16.4)	211 (14.9)	1237 (17)	254 (14.9)	64 (18.5)	12 (12.5)
Grade III (Poorly)	860 (7.9)	153 (10.8)	542 (7.4)	124 (7.3)	34 (9.8)	7 (7.3)
Grade IV (Undifferentiated)	82 (0.8)	10 (0.7)	54 (0.7)	14 (0.8)	3 (0.9)	1 (1)
Unknown	6223 (57.3)	828 (58.3)	4116 (56.5)	1034 (60.5)	185 (53.5)	60 (62.5)
SEER Stage 2000 n (%)
Localized	4785(44.1)	532 (37.5)	3264 (44.8)	774 (45.3)	166 (48)	49 (51)	<0.001
Regional-direct extension	2391 (22)	346 (24.4)	1594 (21.9)	368 (21.6)	69 (20)	14 (14.6)
Regional-lymph nodes only	216 (2)	33 (2.3)	144 (2)	38 (2.2)	1 (0.3)	0
Regional-direct + lymph nodes	218 (2)	29 (2)	150 (2.1)	33 (1.9)	4 (1.2)	2 (2.1)
Distant	1614 (14.9)	257 (18.1)	1038 (14.3)	254 (14.9)	55 (15.9)	10 (10.4)
Unstaged	1628 (15)	223 (15.7)	1092 (15)	241 (14.1)	51 (14.7)	21 (21.9)
Metastasis at Diagnosis, n (%)
None	7975 (73.5)	993 (69.9)	5425 (74.5)	1248 (73.1)	238 (68.8)	71 (74)	0.01
Distant	1540 (14.2)	240 (16.9)	990 (13.6)	245 (14.3)	55 (15.9)	10 (10.4)
Periduodenal	16 (0.2)	5 (0.4)	8 (0.1)	3 (0.2)	0	0
Unknown	1321 (12.2)	182 (12.8)	859 (11.8)	212 (12.4)	53 (15.3)	15 (15.6)
AFP at Diagnosis, n (%)
Elevated	2530 (23.3)	409 (28.8)	1580 (21.7)	427 (25)	94 (27.2)	20 (20.8)	<0.001
Normal	589 (5.4)	59 (4.2)	435 (6)	72 (4.2)	19 (5.5)	4 (4.2)
Borderline	13 (0.1)	0	10 (0.1)	2 (0.1)	1 (0.3)	0
Unknown	7720 (71.1)	952 (67)	5257 (72.2)	1207 (70.7)	232 (67.1)	72 (75)
Surgery Performed, n (%)
None	8402 (77.4)	1174 (82.7)	5639 (77.4)	1262 (73.9)	255 (73.7)	72 (75)	<0.001
RFA	593 (5.5)	53 (3.7)	381 (5.2)	136 (8)	17 (4.9)	6 (6.3)
Local destruction, not RFA	150 (1.4)	19 (1.3)	102 (1.4)	25 (1.5)	2 (0.6)	2 (2.1)
Resection	722 (6.7)	92 (6.5)	493 (6.8)	88 (5.2)	41 (11.9)	8 (8.3)
Hepatectomy NOS	58 (0.5)	8 (0.6)	37 (0.5)	7 (0.4)	4 (1.2)	2 (2.1)
Transplant	784 (7.2)	57 (4)	544 (7.5)	158 (9.3)	20 (5.8)	5 (5.2)
Bile duct excision ±	5 (0.1)	0	3 (0.04)	1 (0.1)	1 (0.3)	0
hepatectomy*	34 (0.3)	2 (0.1)	19 (0.3)	9 (0.5)	3 (0.9)	1(1)
