Diverging Incidence Trends for Hepatocellular Carcinoma in Rural and Urban Settings in the United States

Rurality and Neighborhood Socioeconomic Status are Associated With Overall and Cause-Specific Mortality and Hepatic Decompensation in Type 2 Diabetes

INTRODUCTION

Social determinants of health are key factors driving disease progression. In type 2 diabetes there is limited literature on how distal or intermediate factors (eg, those at the neighborhood level) influence cause-specific mortality or liver disease outcomes.

METHODS

This was a single-center retrospective study of patients with type 2 diabetes seen at an integrated healthcare system in the United States. The primary outcomes were overall mortality; death due to cardiovascular disease, cancer, or liver disease; or hepatic decompensation. The primary predictors were neighborhood-level (intermediate) factors measuring neighborhood poverty (Area Deprivation Index [ADI], affluence score, disadvantage score) and rurality (Rural-Urban Commuting Area scores). Associations were modeled using Cox proportional hazards or Fine-Grey competing risk models.

RESULTS

28,424 participants were included. Higher neighborhood poverty associated with increased overall mortality, with hazard ratio (HR) 1.11 (95% confidence interval 1.10-1.12, P < .001) per 10 points of ADI and HR 1.32 (95% CI 1.26-1.37, P < .001) for 10 points of disadvantage. Conversely, higher neighborhood affluence associated with lower overall mortality with HR 0.87 (95% CI 0.86-0.89, P < .001) per 10 points of affluence. Living in a rural region associated with increased overall mortality: HR 1.08 (95% CI 1.01-1.15, P = .031). Associations were consistent across cause-specific mortality, though effect sizes were larger for liver-related mortality than for other causes. Living in a more rural neighborhood was associated with increased risk of hepatic decompensation.

CONCLUSIONS

Intermediate neighborhood-level socioeconomic status was associated with overall and cause-specific mortality in type 2 diabetes, with larger effects on liver-related mortality than other causes.

HPV-unrelated oropharyngeal cancer has elevated risk of synchronous hepatobiliary second primary malignancies compared to HPV-related oropharyngeal cancer: a population-based study from SEER

BACKGROUND

Our aim was to compare risk of synchronous and metachronous hepatobiliary second primary malignancies (SPMs) in survivors of human papillomavirus (HPV)-related [i.e., p16(+)] and HPV-unrelated [i.e., p16(-)] oropharyngeal cancer (OPC).

METHODS

A retrospective study was conducted for cases with OPC diagnosis during years 2018-2021 who had known p16 status using data of USA from Surveillance, Epidemiology, and End Results (SEER) Program [Incidence - SEER Research Limited-Field Data, 22 Registries (excl IL and MA), Nov 2023 Sub (2000-2021)]. In the statistical analyses, death was considered as a competing event for the development of a hepatobiliary SPM. Bias due to unbalanced baseline characteristics was eliminated by adjustments using propensity score and inverse probability of treatment weighting (IPTW). Risk of development of a hepatobiliary SPM was assessed using propensity-score-adjusted time-varying Cox proportional hazard regression [adjusted hazard ratio (aHR) with 95 % confidence interval (95 % CI)].

RESULTS

Overall, 25759 cases with tumor status of p16(-) (6353) and p16(+) (19406) with median (interquartile range) follow-up times of 14 (6, 26) and 20 (9, 32) months, respectively, were included. From these, 48 had a hepatobiliary SPM. Compared to HPV-related OPC, HPV-unrelated OPC had significantly elevated risk of synchronous all hepatobiliary SPMs [aHR= 2.39 (95 % CI, 1.11-5.15); P = 0.026] and synchronous hepatocellular carcinoma (HCC) SPM [aHR= 2.86 (95 % CI, 1.18-6.92); P = 0.020], but not metachronous ones. Curves of cumulative incidence of a hepatobiliary (or HCC) SPM and cumulative survival probability for those with a hepatobiliary SPM, both stratified by p16 status and adjusted by IPTW, were generated. The median survival time among patients with a hepatobiliary SPM was shorter for HPV-unrelated OPC (0.8 years) compared to HPV-related OPC (2.6 years).

CONCLUSION

The observed elevated risk was likely due to heavy alcohol and tobacco use and the protective role of HPV infection against HCC development in carriers of hepatitis C virus.

