Liver transplantation offers the best survival for early-stage hepatocellular carcinoma (HCC) patients. Prior studies have demonstrated disparities in transplant access; none have examined the early steps of the transplant process. We identified determinants of access to transplant referral and evaluation among HCC patients with a single tumor either within Milan or meeting downstaging criteria in Georgia. Population-based cancer registry data from 2010 to 2019 was linked to liver transplant centers in Georgia. Primary cohort: adult HCC patients with a single tumor ≤ 8 centimeters in diameter, no extrahepatic involvement, and no vascular involvement. Secondary cohort: primary cohort plus patients with multiple tumors confined to one lobe. We estimated time to transplant referral, evaluation initiation, and evaluation completion, accounting for the competing risk of death. In sensitivity analyses, we also accounted for non-transplant cancer treatment. Among 1,379 early-stage HCC patients in Georgia, 26% were referred to liver transplant. Private insurance and younger age were associated with increased likelihood of referral, while requiring downstaging was associated with lower likelihood of referral. Patients living in Census tracts with ≥ 20% of residents in poverty were less likely to initiate evaluation among those referred (csHR: 0.62, 95% CI: 0.42, 0.94). Medicaid patients were less likely to complete the evaluation once initiated (csHR: 0.53, 95% CI: 0.32, 0.89). Different sociodemographic factors were associated with each stage of the transplant process among early-stage HCC patients in Georgia, emphasizing unique barriers to access and the need for targeted interventions at each step.

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