Rates of HCC rising in Black patients without cirrhosis

In the era of direct-acting antivirals, rates of hepatocellular carcinoma are rising in patients without cirrhosis, particularly Black patients, according to a presentation at The Liver Meeting Digital Experience.

“Carcinoma represents the fastest rising cause of cancer related death in the United States, and unfortunately, nationally, there continues to be disparity in the mortality between Black and white patients with hepatocellular carcinoma,” Lauren D. Nephew, MD, MAE, MSC, assistant professor of medicine in the division of gastroenterology and hepatology at Indiana University School of Medicine, said during the presentation.

According to Nephew, multifactorial reasons contribute to the disparity, including higher rates of viral hepatitis in the Black community, less screening for HCC, potential differences in tumor biology and less access to curative therapies in addition to social and structural determinants of health.

“The aim of our study was to evaluate the relationship between cirrhosis status and HCC trends in Black and white patients in the pre-DAA era compared with the DAA era in a multicenter cohort of patients,” Nephew said.

In a retrospective cohort study, Nephew and colleagues evaluated 2,436 patients (18% Black) diagnosed with HCC between 2009 and 2019 at two health centers in Indiana and North Carolina. The electronic medical record was used to identify disease etiology, labs, tumor characteristics, imaging and race. They used Mittal’s criteria to define the presence of cirrhosis in primary analysis and a Fibrosis-4 score greater than 3.25 to define advanced fibrosis in a secondary analysis. The pre-DAA era was defined as 2009 to 2013 and the DAA era was defined as 2014 to 2019.

Of those included in the study, 79% of Black patients and 50% of white patients had hepatitis C virus. Among noncirrhotic patients, 36.8% of Black patients had HCV as did 14.4% of white patients.

“Exploring hepatitis C treatment by race, you can see that Black patients in the pre-DAA era were less likely to receive treatment, and this was also true in our current DAA era, with 44.8% of Black patients not receiving treatment for hepatitis C compared with 31.4% of white patients,” Nephew said. “In regard to tumor characteristics, Black patients in the DAA era had larger tumors with a 4.9 cm measurement for their large tumor compared with 3.5 cm in our white cohort.”

According to Mittal criteria, the odds of a Black patient having noncirrhotic HCC in the DAA era increased 34% per year (95% CI, 1.05- 1.71) while there was no significant change seen in trends for white patients with noncirrhotic HCC. When performing analysis using the FIB-4 score, rates of HCC increased by 22% (95% CI, 1.05-1.42) per year for Black patients in the DAA era and by 12% (95% CI, 1.04-1.21) per year for white patients.

Overall, researchers found that rates of HCC in Black patients with cirrhosis and in both Black and white patients with a FIB-4 score greater than 3.25 declined in the DAA era.

“It's important to note that HCC rates are rising in Black patients without cirrhosis in the DAA era. This may be in part due to lower rates of HCV treatment for Black patients,” Nephew concluded. “More research is needed to better understand the characteristics of patients developing HCC without cirrhosis.”