Reduced survival for rural patients with hepatocellular carcinoma within a tertiary hospital network: treatment equality is not enough.

Background: Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality globally, with increasing incidence rates in Australia. As most treatments are performed in metropolitan centres, we hypothesised that rural patients may be adversely affected.

Aims: To investigate survival outcomes and treatment access between rural and metropolitan HCC patients within a single tertiary hospital network.

Methods: Retrospective cohort study of HCC patients treated at Royal Perth Hospital from May 2012 to May 2023. Analysed variables included clinical and demographic factors, HCC characteristics (including staging), treatment outcomes and adherence to post-intervention surveillance. Overall survival was compared using Kaplan-Meier analysis and multivariable Cox regression to assess potential confounders.

Results: Among 400 patients, 305 were from metropolitan (76.2%) and 95 were from rural (23.8%) areas. Baseline characteristics, including demographics, comorbidities, performance status, HCC stage and alpha-fetoprotein levels at diagnosis, were similar between the two groups. Median overall survival was significantly lower for rural patients compared to metropolitan patients (2.53 vs 4.70 years; P = 0.035). Multivariable analysis indicated that rural residence was an independent predictor of poorer survival (adjusted hazard ratio 1.45, P = 0.026). There was no difference in time to treatment or treatment allocation between groups. Surveillance adherence post-curative intervention was lower in rural patients (63% vs 96%, P < 0.001).

Conclusions: This study highlights a significant survival disadvantage for rural HCC patients, emphasising geographical disparities in healthcare outcomes. While our patients had equal access to treatment, disparities may emerge from challenges in post-treatment care and surveillance adherence. Strategies targeting rural healthcare delivery and patient follow-up are necessary to mitigate these disparities.