Rural-Urban Disparities in Hepatocellular Carcinoma Deaths Are Driven by Hepatitis C-Related Hepatocellular Carcinoma

INTRODUCTION

Recent data suggest emerging rural-urban disparities in hepatocellular carcinoma (HCC) burden in the United States. We aimed to assess (i) trends in rural vs urban HCC-related mortality and (ii) differences in underlying chronic liver disease etiologies contributing to HCC-related deaths.

METHODS

We used the National Vital Statistics System to examine crude and age-adjusted HCC death rates overall and by etiology for rural and urban residents from 2005 to 2023. Using the National Cancer Institute Joinpoint Trend Analysis Software, we identified statistically significant changes in annual percentage change (APC) in HCC mortality rates.

RESULTS

Examining mortality rates over time, average APC in HCC deaths was significantly higher in rural residents (crude average annual percentage change [AAPC] 4.64, 95% confidence interval [CI] 4.10, 5.34; age-adjusted AAPC 3.53, 95% CI 3.09, 4.07) compared with urban residents (crude AAPC 2.72, 95% CI 2.43, 3.01; age-adjusted AAPC 1.68, 95% CI 1.28, 2.13). Differences in HCC death rate changes were driven by a significantly greater recent decline in HCC cases from hepatitis C virus (HCV) in urban residents (crude APC -6.69, 95% CI -8.85, -5.30 from 2017 to 2023) compared with rural residents (crude APC -3.31, 95% CI -8.05, 0.73 from 2016 to 2023).

DISCUSSION

Annual increases in HCC deaths have been more pronounced in rural compared with urban populations. Deaths from HCV-related HCC have declined with a geographical disparity that favors urban populations, possibly driven by decreased access to HCV screening or availability of highly effective direct-acting antiviral therapies for rural residents. These findings underscore the need for targeted HCV screening and treatment strategies in rural populations in addition to ongoing strategies to combat alcohol use and metabolic diseases.

Dosimetric investigation of multi-parametric 4D-MRI for radiotherapy in liver cancer

BACKGROUND

In radiotherapy, inadequate management of organ motion in liver cancer may lead to inadequate delineation accuracy, resulting in the underdosage of target tissues and overdosage of surrounding normal tissues. To investigate the clinical potential of multi-parametric 4D-MRI in the target delineation and dose accuracy for liver cancer radiotherapy.

METHODS

Twenty patients receiving radiotherapy for liver cancer were enrolled. Each patient underwent contrast-enhanced planning CT (free-breathing), contrast-enhanced T1-weighted (free-breathing), T2-weighted (gated) 3D-MRI, and low-quality 4D-MRI using the time resolved imaging with interleaved stochastic trajectories volumetric interpolated breath-hold examination (TWIST-VIBE) sequence. A dual-supervised deformation estimation model was used to generate a 4D deformable vector field (4D-DVF) from 4D-MRI data, and the prior images were deformed using this 4D-DVF to generate multi-parametric 4D-MRI. Assisted by 3D-MRI and multi-parametric 4D-MRI, target contours were performed on the planning CT, resulting in the generation of Target_3D and Target_4D. Clinical plans, Plan_3D and Plan_4D, were designed based on these contours respectively. To explore the dosimetric variations resulting from different contours without re-optimization, Plan_3D was directly applied to Target_4D, and Plan_4D was applied to Target_3D to generate Plan_3D' and Plan_4D' respectively. Target volume, contours, dose-volume histograms (DVHs), conformity index (CI), homogeneity index (HI), maximum and mean dose to organ as risks (OARs) were compared and evaluated.

RESULTS

Mean volume differences between Target_3D and Target_4D were 2.76 cm3 (standard deviation [SD] 3.42 cm3) in the caudate lobe, 181.54 cm3 (SD 68.50 cm3) in the left hepatic lobe, and 26.08 cm3 (SD 20.52 cm3) in the right hepatic lobe. Mean and SD of CI and HI is 1.02 ± 0.04 and 0.108 ± 0.02 in Plan_3D, 1.02 ± 0.01 and 0.107 ± 0.01 in Plan_4D. There were no statistically significant differences in OAR doses between Plan_3D and Plan_3D', between Plan_4D and Plan_4D'. However, a statistically significant difference in target dose was observed between Plan_3D and Plan_3D' (P = 1.47 × 10⁻⁷) and between Plan_4D and Plan_4D' (P = 0.013). Plan_3D' meets 100% of the prescription dose covering mean 77.89% (SD 10.13%) of the Targeted_4D volume, while Plan_4D' covered mean 94.17% (SD 3.12%) of the Targeted_3D volume.

