The 'social gradient' in primary liver cancer in France: A national observational study.

Background & Aims: Social deprivation has been associated with primary liver cancer (PLC); however, its impact on access to curative treatment and survival remains uncertain. We assessed the effect of deprivation on healthcare access and evaluated whether care centralization could improve PLC management at a national level. Methods: We conducted a retrospective longitudinal cohort study using the French National Discharge Database (2017-2021), including all adult patients with PLC. Deprivation was the primary exposure. Primary and secondary outcomes were access to curative treatment (surgery, transplantation, or ablation) and mortality. Associations were assessed using adjusted odds ratios (aORs) and hazard ratios (aHRs) derived from random-effects logistic and Cox models, clustered by French regional departments. G-computation was applied to estimate the absolute effect of centralization (treatment within referral hospitals) on curative treatment access among deprived patients. Results: Among 62,351 patients (median age [IQR], 71 [63-78] years; 70.8% male), 45% (n = 27,872) were classified as deprived. Deprivation was associated with reduced access to curative treatment (aOR 0.89; 95% CI 0.85-0.92; p <0.001) and higher mortality (aHR 1.03; 95% CI 1.01-1.05; p <0.001). These associations were not observed among patients treated in referral hospitals (aOR 1.03; 95% CI 0.98-1.09; aHR 1.02; 95% CI 0.98-1.06). Improving access to referral hospitals was estimated to increase the probability of receiving curative treatment by 25% (95% CI 24-26), potentially benefiting 811 deprived patients per year (range, 730-895). Conclusions: Deprivation reduced access to curative treatment and increased mortality among patients with primary liver cancer in France. Care centralization could help mitigate these disparities and improve outcomes. Impact and implications: Social deprivation is known to increase the risk of developing primary liver cancer (PLC) and to reduce survival. However, it has been unclear if this is due to late-stage diagnoses or limited access to treatments, as earlier studies mostly considered factors like race, ethnicity, sex, and insurance status. Our study highlighted that socially deprived patients with PLC in France face reduced access to curative and palliative treatments, resulting in lower overall survival rates. A key finding was that the negative impact of social deprivation was mitigated by care centralization - when patients were diagnosed or treated in referral centers, social deprivation no longer influenced access to curative treatments or mortality outcomes. These findings support the need for centralized PLC management strategies across the country to improve care outcomes for socioeconomically disadvantaged individuals.