Increased morbidity and mortality of hepatocellular carcinoma patients in lower cost of living areas

Table 1 Baseline characteristics of hepatocellular carcinoma patients by cost of living index group between 2007 and 2015

COLI group		Total	< 901	902-1044	1048-1169	1170+	P value
Number		47894	13515	11379	12167	10833
Median age [IQR]		62.00 [56.00, 70.00]	61.00 [55.00, 69.00]	61.00 [56.00, 68.00]	62.00 [56.00, 71.00]	63.00 [57.00, 72.00]	< 0.001
Survival mo [IQR]		10.00 [2.00, 27.00]	8.00 [2.00, 23.00]	10.00 [2.00, 27.00]	10.00 [2.00, 28.00]	13.00 [3.00, 31.00]	< 0.001
Male sex (%)		37202 (77.7)	10661 (78.9)	8921 (78.4)	9357 (76.9)	8263 (76.3)	< 0.001
Race (%)	White	23220 (48.5)	8062 (59.7)	6108 (53.7)	4864 (40.0)	4186 (38.6)	< 0.001
	Black	6537 (13.6)	2094 (15.5)	2231 (19.6)	1197 (9.8)	1015 (9.4)
	Hispanic	9695 (20.2)	2497 (18.5)	1504 (13.2)	3708 (30.5)	1986 (18.3)
	API	7723 (16.1)	652 (4.8)	1231 (10.8)	2294 (18.9)	3546 (32.7)
	Other/Unkn	719 (1.5)	210 (1.6)	305 (2.7)	104 (0.9)	100 (0.9)
Marital status (%)	Divorced	6125 (12.8)	1978 (14.6)	1673 (14.7)	1466 (12.0)	1008 (9.3)	< 0.001
	Married	23338 (48.7)	6490 (48.0)	5237 (46.0)	5888 (48.4)	5723 (52.8)
	Separated	900 (1.9)	241 (1.8)	242 (2.1)	248 (2.0)	169 (1.6)
	Single	10474 (21.9)	2938 (21.7)	2477 (21.8)	2778 (22.8)	2281 (21.1)
	Unknown	2545 (5.3)	585 (4.3)	710 (6.2)	611 (5.0)	639 (5.9)
	Unmarried	120 (0.3)	33 (0.2)	37 (0.3)	28 (0.2)	22 (0.2)
	Widowed	4392 (9.2)	1250 (9.2)	1003 (8.8)	1148 (9.4)	991 (9.1)
Insurance status (%)	Any Medicaid	11851 (24.7)	3346 (24.8)	2591 (22.8)	3415 (28.1)	2499 (23.1)	< 0.001
	Unknown	1864 (3.9)	536 (4.0)	450 (4.0)	456 (3.7)	422 (3.9)
	Insured	24225 (50.6)	6531 (48.3)	5811 (51.1)	5970 (49.1)	5913 (54.6)
	Insured/Unspecified	7796 (16.3)	2337 (17.3)	2053 (18.0)	1776 (14.6)	1630 (15.0)
	Uninsured	2158 (4.5)	765 (5.7)	474 (4.2)	550 (4.5)	369 (3.4)
State (%)	Alaska	60 (0.1)	0	60 (0.5)	0	0	< 0.001
	California	23501 (49.1)	4266 (31.6)	3005 (26.4)	9219 (75.8)	7011 (64.7)
	Connecticut	1880 (3.9)	0	307 (2.7)	1573 (12.9)	0
	Georgia	4124 (8.6)	1767 (13.1)	2357 (20.7)	0	0
	Hawaii	1054 (2.2)	0	0 (0.0)	293 (2.4)	761 (7.0)
	Iowa	1103 (2.3)	1003 (7.4)	100 (0.9)	0 (0.0)	0
	Kentucky	2047 (4.3)	2047 (15.1)	0	0	0
	Louisiana	2740 (5.7)	2740 (20.3)	0	0	0
	Michigan	2129 (4.4)	0 (0.0)	2129 (18.7)	0	0
	New Jersey	4131 (8.6)	0	0	1082 (8.9)	3049 (28.1)
	New Mexico	1335 (2.8)	636 (4.7)	687 (6.0)	0	12 (0.1)
	Utah	772 (1.6)	770 (5.7)	2 (0.0)	0	0
	Washington	3018 (6.3)	286 (2.1)	2732 (24.0)	0	0
Year (%)	2007-2009		3599 (26.6)	3164 (27.8)	3646 (30.0)	3242 (29.9)	< 0.001
		13651 (28.5)
	2010-2012	16115 (33.6)	4413 (32.7)	3868 (34.0)	4139 (34.0)	3695 (34.1)
	2013-2015	18128 (37.9)	5503 (40.7)	4347 (38.2)	4382 (36.0)	3896 (36.0)

API: Asians and Pacific Islanders; COLI: Cost of living index; HCC: Hepatocellular carcinoma; IQR: Interquartile range..