CONCLUSIONS

3D image-guided target delineation may be more likely to underestimate target volume and compromise dose coverage, suggesting that using multi-parametric 4D-MRI can provide more precise target contours and enhance target dose coverage.

Differential Association of Hepatocellular Carcinoma Related to Hepatitis B Between Urban and Rural Areas in Africa Using Satellite Spatial Scaling Data

PURPOSE

Sub-Saharan Africa carries one of the highest burdens of hepatocellular carcinoma (HCC) in the world, with hepatitis B virus (HBV) as the most common cause. Studies in several regions of the world suggest important cancer differences in rural versus urban settings, but limited studies have been performed in Africa.

METHODS

We performed a scoping review and pooled analysis of studies on HCC in Africa. Using land use data from the European Space Agency, we calculated the distance in kilometers from each study site to the nearest rural area. Regression models were fit to estimate the association between distance to the nearest rural area and HBV, sex, and weighted mean age.

RESULTS

Data from 57 studies including 10,907 patients across 36 towns/cities were included in our analysis. Proximity to rural areas was associated with a higher frequency of HBV-associated HCC in assessment of distance both at midpoint and at quartiles after controlling for country: risk ratio (RR) 1.71 (95% CI, 1.52 to 1.93) and RR 1.51 (95% CI, 1.25 to 1.84), respectively. No association was found between sex and proximity to a rural area: RR 1.02 (95% CI, 0.96 to 1.08). The weighted mean age across the four distance quartiles was 50.09, 53.43, 47.98, and 53.35 years with no statistically significant difference found across the quartiles (P = .81).

CONCLUSION

Individuals living in rural Africa have a higher rate of HBV-related HCC compared with other liver diseases. Increased HBV awareness efforts in these areas should be considered.

Patterns of care and outcomes for hepatocellular carcinoma and pancreatic cancer based on rurality of patient's residence in a rural midwestern state

BACKGROUND

Although advancements in surgical planning and multidisciplinary care have improved the survival of patients with hepatopancreatic cancers in recent years, the impact of the rurality of patient residence on care received and survival is not well known. We aimed to assess the association between the rurality of a patient's residence and cancer-specific survival outcomes among patients with hepatocellular carcinoma (HCC) and pancreatic cancer (PC) in Iowa, hypothesizing that patients in rural areas would experience lower survival.

METHODS

Adult patients diagnosed with HCC or PC between 2010 and 2020 were identified using the Iowa Cancer Registry. Chi-square tests were used to compare categorical variables by rural/urban status. Logistic regression was used to examine factors associated with receiving surgery. Multivariable-adjusted Cox proportional hazards regression was used to determine associations with cancer-specific mortality.

RESULTS

Of 1877 patients with HCC, 58%, 27%, and 16% resided in metropolitan, micropolitan, and rural areas, respectively. Approximately 70% of patients in rural areas traveled ≥50 miles for definitive care. Additionally, those residing in rural areas had the highest proportion of patients receiving definitive care at non-Commission on Cancer (CoC) centers (12.6% metro vs 14% micro vs 22.2% rural, P < .001). In a multivariable-adjusted analysis of patients with stage I to III disease, definitive care at a non-CoC center was independently associated with lower odds of surgery (odds ratio [OR] = 0.23; 95% CI, 0.12-0.45; P < .0001) and higher mortality risk (OR = 1.39; 95% CI, 1.07-1.79; P = .01), though rural residence was not. For PC, 5465 patients were diagnosed, and 51%, 28%, and 20% resided in metropolitan, micropolitan, and rural areas, respectively. Similar to HCC, although rural residence was neither associated with odds of surgery nor with mortality risk, receiving definitive care at non-CoC accredited centers was associated with significantly lower odds of receiving surgery (OR = 0.17; 95% CI, 0.11-0.26; P < .0001) and higher mortality risk (OR = 1.48; 95% CI, 1.23-1.77; P < .0001).

CONCLUSION

Rural residents with hepatopancreatic cancer have the highest proportion of patients receiving definitive care at non-CoC centers, which is associated with lower odds of receiving surgery and higher odds of mortality. This highlights the importance of standardizing complex cancer care and the need to foster collaboration between specialized and non-specialized centers.

