The changing characteristics of hepatocellular cancer in Hawaii over time

The Changing Pathogenesis of Liver Cancer in Hawaii over Three Decades

BACKGROUND

Worldwide trends support the increasing contribution of hepatic steatosis to the incidence of hepatocellular carcinoma (HCC). This study investigates if similar changes are seen in Hawaii, where the incidence of HCC is higher than in most of the United States.

METHODS

This is a retrospective study of 1,651 patients diagnosed with HCC (1991-2023) that includes 60% to 70% of HCC cases in Hawaii. We evaluated changes in patient demographics, risk factors, and disease etiology over the past three decades.

RESULTS

From 1991 to 2023, there were significant increases in the proportion of HCC cases attributable to metabolic dysfunction-associated steatotic liver disease (MASLD), coinciding with an increase in the prevalence of metabolic risk factors including obesity, diabetes, hyperlipidemia, and hypertension. Cases with a history of smoking also increased through 2020. Conversely, HCC cases presenting with cirrhosis alone decreased. Hepatitis C virus (HCV)-associated cases increased through 2015 and then tapered, whereas Hepatitis B virus (HBV)-associated cases decreased through 2020. There was no significant change in the proportion of alcohol-associated cases.

CONCLUSIONS

Although HBV continues to be a major contributor to HCC in Hawaii, HCV-related HCC cases have tapered, whereas metabolic risk factors for HCC and cases attributable to MASLD have increased over time, paralleling overall trends observed in the United States. Efforts are needed to manage these metabolic factors to address the burden of HCC.

IMPACT

Although Hawaii continues to have a large burden of viral hepatitis-related HCC, metabolic factors and MASLD have affected the pathogenesis of liver cancer in Hawaii over the past three decades.

Hepatitis B Core Antibody Positivity Associated with Increased Risk of Liver Cancer in Patients with Chronic Hepatitis C: Analysis of a Large Patient Cohort in Hawai'i

Chronic hepatitis C infection is a major cause of liver cancer in the United States. Hawai'i's incidence of liver cancer consistently ranks among the highest in the US, due in part to the high prevalence of hepatitis B in the state. To better understand the factors associated with liver cancer among patients in Hawai'i with hepatitis C virus (HCV) infection, the patient database of Kaiser Permanente's Hawai'i region was used to identify a cohort of 3198 patients with a history of chronic HCV infection, of whom 159 (5%) were diagnosed with liver cancer between the years 2004-2020. Multiple logistic regression was used to identify factors independently associated with liver cancer. Male sex (AOR 2.02, 95% CI 1.34-3.06), Asian race (AOR 1.78, 1.16 - 2.74) and hepatitis B core antibody (HBCAB) positivity (AOR 1.76, 95% CI 1.25 - 2.49) emerged as independent predictors of liver cancer among patients with chronic HCV infection. A history of diabetes (AOR 1.56, 1.07 - 2.27) and older age at the time of HCV diagnosis (AOR 1.19, 1.09-1.29) also emerged as significant associations. HBCAB-positive individuals did not differ significantly from those who were HBCAB-negative in regards to demographics or 5-year survival rate. In this cohort of patients with chronic HCV, a positive HBCAB without evidence of active hepatitis B infection was associated with 1.76 increased odds of liver cancer compared to those with negative HBCAB. This finding may have important implications for screening algorithms among individuals with hepatitis C infection.

The Asian Immigrant Cancer Survivor Experience in the United States: A Scoping Review of the Literature

BACKGROUND

Cancer is the leading cause of death for Asian Americans, a growing population in the United States. While cancer survivors often experience complex issues after diagnosis, being an immigrant and having cancer pose additional challenges.

OBJECTIVE

This scoping review analyzed research about immigrant cancer survivors of Asian ethnicity in the United States and provided a structured method to understand an area of research and evidence. Aims focused on immigrants' experiences and how findings could tailor evidence-based interventions, programs, and resources.

METHODS

The PubMed, CINAHL, and Scopus databases were searched to identify studies in English (2009-2018) targeting Asian immigrant cancer survivors in the United States. While 385 records were initially identified, 32 studies met the inclusion criteria.

RESULTS

Thematic analysis of charted study elements revealed 4 themes with subthemes: (1) survival patterns, (2) barriers, (3) culturally informed care, and (4) quality of life (QOL). While qualitative studies provided insight about the cancer experience from immigrants' perspectives, quantitative designs posed descriptions and associations among QOL concepts.

