Social determinants of health and access to Liver Transplantation in patients with hepatocellular carcinoma within a universal healthcare system: A retrospective cohort study.

BACKGROUND AND AIM: Hepatocellular carcinoma (HCC) remains a major contributor to cancer-related illness and death globally. For eligible patients, liver transplantation (LT) represents a potentially curative option. Social determinants of health (SDOH) impact HCC outcomes, but their influence across the multi-step LT continuum remains poorly defined. We evaluated how SDOH measured through the Canadian Index of Multiple Deprivation (CIMD) and census metrics, relate to LT access and tumor burden among HCC-referred patients. METHODS: We analyzed a retrospective cohort of 576 patients with HCC referred for LT (2003-2021). Multivariable multinomial, linear, and competing risks regression examined relationships between SDOH and outcomes across the LT pathway. RESULTS: High residential instability was associated with presenting beyond Milan criteria at referral (ptrend=0.02), and higher odds of non-listing due to psychosocial factors (quintile 5, RRR 4.74, p=0.02). Amont waitlisted patients, higher residential instability scores predicted prolonged time-to-listing (β=0.08, p=0.04), whereas higher area-level marriage (B=-0.01, p=0.03) and private vehicle commuting rates (B=-0.01, p=0.002) predicted faster listing. In competing risks analysis (death/delisting as competitors), area-level CIMD dimensions did not influence LT probability once listed, and only a higher vehicle commuting rate remained significantly associated with transplantation (SHR 1.01, p=0.05). Ethnocultural quintile 2 was uniquely protective against psychosocial non-listing (RRR 0.14, p=0.01). CONCLUSION: SDOH inequities primarily restrict the pre-listing stages of LT continuum, influencing tumor burden at referral, listing eligibility, and evaluation velocity, rather than post-listing organ allocation. Targeted interventions to ensure equitable transplantation access should focus on early social work navigation and logistical transportation support.