Disparities in hepatocellular carcinoma survival by Medicaid-status: A national population-based risk analysis

Published:December 05, 2022DOI:



      Previous studies have demonstrated disparities in survival surrounding hepatocellular carcinoma (HCC) across a variety of socio-demographic factors; however, the relationship between Medicaid-status and HCC survival is poorly understood.


      We constructed 5-year, disease-specific survival curves using the Kaplan-Meier method and performed an adjusted survival analysis using multivariate Cox-proportional hazard regression.


      We analyzed 17,059 non-elderly patients (12,194 non-Medicaid, 4875 Medicaid) diagnosed between 2006 and 2013 and found that Medicaid status was not associated with higher risk of diseases-specific death compared to other insurance types (p = .232, aHR 1.02, 95% CI: 0.983–1.07) after for controlling for a variety of co–variates (ie. marital status, urbanicity, etc.). We found no difference in the risk of death between patients enrolled in Medicaid for more than three years versus those enrolled for less than three years. In all models, rurality and unmarried status were also associated with an increased risk of death (aHR 1.11, 95% CI: 1.03–1.18, p = .002 and aHR 1.18, 95% CI: 1.13–1.23, p < .001, respectively).


      Those enrolled in Medicaid prior to HCC diagnosis may not be associated with a higher risk of disease-specific death compared to non-Medicaid enrolled patients.


