Q&A: Causes of hepatocellular carcinoma ‘differ remarkably’ by race, ethnicity
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Key takeaways:
- Rates of hepatitis C virus-related hepatocellular carcinoma declined 9.6% annually since 2015.
- HCC caused by alcohol-related disease and nonalcoholic fatty liver disease increased by 6% and 4.3%, respectively.
Rates of hepatocellular carcinoma caused by alcohol-related disease and nonalcoholic fatty liver disease are on the rise, especially among Hispanic individuals, according to research in Clinical Gastroenterology and Hepatology.
Using the Florida Cancer Data System, Paulo S. Pinheiro, MD, PhD, a research associate professor of epidemiology at University of Miami Miller School of Medicine, and colleagues examined etiology-specific incidence rates and population-based trends for HCC.
Of 14,420 HCC cases diagnosed between 2010 and 2018, hepatitis C virus was the main cause (46.6%), followed by NAFLD (27.2%), alcohol-related disease (13%) and hepatitis B virus (4.4%). Puerto Rican men had the highest HCC rates (19.6 per 100,000), while Mexican women born outside of the U.S. had the highest rates (5.9 per 100,000).
Overall age-adjusted incidence rates for HCC in Florida were 9.3 per 100,000 (95% CI, 9.2-9.5) among men — nearly fourfold higher than among women (2.4 per 100,000; 95% CI, 2.4-2.5). HCV continues to be the primary cause of HCC among men, while NAFLD has become the leading cause among women.
HCV-HCC incidence rates were highest in U.S.-born Puerto Rican men (10.9 per 100,000), followed by African American (8 per 100,000) and U.S.-born Mexican American (7.6 per 100,000) men. Similar trends were reported among women in these ethnic groups.
HBV-HCC rates were high among Asian and Haitian Black men (4.9 and 4.6 per 100,000, respectively), while these rates were low among women (< 0.2 per 100,000), with the exception of Asian women (1.2 per 100,000).
NAFLD-HCC was more common among Hispanic and Filipino people, while alcohol-related liver disease-HCC was high among Puerto Rican, Hispanic Central American and Mexican men but low among women of all ethnic groups.
Population-based rates of HCV-HCC declined 9.6% annually since 2015 in all groups, while alcohol-related disease-HCC and NAFLD-HCC rose 6% and 4.3%, respectively, from 2010 to 2018.
In a Healio interview exclusive, Pinheiro discusses notable takeaways and how they may inform patient care going forward.
Healio: Why did your team undertake this investigation?
Pinheiro: Liver cancer mortality keeps increasing, and trends in racial-ethnic groups have always been a puzzle to explain, as liver cancer differs from other cancers in several respects.
For example, unlike breast, colorectal or pancreatic cancers, for which we do not know the causes for the overwhelming proportion of these cancers, we do know the causes of liver cancer and can pinpoint those in nearly 90% of patients.
The key to understanding liver cancer by race-ethnicity is etiology, as these causes differ remarkably by each race-ethnicity. Discovering differences in etiology can help detect racial-ethnic groups that have been overlooked in terms of liver cancer risk.
Liver cancer etiology does not really impact treatment, as it is treated the same way regardless of cause, but it does impact prevention.
Healio: What were the most notable takeaways?
Pinheiro: The liver cancer causes that are increasing — fatty liver and alcohol — are both more prevalent among Hispanics. The liver cancer causes that are decreasing, primarily HCV, are more prevalent in U.S.-born populations like whites and U.S.-born Blacks.
Moreover, we were surprised by the heterogeneity of liver cancer patterns by detailed racial-ethnic group. Simply put, all Blacks are not the same, all Hispanics are not the same and all Asians are not the same.
There were many unexpected findings from this analysis, which include the following:
- Two Caribbean populations, Puerto Rican and Cuban men, have a threefold difference in rates, that being higher in Puerto Ricans, which proves that grouping all Hispanics in the same category may obscure large differences across ethnicity.
- Filipino persons have higher rates of fatty liver-related liver cancer, which displays similarities with Hispanics.
- HBV infection as the primary liver cancer cause is not only a problem among Asians (previously known) but is also common in Haitian Black males.
Healio: How do these results inform patient care going forward?
Pinheiro: The most important awareness aspect is among primary care physicians, who should be following the recommendations of the CDC to screen all asymptomatic adult populations in the U.S. for HCV and HBV.
Unfortunately, that is not always the case, and even when screening is done, the specific recommended tests are not always prescribed. Moreover, empirical evidence shows those primary care physicians that are less aware of these recommendations often serve areas where populations more afflicted by chronic hepatitis B and C tend to reside.
These recommendations are important because if patient screening results in a positive, the patient can be referred to a liver specialist and treated for HCV, for which a cure exists, or their HBV can be controlled in a way that lowers the odds of getting liver cancer in the future.
Healio: What additional research is needed?
Pinheiro: The next step after this research is to reinforce the need for screening tests for hepatitis C and B viral infection for all adults in Florida, starting with increased awareness among all medical practitioners.
Moreover, an important step forward would be to expand this surveillance of etiology-specific liver cancer, rather than all liver cancer combined, from 2018 onward on a permanent basis in Florida but also in other states across the country.
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