Surgery NOS	104 (1)	15 (1.1)	64 (0.9)	22 (1.3)	3 (0.9)	0
Unknown
Time to 1^st surgery, days	43	39	47	39	33.5	42.5	0.19
Median (IQR)	(5-88.5)	(1-82)	(9-90)	(0-86)	(5-74)	(0.5-94.5)
Chemotherapy, n (%)	3529 (32.5)	452 (31.8)	2365 (32.5)	562 (32.9)	112 (32.4)	38 (39.6)	0.63
Radiation, n (%)	659 (6.1)	72 (5.1)	488 (6.7)	70 (4.1)	26 (7.5)	3 (3.1)	0.01
Treatment Status, n (%)
No treatment given	1893 (17.4)	279 (19.7)	1255 (17.2)	307 (18)	41 (11.9)	11 (11.5)	<0.001
Treatment given	5909 (54.5)	703 (49.5)	3976 (54.6)	961 (56.3)	209 (60.4)	60 (62.5)
Active surveillance	62 (0.6)	9 (0.6)	42 (0.6)	9.7 (0.4)	3 (0.9)	2 (2.1)
Unknown	2988 (27.5)	429 (30.2)	2009 (27.6)	434 (25.4)	93 (26.9)	23 (24)
Time to Treatment, days	37 (14-69)	35 (11-71)	39 (16-69)	35 (11-71)	29 (8-59.5)	25 (7-60)	0.02
Median (IQR)
No evidence of cancer, n (%)	1549 (14.3)	137 (9.7%)	1072 (14.7%)	259 (15.2%)	62 (17.9%)	19 (19.8%)	<0.001
Alive at 1 Year, n (%)	5639 (52%)	647 (45.6%)	3790 (52.1%)	946 (55.4%)	201 (58.1%)	55 (57.3%)	<0.001
Alive at 3 Years, n (%)	4227 (39)	487 (34.3%)	2856 (39.2%)	668 (39.1%)	166 (48%)	50 (52.1%)	<0.001
Alive at 5 Years, n (%)	3945 (36.4)	450 (31.7%)	2655 (36.5%)	631 (36.9%)	160 (46.2%)	49 (51%)	<0.001
Alive at 10 Years, n (%)	3854 (35.5)	443 (31.2%)	2587 (35.5%)	618 (36.2%)	158 (45.7%)	48 (50%)	<0.001
Survival, days	169 (54-442)	136 (43-370)	171 (55-442)	208 (63-518)	158 (57-427)	136 (33-284)	<0.001
Median (IQR)
Birth Continent, n (%)
North America	3582 (33)	503 (35.4)	2879 (39.5)	152 (8.9)	34 (9.8)	14 (14.6)
Caribbean	741 (6.8)	188 (13.2)	26 (0.4)	521 (30.5)	2 (0.6)	4 (4.2)
Central America	86 (0.8)	7 (0.5)	4 (0.1)	74 (4.3)	1 (0.3)	0
South America	140 (1.3)	6 (0.4)	13 (0.2)	120 (7)	1 (0.3)	0	<0.001
Europe	133 (1.2)	1 (0.1)	123 (1.7)	8 (0.5)	0	1 (1)
Africa	14 (0.1)	5 (0.4)	5 (0.1)	0	0	4 (4.2)
Asia	216 (2)	1 (0.1)	26 (0.4)	1 (0.1)	180 (52)	8 (8.3)
Australia	4 (0.04)	0	4 (0.1)	0	0	0
Unreported	5936 (54.7)	709 (49.9)	4202 (57.7)	832 (48.7)	128 (37)	65 (67.7)