CONCLUSIONS

Study results illustrate the need for survival research that explores outcomes by Asian ethnic subgroups and tracks the influence of acculturation. Future research should test culturally informed interventions that minimize barriers and foster QOL across the cancer continuum. Culturally tailored instruments can expedite larger-scaled studies that allow generalization.

IMPLICATIONS FOR PRACTICE

Asian immigrants comprise an underserved, vulnerable, and growing group with various cancers. Nurses who care for immigrants and their families should be cognizant of cultural beliefs, values, practices, and issues related to communication, care access, and socioeconomics.

A review of incidence and mortality of colorectal, lung, liver, thyroid, and bladder cancers in Iran and compared to other countries

In Iran, a developing country in southwest Asia, an epidemiologic transition is underway from communicable to noncommunicable diseases. In Iran, cancer is the second largest group of chronic non-communicable diseases (NCDs) and the third most common cause of death following heart disease, accidents and other natural phenomena. There are some studies reporting an increasing trend in the incidence and mortality rate of a variety of cancers in Iran. Therefore, controlling and preventive interventions pertaining to cancers must be a main priority for health policy and it is recommended that the high-risk population receive earlier screening. In this review, incidence and mortality of colorectal, lung, liver, thyroid, and bladder cancers in Iran are reported.

Hepatitis B Prevalence and Risk Factors in a Foreign-Born Asian and Pacific Islander Population at a Community Health Center in Hawai'i

Hawai'i has one of the highest rates of liver cancer in the United States. This is in large part due to undiagnosed chronic hepatitis B (CHB) infection among foreign-born Asian and Pacific Islanders (APIs). In order to estimate the prevalence of CHB infection among foreign-born APIs in Hawai'i, the Hawai'i State Department of Health conducted a cross-sectional study from August 2013 through August 2015 of patients of a federally qualified health center serving the largest population of medically underserved APIs in the state. Among 1261 patients surveyed, the prevalence of CHB infection (based on HBsAg seropositivity) was 5.6% (71/1259). No significant differences were detected by place of birth, age, or gender; however, the adjusted prevalence ratio of CHB infection was 6.0 times higher among persons reporting household contact with hepatitis B virus compared with those without such contact. Our findings underscore the need for targeted screening of at-risk individuals and their household contacts.

Clinical and molecular sub-classification of hepatocellular carcinoma relative to alpha-fetoprotein level in an Asia-Pacific island cohort

Aim

Increased serum alpha-fetoprotein (AFP) levels are associated with specific molecular sub-classes of hepatocellular carcinoma (HCC), supporting AFP as a predictive or therapeutic biomarker for precision treatment of this disease. Considering recent efforts to validate HCC molecular classification systems across different populations, we applied existing signature-based classification templates to Hawaii cohorts and examined whether associations between HCC molecular sub-class, AFP levels, and clinical features found elsewhere can also be found in Hawaii, a region with a unique demographic and risk factor profile for HCC.

Methods

Whole-genome expression profiling was performed on HCC tumors collected from 40 patients following partial hepatectomy. Tumors underwent transcriptome-based categorization into 3 molecular sub-classes (S1, S2, and S3). Patient groups based on molecular sub-class and AFP level were then compared with regards to clinical features and survival. Differences associated with AFP level and other clinical parameters were also examined at the gene signature level by gene set enrichment analysis.

Results

Statistically confident (false discovery rate < 0.05) sub-classifications were made in 98% (39/40) of tumors. Patient sub-groups differed significantly with regards to serum AFP level, with significantly lower levels in the S3 sub-group as compared to S1 (P = 0.048) and S2 (P = 0.010). Serum AFP > 400 ng/mL predicted significant tumor enrichment for genes corresponding to MYC target activation, high cell proliferation, poor clinical prognosis, and the S2 sub-class. AFP > 400 ng/mL and non-S3 tumor classification were found to be significant predictors of overall survival.

Conclusion

Distinct sub-classes of HCC associated with different molecular features and survival outcomes can be detected with statistical confidence in a Pacific Island cohort. Molecular classification signatures and other predictive markers for HCC that are valid for all patient populations are needed to support multi-center efforts to develop targeted therapies for HCC.