Changing Epidemiology of Hepatocellular Carcinoma Within the United States and Worldwide

Globally, hepatocellular carcinoma (HCC) is a major cause of cancer-related death and a leading cause of morbidity and mortality in patients with chronic liver disease and cirrhosis. The predominant cause of HCC is shifting from viral to nonviral causes, in parallel with the high global prevalence of nonalcoholic fatty liver disease and increasing alcohol consumption in many countries. There have been promising recent advances in the treatment of all stages of HCC; however, improvements in early detection, increased utilization of HCC surveillance, and equitable access to HCC therapies are needed to curb increases in HCC mortality.

Geographic disparities in access to liver transplantation

Since the Final Rule regarding transplantation was published in 1999, organ distribution policies have been implemented to reduce geographic disparity. While a recent change in liver allocation, termed acuity circles, eliminated the donor service area as a unit of distribution to decrease the geographic disparity of waitlisted patients to liver transplantation, recently published results highlight the complexity of addressing geographic disparity. From geographic variation in donor supply, as well as liver disease burden and differing model for end-stage liver disease (MELD) scores of candidates and MELD scores necessary to receive liver transplantation, to the urban-rural disparity in specialty care access, and to neighborhood deprivation (community measure of socioeconomic status) in liver transplant access, addressing disparities of access will require a multipronged approach at the patient, transplant center, and national level. Herein, we review the current knowledge of these disparities-from variation in larger (regional) to smaller (census tract or zip code) levels to the common etiologies of liver disease, which are particularly affected by these geographic boundaries. The geographic disparity in liver transplant access must balance the limited organ supply with the growing demand. We must identify patient-level factors that contribute to their geographic disparity and incorporate these findings at the transplant center level to develop targeted interventions. We must simultaneously work at the national level to standardize and share patient data (including socioeconomic status and geographic social deprivation indices) to better understand the factors that contribute to the geographic disparity. The complex interplay between organ distribution policy, referral patterns, and variable waitlisting practices with the proportion of high MELD patients and differences in potential donor supply must all be considered to create a national policy strategy to address the inequities in the system.

Health disparities in chronic liver disease

The syndemic of hazardous alcohol consumption, opioid use, and obesity has led to important changes in liver disease epidemiology that have exacerbated health disparities. Health disparities occur when plausibly avoidable health differences are experienced by socially disadvantaged populations. Highlighting health disparities, their sources, and consequences in chronic liver disease is fundamental to improving liver health outcomes. There have been large increases in alcohol use disorder in women, racial and ethnic minorities, and those experiencing poverty in the context of poor access to alcohol treatment, leading to increasing rates of alcohol-associated liver diseases. Rising rates of NAFLD and associated fibrosis have been observed in Hispanic persons, women aged > 50, and individuals experiencing food insecurity. Access to viral hepatitis screening and linkage to treatment are suboptimal for racial and ethnic minorities and individuals who are uninsured or underinsured, resulting in greater liver-related mortality and later-stage diagnoses of HCC. Data from more diverse cohorts on autoimmune and cholestatic liver diseases are lacking, supporting the need to study the contemporary epidemiology of these disorders in greater detail. Herein, we review the existing literature on racial and ethnic, gender, and socioeconomic disparities in chronic liver diseases using a social determinants of health framework to better understand how social and structural factors cause health disparities and affect chronic liver disease outcomes. We also propose potential solutions to eliminate disparities, outlining health-policy, health-system, community, and individual solutions to promote equity and improve health outcomes.

The hexokinase "HKDC1" interaction with the mitochondria is essential for liver cancer progression

Liver cancer (LC) is the fourth leading cause of death from cancer malignancies. Recently, a putative fifth hexokinase, hexokinase domain containing 1 (HKDC1), was shown to have significant overexpression in LC compared to healthy liver tissue. Using a combination of in vitro and in vivo tools, we examined the role of HKDC1 in LC development and progression. Importantly, HKDC1 ablation stops LC development and progression via its action at the mitochondria by promoting metabolic reprogramming and a shift of glucose flux away from the TCA cycle. HKDC1 ablation leads to mitochondrial dysfunction resulting in less cellular energy, which cannot be compensated by enhanced glucose uptake. Moreover, we show that the interaction of HKDC1 with the mitochondria is essential for its role in LC progression, and without this interaction, mitochondrial dysfunction occurs. As HKDC1 is highly expressed in LC cells, but only to a minimal degree in hepatocytes under normal conditions, targeting HKDC1, specifically its interaction with the mitochondria, may represent a highly selective approach to target cancer cells in LC.