Table 2 Characteristics of hepatocellular carcinoma by cost of living index group between 2007 and 2015

COLI group		≤ 901	902-1044	1048-1169	≥ 1170	P value
Stage (%)	I	4403 (32.6)	3764 (33.1)	3977 (32.7)	3704 (34.2)	< 0.001
	II	2201 (16.3)	2057 (18.1)	2006 (16.5)	1988 (18.4)
	III	2804 (20.7)	2380 (20.9)	2350 (19.3)	2100 (19.4)
	IV	2055 (15.2)	1582 (13.9)	1674 (13.8)	1410 (13.0)
	UNK	2052 (15.2)	1596 (14.0)	2160 (17.8)	1631 (15.1)
Tumor size (%)	≤ 20	1335 (9.9)	1379 (12.1)	1378 (11.3)	1338 (12.4)	< 0.001
	21-30	1786 (13.2)	1835 (16.1)	1776 (14.6)	1598 (14.8)
	31-50	2701 (20.0)	2353 (20.7)	2522 (20.7)	2136 (19.7)
	51	4780 (35.4)	3830 (33.7)	4164 (34.2)	3664 (33.8)
	UNK	2913 (21.6)	1982 (17.4)	2327 (19.1)	2097 (19.4)
≤ 20 mm (%)		1335 (9.9)	1379 (12.1)	1378 (11.3)	1338 (12.4)	< 0.001
≤ 30.mm (%)		3121 (23.1)	3214 (28.2)	3154 (25.9)	2936 (27.1)	< 0.001
≤ 50.mm (%)		5822 (43.1)	5567 (48.9)	5676 (46.7)	5072 (46.8)	< 0.001
LRT (%)		819 (6.1)	1268 (11.1)	1286 (10.6)	1244 (11.5)	< 0.001
Resection (%)		949 (7.0)	695 (6.1)	1000 (8.2)	1154 (10.7)	< 0.001
Transplant (%)		889 (6.6)	637 (5.6)	507 (4.2)	481 (4.4)	< 0.001

COLI: Cost of living index; HCC: Hepatocellular carcinoma.

Table 3 Survival by year and cost of living index group

COLI group	Survival in mo (95%CI)				P value
	2007-2015	2007-2009	2010-2012	2013-2015
≤ 901	8 (7-8)	6 (6-7)	7 (7-8)	9 (8-10)	< 0.001
902-1044	10 (10-11)	8 (7-9)	11 (10-11)	13 (12-13)
1048-1169	11 (11-12)	9 (8-10)	12 (11-13)	13 (13-14)
≥ 1170	14 (14-15)	12 (11-13)	14 (13-16)	16 (15-18)

CI: Confidence interval; COLI: Cost of living index.