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        • Zhang W.
        • Sun B.
        Impact of age on the survival of patients with liver cancer: an analysis of 27,255 patients in the SEER database.
        Oncotarget. 2015; 6: 633-641
        • Shen Q.
        • Fan J.
        • Yang X.R.
        • et al.
        Serum DKK1 as a protein biomarker for the diagnosis of hepatocellular carcinoma: a large-scale, multicentre study.
        Lancet Oncol. 2012; 13: 817-826
        • Abdel-Rahman O.
        Role of liver-directed local tumor therapy in the management of hepatocellular carcinoma with extrahepatic metastases: a SEER database analysis.
        Expet Rev Gastroenterol Hepatol. 2017; 11: 183-189
        • Izzo F.
        • Piccirillo M.
        • Albino V.
        • et al.
        Prospective screening increases the detection of potentially curable hepatocellular carcinoma: results in 8900 high-risk patients.
        HPB. 2013; 15: 985-990
        • Minagawa M.
        • Ikai I.
        • Matsuyama Y.
        • Yamaoka Y.
        • Makuuchi M.
        Staging of hepatocellular carcinoma: assessment of the Japanese TNM and AJCC/UICC TNM systems in a cohort of 13,772 patients in Japan.
        Ann Surg. 2007; 245: 909-922
        • Xu L.
        • Kim Y.
        • Spolverato G.
        • Gani F.
        • Pawlik T.M.
        Racial disparities in treatment and survival of patients with hepatocellular carcinoma in the United States.
        Hepatobiliary Surg Nutr. 2016; 5: 43-52
        • Artinyan A.
        • Mailey B.
        • Sanchez-Luege N.
        • et al.
        Race, ethnicity, and socioeconomic status influence the survival of patients with hepatocellular carcinoma in the United States.
        Cancer. 2010; 116: 1367-1377
        • Shebl F.M.
        • Capo-Ramos D.E.
        • Graubard B.I.
        • McGlynn K.A.
        • Altekruse S.F.
        Socioeconomic status and hepatocellular carcinoma in the United States.
        Cancer Epidemiol Biomarkers Prev. 2012; 21: 1330-1335
        • Bradley C.J.
        • Stevens J.L.
        • Enewold L.
        • Warren J.L.
        Stage and mortality of low-income patients with cancer: evidence from SEER-Medicaid.
        Cancer. 2021; 127: 229-238
        • Zaydfudim V.
        • Whiteside M.A.
        • Griffin M.R.
        • Feurer I.D.
        • Wright J.K.
        • Pinson C.W.
        Health insurance status affects staging and influences treatment strategies in patients with hepatocellular carcinoma.
        Ann Surg Oncol. 2010; 17: 3104-3111
        • Wang J.
        • Ha J.
        • Lopez A.
        • Bhuket T.
        • Liu B.
        • Wong R.J.
        Medicaid and uninsured hepatocellular carcinoma patients have more advanced tumor stage and are less likely to receive treatment.
        J Clin Gastroenterol. 2018; 52: 437-443
        • Adler Jaffe S.
        • Myers O.
        • Meisner A.L.W.
        • Wiggins C.L.
        • Hill D.A.
        • McDougall J.A.
        Relationship between insurance type at diagnosis and hepatocellular carcinoma survival.
        Cancer Epidemiol Biomarkers Prev. 2020; 29: 300-307
        • Warren J.L.
        • Benner S.
        • Stevens J.
        • et al.
        Development and evaluation of a process to link cancer patients in the SEER registries to national Medicaid enrollment data.
        JNCI Monographs. 2020; 2020: 89-95
        • Allen H.
        • Gordon S.H.
        • Lee D.
        • Bhanja A.
        • Sommers B.D.
        Comparison of utilization, costs, and quality of Medicaid vs subsidized private health insurance for low-income adults.
        JAMA Netw Open. 2021; 4e2032669
        • Epstein A.J.
        • Gray B.H.
        • Schlesinger M.
        Racial and ethnic differences in the use of high-volume hospitals and surgeons.
        Arch Surg. 2010; 145: 179-186
        • Al-Refaie W.B.
        • Muluneh B.
        • Zhong W.
        • et al.
        Who receives their complex cancer surgery at low-volume hospitals?.
        J Am Coll Surg. 2012; 214: 81-87
        • Akinyemiju T.
        • Jha M.
        • Moore J.X.
        • Pisu M.
        Disparities in the prevalence of comorbidities among US adults by state Medicaid expansion status.
        Prev Med. 2016; 88: 196-202
        • White T.J.
        • Redner R.
        • Bunn J.Y.
        • Higgins S.T.
        Do socioeconomic risk factors for cigarette smoking extend to smokeless tobacco use?.
        Nicotine Tob Res. 2016; 18: 869-873
      1. International classification of diseases for oncology.
        (ICD-O-3) (third ed.)
        • Bradley C.J.
        • Sabik L.M.
        • Entwistle J.
        • Stevens J.L.
        • Enewold L.
        • Warren J.L.
        Role of Medicaid in early detection of screening-amenable cancers.
        Cancer Epidemiol Biomarkers Prev. 2022; 31: 1202-1208
        • Smartt A.A.
        • Jang E.S.
        • Tyler W.K.
        Is there an association between insurance status and survival and treatment of primary bone and extremity soft-tissue sarcomas? A SEER database study.
