Study Underscores the Impact of Socioeconomic Status on HCC Prognosis

Research shows how socioeconomic status can affect prognosis among patients with hepatocellular carcinoma (HCC).

Socioeconomic status (SES) plays an important role in the prognosis of patients with hepatocellular carcinoma (HCC), according to study results published in Cancer Medicine. Findings suggest policy makers can make more precise and socially approved policies to improve patients’ cancer-specific survival (CSS) and overall survival (OS), authors wrote.

Although HCC is the most common type of primary liver cancer, a lack of specific clinical manifestations means the disease is often detected at intermediate or advanced stages. It is also one of the deadliest cancers in the world and has an 18% 5-year survival rate in the United States.

“The impacts of patients’ SES on HCC prognosis are often overlooked. In fact, their survival outcomes usually change when patients with different SESs receive the same or various treatment,” researchers explained.

Using data from the Surveillance, Epidemiology, and End Results (SEER) Program, a population-based database, investigators aimed to identify the impact of SES on HCC patients and sought to improve accuracy of nomograms in predicting these individuals’ prognoses.

SEER program data represent 18 cancer registries that cover 30% of the US population. In the current study, patients were included if they were diagnosed with HCC between 2011 and 2015. SES was defined as age at diagnosis, race, sex, median family income, education level, insurance status, marital status, resident, cost-of-living index (COLI), and poverty rate.

In total, SES and clinicopathological data from 33,670 individuals were included in the analysis, with 23,570 individuals assigned to a training cohort and 10,100 to the validation cohort. “The main SES of patients was ≤66 years old, White race, male, COLI between 0.885 and 1.167, income between $60,460 and $82,200, private insured, marital status married or domestic partner, living in the metropolitan,” authors wrote.

In addition, the poverty rate and education level at the county level were 1.8% to 14.2% and 78.7% to 86.7%, respectively, they noted. Investigators established nomograms consisting of 19 variables and found their C-indexes “are higher than tumor, node, metastasis (TNM) staging system, which predicts the CSS (0.789 vs. 0.692; P < .01) and OS (0.777 vs. 0.675; P < .01).” In other words, researchers’ models exhibited better accuracy in predicting the prognosis of HCC.

Furthermore, “the receiver operating characteristic (ROC) curve, calibration diagram, integrated discrimination improvement (IDI), and net reclassification improvement (NRI) showed the improved prognostic value in 1-, 3-, and 5-year survival rates.”

Older age was associated with poor prognosis in these patient—an expected finding as old age is linked with higher numbers of comorbidities.

Although the survival rates of patients with HCC have improved thanks to the development of medical techniques, research showed these improvements were not uniform across racial groups, as worse survival was seen among African Americans and superior survival in Asian populations. This could be due to factors such as income inequality, or separate and unequal systems of health care in the United States.

Results also showed patient who were married or had domestic partners had the longest survival while those with insurance tended to have a better prognosis due to an overall improved SES or insurance covering treatment costs.

A lack of information on socioeconomic factors including lifestyle habits marks a limitation to this study, in addition to the absence of data on adjuvant therapy, comorbidities, and recurrence.

Overall, “age, race, sex, COLI, insurance, marital status, and poverty rate were identified as independent prognostic factors for HCC patients, and nomograms for CSS and OS for HCC patients were constructed with good predictive power.”

“Socioeconomic inequalities in survival remain a serious public health problem for a health care system based on equity,” researchers concluded.


Zheng Y, Zhang X, Lu J, Liu S, Qian Y. Association between socioeconomic status and survival in patients with hepatocellular carcinoma. Cancer Med. Published online August 20, 2021. doi:10.1002/cam4.4223