Notes: ^†Percentages based on respondents with non-missing data. ^‡p-values calculated using Wilcoxon rank-sum and Kruskal–Wallis tests for continuous variables and Pearson’s chi-square for categorical variables. * Bile duct excision ± hepatectomy is another way to code transplant, however since we cannot confirm that these persons received transplant, the data are provided separately.

Abbreviations: AFP, alpha-fetoprotein; IPHS, Indian Public Health Service; IQR, interquartile range, mm = millimeter; NOS, not otherwise specified; RFA, Radiofrequency ablation; SEER, Surveillance, Epidemiology, and End Results Program; VA, Veteran’s Administration.

Table 2 Selected Population Characteristics Of The Overall Sample And The Sample Stratified By Race

Behavioral Risk Factor Surveillance System (BRFSS)
	Overall	Black	White	Hispanic	Asian	Other	p value
	(n = 10852)	(n = 1420)	(n = 7282)	(n = 1708)	(n = 346)	(n = 96)
% with high cholesterol^†	33.6	33.1	36.2	27.8	33.2	33.4	<0.001
	(28.4-38.2)	(27.8-37.1)	(30.4-38.4)	(27.8-33.4)	(28.4-37.4)	(28.4-37.7)
% with prediabetes	7.2	7.7	7.6	4.7	7.8	7	<0.001
	(5.6-8.6)	(4.7-8.6)	(6.8-8.6)	(4.7-7.8)	(6.9-8.6)	(5.9-8.6)
% with diabetes	11	10.7	11	8.9	10.7	11.5	<0.001
	(9.7-12.4)	(8.9-12.4)	(9.8-12.4)	(8.9-11)	(9.7-12.4)	(9.7-12.4)
% of diabetics with diabetes education	47.9	46.6	50.6	39.6	47.9	46.2	<0.001
	(44.3-54.4)	(44.3-56)	(45.2-55.7)	(35.9-46.6)	(45.2-54.4)	(42-54.3)
% overweight	36.2	36.2	35.7	39.8	36.2%	36.6	<0.001
	(34.7-38.6)	(34.8-39.8)	(34.6-38)	(36.2-39.8)	(34.8-38.2)	(34.8-38.2)
% obese	25.6	25.8	25.8	23.8	25.6	25.8	<0.001
	(24.1-29.3)	(23.8-29.3)	(24.4-29.3)	(23.8-25.8)	(24.1-29.2)	(24.1-29.3)
% healthy weight	35.1	35	35.8	35	35.8	35	<0.001
	(32.7-36.8)	(31-36.8)	(31.6-36.8)	(35-35.8)	(32.7-36.8)	(31-36.8)
% binge or heavy alcohol	18	18.2	17.5	18.2	18.2	17.8	<0.001
	(15.3-19)	(15.4-19)	(15.1-19.2)	(17-18.2)	(15.3-19.6)	(15.3-19)
% who currently smoke	17.9	16	18.2	14	18.1	18.2	<0.001
	(14-19.4)	(14-18.2)	(14-19.5)	(14-18.2)	(14-19.4)	(14-19.4)
% mammogram in past year	58.5	58.5	57.4	64	56.9	57.4	<0.001
