Liver cancer in 2021: Global Burden of Disease study

Racial and ethnic differences in social determinants of health among patients with HCC

BACKGROUND

Racial and ethnic minority populations are disproportionately impacted by HCC due to more advanced tumor burden and underuse of treatments. We explored racial and ethnic differences in medical mistrust, barriers to treatment, and health literacy among patients with HCC.

METHODS

We conducted a multicenter survey among patients with newly diagnosed HCC between September 2018 and July 2023 at 4 large U.S. health systems. The survey assessed medical mistrust [Group-Based Medical Mistrust Scale (GBMMS)], health literacy (CHEW Assessment of Health Literacy), and barriers to HCC treatment. We performed multivariable logistic regression to evaluate associations between race and ethnicity and survey measures.

RESULTS

Of 1245 eligible patients, 833 (66.9%) completed the survey (45.9% Hispanic, 35.9% White, and 14.2% Black). A higher proportion of Black and Hispanic patients had high medical mistrust than White patients (14.2% and 3.3% vs. 0.7%, respectively; p<0.001). In multivariable analysis, Black race (OR: 19.2, 95% CI: 4.2-87.7) but not Hispanic ethnicity (OR: 3.72, 95% CI: 0.80-17.2) was significantly associated with high mistrust. Compared to White patients, Black and Hispanic patients both reported greater barriers to HCC treatment, with the most common barriers being concerns about pain (41.6%), financial burden (37.6%), and time commitment (31.1%). Limited health literacy was reported by 38.1% of patients (46.8% Hispanic, 41.0% Black, 26.2% White; p<0.001).

CONCLUSIONS

Medical mistrust, barriers to treatment, and limited health literacy are prevalent among Black and Hispanic patients with HCC. Understanding the interplay between race, ethnicity, and these factors is essential to address HCC disparities.

Multifaceted roles of lactate dehydrogenase in liver cancer (Review)

Hepatocellular carcinoma (HCC) has high morbidity and mortality rates, and metabolic reprogramming of HCC cells supports the proliferation and development of tumor cells. Lactate dehydrogenase (LDH), a key metabolic enzyme, can maintain the rapid proliferative demand of tumor cells by promoting glycolysis and lactate production in HCC cells. In addition, LDH regulates redox homeostasis and influences lipid synthesis and signaling pathways, further promoting tumor invasion and metastasis. In the tumor microenvironment, LDH affects the function of immune cells and stromal cells by regulating the lactate concentration in and promoting the immune escape and angiogenesis of tumor cells. Since elevated levels of LDH are closely associated with tumor load, invasiveness and poor prognosis, LDH also has promising applications in the early diagnosis, treatment and prognostic assessment of HCC. The present study reviewed the roles of LDH in the occurrence, development, diagnosis, prognosis and treatment of HCC and explored its value as an important biomarker and potential therapeutic target, with the aim of providing a comprehensive reference for HCC‑related research and clinical practice.

Metabolic dysfunction-associated steatotic liver disease: A sexually dimorphic disease and breast and gynecological cancer

Metabolic dysfunction-associated steatotic liver disease (MASLD) has become a global public health and economic burden worldwide in the past few decades. Epidemiological studies have shown that MASLD is a multisystem disease that is associated not only with liver-related complications but also with an increased risk of developing extrahepatic cancers. MASLD is a sexually dimorphic disease with sex hormones playing an important role in the development and progression of MASLD, especially by the levels and ratios of circulating estrogens and androgens. MASLD is associated with hormone-sensitive cancers including breast and gynecological cancer. The risk of breast and gynecological cancer is elevated in individuals with MASLD driven by shared metabolic risk factors including obesity and insulin resistance. Multiple potential mechanisms underline these associations including metabolic dysfunction, gut dysbiosis, chronic inflammation and dysregulated release of hepatokines. However, the effect of hormone therapy including hormone replacement therapy and anti-estrogen treatment on MASLD and female-specific cancers remains debatable at this time. This synopsis will review the associations between MASLD and breast and gynecological cancer, their underlying mechanisms, implications of hormonal therapies, and their future directions.

