E.M. Dickey1, K.L. Koch1, H. Amiran1, M.P. Martos1, A. Francesco3, N. Ezenwajiaku2, J. Pizzolato2, N.B. Merchant1, A. Pimentel2, J. Datta1 1University Of Miami, Division Of Surgical Oncology, Miami, FL, USA 2University Of Miami, Division Of Medical Oncology, Miami, FL, USA 3University of Miami, Department Of Radiology, Maimi, FL, USA
Introduction:
In patients with unresectable colorectal liver metastasis (uCRLM), regional chemotherapy via hepatic artery infusion chemotherapy (HAIC) with systemic chemotherapy can achieve hepatic disease control and improve overall survival (OS). We sought to evaluate factors associated with equitable access to HAIC at a high-volume tertiary referral center.
Methods:
After multidisciplinary review, uCRLM patients selected to undergo HAI pump placement were included (01/2018-01/2024). The primary outcome was time to initiation (TTI) of HAIC from uCRLM diagnosis. We reviewed clinical, genomic (derived from tumor next-generation sequencing [NGS]), demographic, and socioeconomic factors and its association with TTI of HAIC. Tiers of socioeconomic disadvantage were inferred from national percentile rankings of Area Deprivation Index (ADI) obtained from the Neighborhood Atlas (2022). Patients were grouped into ADI quintiles (Q)—higher Q reflecting greater neighborhood disadvantage.
Results:
Of 84 uCRLM patients (69% male, 42% Hispanic) receiving HAIC at our institution, TTI of HAIC from uCRLM diagnosis did not vary by sex (p=0.17) or race (p=0.64); however, Hispanic ethnicity (p=0.02) and increasing ADI (p=0.02) were significantly associated with longer TTI. TTI increased with higher ADI, ranging from median 7.8 (IQR:4.6-13.0) months in ADI-Q1 patients to 17.07 (IQR:16.5-17.6) months in ADI-Q5 patients. Interestingly, factors related to hepatic disease burden, such as Fong score ≥3 (p=0.51) and synchronous disease (p=0.13) were not associated with TTI. Mutational status on NGS, notably pathogenic KRAS mutations (p=0.46), did not correlate with increased TTI. When stratifying by national ADI quintiles in our cohort, 26 patients (31%) were in Q1, 34 (41%) in Q2, 17 (20%) in Q3, 5 (6%) in Q4, and 2 (2%) in Q5. Patients across ADI quintiles did not differ by age, sex, race, and ethnicity. Hepatic disease burden, genomic alterations, and number of chemotherapy lines prior to HAIC also did not differ across ADI subgroups. Despite a delay in TTI of HAIC in patients with higher ADI, these patients received similar number of HAIC-FUDR cycles (p=0.6) and simultaneous systemic chemotherapy (p=0.97), and did not suffer procedure-related complications (e.g., biliary sclerosis or infection), disproportionately to their lower-ADI counterparts. To avoid immortal time bias, median OS was calculated from HAIC pump placement. Notably, increasing ADI (Q3-23 v Q2-35 v Q1-50; p= 0.03), but not Hispanic ethnicity (p=0.75), was associated with worse median OS in this cohort.
Conclusion:
Higher neighborhood disadvantage may be associated with inequitable access to regional chemotherapy in a selected cohort of uCRLM patients. Efforts to broaden access to high-quality care may improve outcomes in socioeconomically disadvantaged patients with uCRLM.