title: Missing the obvious: psychosocial obstacles in Veterans with hepatocellular carcinoma.
abstract: BACKGROUND
  Socioeconomic disparities in patients with hepatocellular carcinoma (HCC) influence medical treatment. In addition to socioeconomic barriers, the Veteran population suffers from significant psychosocial obstacles. This study identifies the social challenges that Veterans face while undergoing treatment for HCC.
  
  
  METHODS
  One hundred Veterans at the Palo Alto VA treated for HCC from 2009 to 2014 (50 consecutive patients who underwent a surgical procedure; 50 treated with intra-arterial therapy) were retrospectively reviewed.
  
  
  RESULTS
  Substance abuse history was identified in 96%, and half were unemployed. Most patients survived on a limited income [median $1340, interquartile range (IQR) 900-2125]; 36% on ≤ $1000/month, 37% between $1001-2000/month and 27% with >$2000/month. A history of homelessness was found in 30%, more common in those of the lowest income (57% of ≤$1K/month group, 23% of $1-2K/month group and 9% of >$2K/month group, P < 0.01). Psychiatric illness was present in 64/100 patients; among these the majority received ongoing psychiatric treatment. Transportation was provided to 23% of patients who would otherwise have been unable to attend medical appointments.
  
  
  CONCLUSIONS
  Psychiatric disease and substance abuse are highly prevalent among Veterans with HCC. Most patients survive on a very meager income. These profound socioeconomic and psychosocial problems must be recognized when providing care for HCC to this population to provide adequate treatment and surveillance.
authors.affiliation: Department of Surgery, Palo Alto Veterans Affairs, Palo Alto, CA, USA.
authors.forename: Kimberly J
authors.initials: KJ
authors.lastname: Hwa
authors.affiliation: Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.
authors.forename: Monica M
authors.initials: MM
authors.lastname: Dua
authors.affiliation: Department of Surgery, Palo Alto Veterans Affairs, Palo Alto, CA, USA.|Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.
authors.forename: Sherry M
authors.initials: SM
authors.lastname: Wren
authors.affiliation: Department of Surgery, Palo Alto Veterans Affairs, Palo Alto, CA, USA.|Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.
authors.forename: Brendan C
authors.initials: BC
authors.lastname: Visser
mesh_terms: D002140:California / Q000453:epidemiology; D006528:Carcinoma, Hepatocellular / Q000191:economics / Q000453:epidemiology / Q000473:pathology / Q000523:psychology / Q000628:therapy*; D015897:Comorbidity; D015438:Health Behavior; D007722:Health Knowledge, Attitudes, Practice; D006297:Health Services Accessibility; D054625:Healthcare Disparities / Q000191:economics; D006703:Ill-Housed Persons / Q000523:psychology; D006801:Humans; D007182:Income; D008113:Liver Neoplasms / Q000453:epidemiology / Q000235:genetics / Q000473:pathology / Q000523:psychology / Q000628:therapy*; D001523:Mental Disorders / Q000453:epidemiology / Q000523:psychology; D008875:Middle Aged; D015995:Prevalence; D012111:Residence Characteristics; D012189:Retrospective Studies; D019966:Substance-Related Disorders / Q000453:epidemiology / Q000523:psychology; D014187:Transportation of Patients; D016896:Treatment Outcome; D014478:Unemployment / Q000523:psychology; D014728:Veterans / Q000523:psychology*; D058014:Veterans Health / Q000191:economics