Healthcare Disparities in the Treatment and Outcomes of Hepatocellular Carcinoma in South Africa

Abstract

Background: The impact of healthcare disparities on the outcomes for hepatocellular carcinoma (HCC) has not been explored in South Africa. This study aims to evaluate and compare the presentation, treatment, and outcomes of HCC in a cohort of patients treated in the public and private sectors.

Methods: The records of 551 consecutive patients treated at a public hospital compared to those of 51 treated in the private sector from 1 December 2001 to 29 February 2024 were retrospectively reviewed.

Results: Patients managed in the public sector were significantly younger (mean age: 49.6 ± 14.8 vs. 59.6 ± 14.3 years, p < 0.00001) and more likely to have hepatitis B virus (HBV)-related HCC (62.1% vs. 17.6%, p < 0.00001). The prevalence of multifocal disease (59.2% vs. 15.7%, p < 0.00001), portal vein tumor thrombosis (44.6% vs. 5.9%, p < 0.00001), and pulmonary metastases (16.2% vs. 3.9%, p = 0.0143) was significantly higher in public sector patients. A significantly higher number of public sector patients received best supportive care as their only treatment (69.7% vs. 15.7%, p < 0.00001). A higher proportion of private sector patients were treated with curative-intended therapies (ablation, liver resection, and liver transplantation) and transarterial modalities. Median survival was lower in public sector patients (68 [IQR: 25-232] vs. 703 [IQR: 388-1327] days, p < 0.001). There was no difference in survival between public and private sector patients treated with curative-intended therapies.

Conclusions: In the public sector, patients present with more advanced HCC, which limits their access to curative-intended therapies, resulting in lower survival. Patients treated with curative-intended therapies have similar survival rates in the public and private sectors. With the introduction of universal health coverage through the National Health Insurance program in South Africa, these data highlight the gaps in HCC care in the public sector, where health initiatives such as HBV vaccination, early treatment of HBV, patient education, and screening of at-risk patients should be prioritized.

Keywords: South Africa; disparities; hepatocellular carcinoma; outcomes; private healthcare.

FIGURE 1

*Survival of entire cohort (78[IQR: 26–288.7]), patients treated in public sector (68[IQR: 25–232]) and patients treated in private sector (703 [IQR: 388–1327]), p < 0.001 *Survival expressed as median (days).