        Clin Orthop Relat Res. 2020; 478: 527-536
        • Du L.
        • Shi H.Y.
        • Qian Y.
        • et al.
        Insurance status and risk of suicide mortality among patients with cancer: a retrospective study based on the SEER database.
        Publ Health. 2021; 194: 89-95
        • Zhang W.
        • Wang X.
        • Huang R.
        • et al.
        Prognostic value of marital status on stage at diagnosis in hepatocellular carcinoma.
        Sci Rep. 2017; 741695
        • Baine M.
        • Sahak F.
        • Lin C.
        • Chakraborty S.
        • Lyden E.
        • Batra S.K.
        Marital status and survival in pancreatic cancer patients: a SEER based analysis.
        PLoS One. 2011; 6e21052
        • Wang X.D.
        • Qian J.J.
        • Bai D.S.
        • Li Z.N.
        • Jiang G.Q.
        • Yao J.
        Marital status independently predicts pancreatic cancer survival in patients treated with surgical resection: an analysis of the SEER database.
        Oncotarget. 2016; 7: 24880-24887
        • Segel J.E.
        • Hollenbeak C.S.
        • Gusani N.J.
        Rural-urban disparities in pancreatic cancer stage of diagnosis: understanding the interaction with medically underserved areas.
        J Rural Health. 2020; 36: 476-483
        • Jones P.D.
        • Diaz C.
        • Wang D.
        • Gonzalez-Diaz J.
        • Martin P.
        • Kobetz E.
        The impact of race on survival after hepatocellular carcinoma in a diverse American population.
        Dig Dis Sci. 2018; 63: 515-528
        • Ooka K.
        • Connolly J.J.
        • Lim J.K.
        Medicaid reimbursement for oral direct antiviral agents for the treatment of chronic hepatitis C.
        Off J Am Coll Gastroenterol ACG. 2017; 112: 828-832
        • Popescu I.
        • Heslin K.C.
        • Coffey R.M.
        • et al.
        Differences in use of high-quality and low-quality hospitals among working-age individuals by insurance type.
        Med Care. 2017; 55: 148-154
        • Gardner L.
        • Vishwasrao S.
        Physician quality and health care for the poor and uninsured.
        Inquiry. 2010; 47: 62-80
        • Nguyen K.H.
        • Sommers B.D.
        Access and quality of care by insurance type for low-income adults before the affordable care Act.
        Am J Publ Health. 2016; 106: 1409-1415
        • McWilliams J.M.
        Health consequences of uninsurance among adults in the United States: recent evidence and implications.
        Milbank Q. 2009; 87: 443-494
        • Yabroff K.R.
        • Reeder-Hayes K.
        • Zhao J.
        • et al.
        Health insurance coverage disruptions and cancer care and outcomes: systematic review of published research.
        J Natl Cancer Inst. 2020; 112: 671-687
        • Kolomaya A.
        • Amin S.
        • Lin C.
        The association of health insurance with the survival of cancer patients with brain metastases at diagnosis.
        Tech Innov Patient Support Radiat Oncol. 2021; 20: 46-53
        • Berrian J.L.
        • Liu Y.
        • Lian M.
        • Schmaltz C.L.
        • Colditz G.A.
        Relationship between insurance status and outcomes for patients with breast cancer in Missouri.
        Cancer. 2021; 127: 931-937
        • Niu X.
        • Roche L.M.
        • Pawlish K.S.
        • Henry K.A.
        Cancer survival disparities by health insurance status.
        Cancer Med. 2013; 2: 403-411
      2. States with the most and least Medicaid coverage. WalletHub.
      3. (Jul 21 P)Status of state Medicaid expansion decisions: interactive map. KFF. 2022 (Published July 21, 2022)
        • Wu C.
        • Chen P.
        • Qian J.J.
        • et al.
        Effect of marital status on the survival of patients with hepatocellular carcinoma treated with surgical resection: an analysis of 13,408 patients in the surveillance, epidemiology, and end results (SEER) database.
        Oncotarget. 2016; 7: 79442-79452
        • Zhang X.
        • El-Serag H.B.
        • Thrift A.P.
        Predictors of five-year survival among patients with hepatocellular carcinoma in the United States: an analysis of SEER-Medicare.
        Cancer Causes Control. 2021; 32: 317-325
        • Ding J.
        • Wen Z.
        Survival improvement and prognosis for hepatocellular carcinoma: analysis of the SEER database.
        BMC Cancer. 2021; 21: 1157
        • Current C.D.C.
        Cigarette smoking among adults in the United States. Centers for disease control and prevention.
        (Published March 16, 2022)
      4. Excessive alcohol use and risks to men's health | CDC.
        (Published July 28)
        Date: 2022
        Date accessed: July 31, 2022
      5. (Nov 06 ADP)
        • Tolbert J.
        Key facts about the uninsured population. KFF.
        (Published November 6, 2020)
        • Virnig B.A.
        Associating insurance status with cancer stage at diagnosis.
        Lancet Oncol. 2008; 9: 189-191