Table 4 Univariate and multivariate Cox regression

	Univariate		Multivariate
	HR	95%CI	HR	95%CI
COLI ≤ 901- vs 1048-1169	1.162	1.131-1.195	1.141	1.109-1.174
COLI ≤ 901- vs 1170 ≤	1.300	1.263-1.338	1.218	1.181-1.255
COLI ≤ 901- vs 902-1044	1.130	1.099-1.163	1.067	1.037-1.097
COLI 1048-1169 vs 1170 ≤	1.118	1.085-1.001	1.067	1.035-1.100
COLI 1048-1169 vs 902-1044	0.972	0.944-1.001	0.934	0.907-0.963
COLI 1170 ≤ vs 902-1044	0.869	0.843-0.896	0.876	0.849-0.904
Age	1.014	1.013-1.015	1.012	1.011-1.013
Sex female vs male	0.903	0.881-0.926	0.925	0.901-0.950
API vs Black	0.710	0.684-0.737	0.817	0.785-0.851
API vs Hispanic	0.809	0.781-0.838	0.874	0.842-0.906
API vs Other/unknown	0.895	0.818-0.980	1.000	0.913-1.096
API vs White	0.813	0.788-0.838	0.839	0.813-0.867
Black vs Hispanic	1.139	1.100-1.180	1.069	1.031-1.108
Black vs Other/unknown	1.261	1.152-1.380	1.223	1.118-1.339
Black vs White	1.145	1.110-1.180	1.027	0.996-1.060
Hispanic vs Other/unknown	1.107	1.012-1.210	1.145	1.047-1.252
Hispanic vs White	1.005	0.978-1.032	0.961	0.935-0.988
Other/unknown vs White	0.908	0.832-0.991	0.839	0.769-0.916
Married (including common law) vs Separated/Divorced	0.839	0.814-0.865	0.909	0.881-0.937
Married (including common law) vs Single/Unmarried or domestic partner	0.799	0.779-0.820	0.876	0.852-0.901
Married (including common law) vs Unknown	0.916	0.873-0.961	1.037	0.988-1.089
Married (including common law) vs Widowed	0.708	0.683-0.733	0.881	0.847-0.915
Separated/divorced vs Single/unmarried or domestic partner	0.953	0.921-0.985	0.964	0.932- 0.998
Separated/divorced vs Unknown	1.092	1.036-1.150	1.142	1.083-1.204
Separated/divorced vs Widowed	0.843	0.809-0.879	0.969	0.927-1.013
Single/unmarried or domestic partner vs Unknown	1.146	1.090-1.205	1.184	1.125-1.247
Single/Unmarried or domestic partner vs Widowed	0.885	0.852-0.920	1.005	0.963-1.049
Unknown vs Widowed	0.773	0.731-0.817	0.849	0.801-0.899
Any Medicaid vs Insured	1.211	1.182-1.240	1.141	1.113-1.170
Any Medicaid vs Uninsured	0.705	0.670-0.741	0.830	0.789-0.874
Any Medicaid vs Unknown	0.678	0.644-0.715	0.904	0.856-0.956
Insured vs Uninsured	0.582	0.555-0.611	0.728	0.693-0.764
Insured vs Unknown	0.560	0.533-0.589	0.792	0.751-0.836
Uninsured vs Unknown	0.962	0.900-1.029	1.089	1.016-1.168
Stage I vs II	0.938	0.907-0.970	0.833	0.805-0.862
Stage I vs III	0.373	0.363-0.385	0.570	0.552-0.590
Stage I vs IV	0.221	0.214-0.229	0.372	0.359-0.386
Stage vs Unknown	0.370	0.359-0.382	0.656	0.632-0.681
Stage II vs III	0.398	0.385-0.412	0.685	0.658-0.713
Stage II vs IV	0.236	0.227-0.245	0.447	0.429-0.466
Stage II vs Unknown	0.395	0.381-0.409	0.788	0.754-0.823
Stage III vs IV	0.593	0.574-0.613	0.653	0.631-0.675
Stage III vs Unknown	0.992	0.961-1.024	1.151	1.108-1.196
Stage IV vs Unknown	1.673	1.6161.732	1.763	1.699-1.830
20 vs 21-30	0.796	0.758-0.835	0.835	0.796-0.876
20 vs 31-50	0.564	0.540-0.590	0.672	0.643-0.703
20 vs 50+	0.308	0.296-0.321	0.506	0.484-0.529
20 vs Unknown	0.235	0.225-0245	0.454	0.432-0.476
21-30 vs 31-50	0.710	0.683-0.737	0.805	0.774-0.837
21-30 vs 50+	0.387	0.374-0.401	0.606	0.582-0.630
21-30 vs Unknown	0.295	0.284-0.306	0.543	0.520-0.568
31-50 vs 50+	0.546	0.530-0.562	0.753	0.728- 0.778
31-50 vs Unknown	0.416	0.403-0.430	0.675	0.650-0.701
50+ vs Unknown	0.763	0.742-0.783	0.897	0.869-0.926
LRT	2.184	2.099-2.273	1.931	1.852-2.012
Resection	2.670	2.548-2.799	2.986	2.845-3.135
Transplant	6.311	5.837-6.822	5.352	4.941-5.796
2007-2009 vs 2010-2012	1.071	1.044-1.098	1.074	1.048-1.102
2007-2009 vs 2013-2015	1.153	1.123-1.184	1.143	1.113-1.174
2010-2012 vs 2013-2015	1.077	1.050-1.104	1.064	1.037-1.091

Bold indicates nonsignificant confidence interval. API: Asians and Pacific Islanders; CI: Confidence interval; COLI: Cost of living index; HR: Hazard ratio; LRT: Locoregional therapy.