	(52.6-62.7)	(52.8-64)	(51.6-62)	(53-64)	(52.6-61.4)	(52.6-62.4)
% pap smear in past year	52.1	53.8	51.7	53.8	53.8	51.7	<0.001
	(47.5-55.2)	(51.4-56.2)	(47-55.2)	(51.4-53.8)	(50.2-55.5)	(47-54.7)
% with stool test in past year	13.6	12.9	13.4	16.9	12.3	14.1	<0.001
	(10.8-16.9)	(8.9-16.9)	(10.8-16.9)	(12-16.9)	(8.9-16.9)	(12-16.9)
% with colonoscopy in past 5 years	54.6	53.7	55.8	50.7	53.7	53.7	<0.001
	(51.2-59.4)	(50.7-60.3)	(53.4-59.7)	(50.7-53.7)	(51-59.4)	(51.2-57.1)
% in poor health	14.2	14.2	14.1	15.5	13.4	14.2	<0.001
	(12.9-15.5)	(12.9-15.5)	(12.9-15.3)	(12.9-15.5)	(12.4-15.3)	(12.9-15.5)
Days where physical or mental health interfere with activity in the past 30 days	5.1	5	5.1	5.4	5	5.1	<0.001
	(4.7-5.4)	(4.7-5.4)	(4.7-5.7)	(4.7-5.4)	(4.7-5.4)	(4.7-5.4)
2010-2014 US Census American Community Survey—Selected Economic Characteristics
% of families/people with income below poverty level^‡	10.7	11.1	10.4	11.9	10.7	10.6	<0.001
	(5.4-18.6)	(5.9-19.5)	(5.2-17.6)	(5.6-21.1)	(5.7-19.8)	(5.3-19.6)
Neighborhood							<0.001
poverty*, n (%)	2681 (24.7)	300 (21.1)	1894 (26)	378 (22.1)	83 (24)	26 (27.1)
1^st (Least Poverty)	2653 (24.5)	352 (24.8)	1822 (25)	372 (21.8)	88 (25.4)	19 (19.8)
2^nd Quartile	2673 (24.6)	376 (26.5)	1788 (24.6)	409 (24)	77 (22.3)	23 (24)
3^rd Quartile	2660 (24.5)	374 (26.3)	1655 (22.7)	517 (30.3)	89 (25.7)	25 (26)
4^th (Greatest Poverty) Unknown Poverty Level	185 (1.7)	18 (1.3)	123 (1.7)	32 (1.9)	9 (2.6)	3 (3.1)
Mean household income, US dollars	57231	57231	57851	55268	58654	57658	<0.001
	(45597-77839)	(46239-74223)	(46472-78989)	(42635-77281)	(46662-79785)	(45129-91299)
% with food stamps/SNAP in last 12 months	12.1	12.7	11.4	13.9	12.9	10.8	<0.001
	(6.1-21.8)	(7.1-22.7)	(5.8-20.3)	(6.5-27.5)	(5.9-24.6)	(4.7-21.7)
% with no health insurance	18.1	19	17.5	21.1	18.3	18.8	<0.001
	(12.2-25.8)	(13-27)	(11.8-24.3)	(13.3-31.1)	(12.7-27.5)	(10.2-27.2)
% with cash public assistance in last 12 months	1.8	1.6	1.8	1.7	1.7	1.3	0.08
	(0.8-3.1)	(0.8-3.1)	(0.8-3.1)	(0.6-3.1)	(0.8-2.9)	(0.8-3)
% Unemployed- Civilian	10.4	10.6	10.3	10.5	10.3	10.9	0.58
	(7-14.6)	(7.2-14.7)	(7-14.4)	(6.8-15.1)	(7.4-15)	(6.8-14.3)

Notes: †For BRFSS Variables, all results are reported as median (interquartile range) unless otherwise specified and can be interpreted as follows: In the counties where Blacks with HCC lived, 33.1% (median percentage) of adults reported a diagnosis of high cholesterol. ‡For Census variables, all results are reported as median (interquartile range) and can be interpreted as follows: In the census tracts where Blacks with HCC lived, 11.1% of families/people had income below the poverty level. *Quartiles were created using the percentage of families/peoples with income below poverty level.

Abbreviation: SNAP, Supplemental Nutrition Assistance Program.

Figure 2 Geographic distribution of HCC cases throughout Florida, unadjusted for population density. Regions in red have the highest raw number of HCC cases.

Figure 3 Kaplan–Meier curves (A) stratified by race/ethnicity and (B) stratified by race/ethnicity and adjusted for gender, age at diagnosis, insurance type, SEER Summary Tumor Stage, surgery type, and treatment status.

Table 3 Factors Associated With Survival On Univariate And Multivariate Analysis

	Univariate Analysis			Multivariate Analysis
	Hazard Ratio	95% CI	p Value	Hazard Ratio	95% CI	p Value
Race/Ethnicity
Hispanic	Referent			Referent
White	1.07	1–1.14	0.04		1.02–1.17	0.02
Black	1.29	1.18–1.4	<0.001	1.09	1.07–1.29	0.001
Asian	0.94	0.8–1.1	0.43	1.171.01	0.85–1.21	0.89
Unknown	1.02	0.75–1.39	0.89	1.29	0.97–1.72	0.08
Age at Diagnosis	1.01	1.01–1.01	<0.001	1.01	1.01–1.01	<0.001
Gender
Female	Referent			Referent
Male	1.15	1.08–1.21	<0.001	1.13	1.06–1.21	<0.001
Hermaphrodite	2.68	1.79–4.02	<0.001	1.72	0.86–3.47	0.13
Payer
Uninsured	Referent	0.71–0.9	<0.001	Referent	0.78–1.01	0.08
Medicaid	0.80	0.5–0.63	<0.001	0.89	0.67–0.86	<0.001
Private	0.56	0.67–0.82	<0.001	0.76	0.71–0.90	<0.001
Medicare	0.74	0.46–0.81	0.001	0.79	0.61–1.03	0.08
Military/Tricare	0.61	0.57–0.82	<0.001	0.79	0.58–0.89	0.002
VA	0.68			0.72
Indian Public Health Service	0.93	0.66–1.3	0.65	0.96	0.69–1.33	0.8
Insurance NOS	0.6	0.52–0.7	<0.001	0.82	0.7–0.96	0.01
Unknown	0.69	0.59–0.81	<0.001	0.63	0.52–0.76	<0.001
SEER Stage 2000	Referent
Localized				Referent
Regional-direct extension (DE)	1.72	1.61–1.83	<0.001	1.53	1.43–1.64	<0.001
Regional-lymph nodes (LN)	1.58	1.35–1.87	<0.001	1.28	1.08–1.51	0.004
Regional (DE & LN)	2.50	2.14–2.92	<0.001	2.19	1.86–2.57	<0.001
Distant	3.44	3.21–3.7	<0.001	2.5	2.32–2.7	<0.001
Unstaged	1.97	1.84–2.12	<0.001	1.25	1.15–1.36	<0.001
Surgery Type
No surgery performed	Referent			Referent
Radiofrequency Ablation	0.38	0.34–0.42	<0.001	0.69	0.62–0.77	<0.001
Local destruction, not RFA	0.5	0.41–0.61	<0.001	0.87	0.71–1.08	0.21
Resection	0.33	0.29–0.36	<0.001	0.59	0.53–0.66	<0.001
Hepatectomy NOS	0.21	0.13–0.33	<0.001	0.37	0.23–0.58	<0.001
Transplant	0.13	0.11–0.15	<0.001	0.25	0.22–0.29	<0.001
Bile duct excision ± hepatectomy*	0.11	0.02–0.78	0.03	0.21
Surgery NOS	0.42	0.29–0.6	-<0.001	0.74	0.03–1.31	0.1
Unknown	0.81	0.66-1	0.05	0.62	0.51–1.07	0.11
Treatment Status
No treatment given	Referent			Referent
Treatment given	0.33	0.31–0.36	<0.001	0.47	0.43–0.51	<0.001
Active surveillance	0.43	0.31–0.61	<0.001	0.52	0.37–0.73	<0.001
Unknown	1.08	0.99–1.17	0.08	1.12	1.03–1.22	0.01
Neighborhood Poverty
1^st Quartile (least poverty)	Referent
2^nd Quartile	0.99	0.93–1.06	0.88
3^rd Quartile	0.99	0.93–1.06	0.86
4^th Quartile	0.95	0.88–1.01	0.11
Unknown poverty level	0.94	0.78–1.14	0.53
Distance to Transplant Center
≤30 miles	Referent
31–60 miles	1.04	0.98–1.1	0.22
61.90 miles	1.04	0.95–1.14	0.42
91–120 miles	1.03	0.91–1.17	0.65
121–180 miles	1.17	0.99–1.37	0.07
181–240 miles	1.15	0.95–1.38	0.15
241–300 miles	1.22	0.04–1.44	0.02
>300 miles	1.18	0.93–1.5	0.18
Distance to Cancer Center
≤30 miles	Referent
31–60 miles	1	0.94–1.07	0.93
61–90 miles	0.89	0.84–0.95	<0.001
91–120 miles	0.94	0.87–1.12	0.13
121–180 miles	0.93	0.8–1.08	0.37
181–240 miles	1.1	0.91–1.33	0.33
241–300 miles	1.14	0.97–1.34	0.12
>300 miles	1.2	0.93–1.54	0.17

Notes: *Bile duct excision ± hepatectomy is another way to code transplant, however since we cannot confirm that these persons received transplant, the data are provided separately.

Abbreviations: NOS, not otherwise specified; RFA, radiofrequency ablation; SEER, Surveillance, Epidemiology and End Results Program; VA, Veteran’s Administration.