Unlocking the lipid code: SREBPs as key drivers in gastrointestinal tumour metabolism

In recent years, metabolic reprogramming has emerged as a significant breakthrough in elucidating the onset and progression of gastrointestinal (GI) malignancies. As central regulatory hubs for lipid metabolism, sterol regulatory element binding proteins (SREBPs) integrate dietary metabolic signals and carcinogenic stimuli through subtype-specific mechanisms, thereby promoting malignant tumour phenotypes. In this review, we first present the molecular background, structural characteristics, and posttranscriptional regulatory networks associated with SREBPs. We subsequently describe a systematic analysis of the distinct activation patterns of SREBPs in liver, gastric, colorectal, and other gastrointestinal cancers. Furthermore, we explore targeted intervention strategies for different SREBP subtypes, including small molecule inhibitors (such as fatostatin, which inhibits SREBP cleavage), natural compounds (such as berberine, which modulates the AMPK/mTOR pathway), and statin-mediated inhibition of the mevalonic acid pathway. These strategies may enhance tumour cell sensitivity to chemotherapeutic agents (such as 5-FU, gezil, and tabine) and improve the response to synergistic chemoradiotherapy by reversing adaptive metabolic resistance driven by the tumour microenvironment. Through this review, we hope to provide new insights into precise interventions targeting various subtypes of the SREBP molecule.

Esculetin inhibits liver cancer by targeting glucose-6-phosphate isomerase mediated glycolysis

BACKGROUND

Liver cancer is challenging to detect in its early stages, and the global incidence rate and mortality associated with this disease have reached alarming levels. Currently, treatment options for liver cancer are limited, and there is a significant lack of safe and effective therapeutic agents. Esculetin is a natural product, exhibits almost non-toxic and inhibitory properties against various malignancies, making it a subject worthy of further investigation in liver cancer.

METHODS

In this study, potential targets of esculetin in liver cancer were identified through transcriptomics, network pharmacology, and molecular docking technologies, and gene interference. Direct binding targets of esculetin were identified using surface plasmon resonance (SPR). The molecular mechanisms by which esculetin affects glucose metabolism in liver cancer were also explored. Finally, the activity against liver cancer and mechanisms of action of esculetin were validated in vivo using a mouse tumor model.

RESULTS

Glucose-6-phosphate isomerase (GPI) was shown to have a direct binding affinity for this compound. Esculetin inhibits glycolysis in liver cancer through its interaction with GPI and it was shown to exert a significant inhibitory effect on the genes and proteins associated with glycolysis such as ALDOA, ENO1, GAPDH, LDHA, PFKL, PGAM1, PGK1, and PKM2. Furthermore, esculetin not only suppresses the growth of liver cancer cells in vitro but also exhibits notable anti-tumor effects in vivo.

CONCLUSIONS

This study demonstrated the inhibitory effects of esculetin against liver cancer both in vitro and in vivo, demonstrating inhibition of glycolysis in liver cancer cells. In addition, the key glycolysis enzyme GPI was identified as a direct target of esculetin.

Advances in Locoregional and Systemic Treatments for Hepatocellular Carcinoma

Significant advances have occurred in the locoregional and systemic therapy landscape for hepatocellular carcinoma (HCC), with the most notable being the introduction of immune checkpoint inhibitor (ICI) combinations. ICI combinations have significantly improved the overall survival of patients with unresectable HCC, affording median survival over 2 years and long-term survival exceeding 5 years in a subset of patients. Accordingly, there has been increased interest in the earlier application of systemic therapies, including (neo)adjuvant therapy in the perioperative setting or in combination with intra-arterial therapies. However, recent data failed to demonstrate improved recurrence-free survival with use of adjuvant ICI therapy. Conversely, 2 trials showed improved progression-free survival when ICI therapies were combined with transarterial chemoembolization, although data regarding the impact on overall survival are still immature. These improved outcomes raise several new questions, including which patients with liver-localized HCC should receive systemic therapy, how should this be sequenced or combined with other available therapies, and how to manage those patients with marked responses, including consideration of liver transplantation. These questions are often determined on a case-by-case basis and best made in a multidisciplinary manner considering several factors, including tumor burden, degree of liver dysfunction, performance status, and patient's long-term goals of care.

Hepatitis B surface antigen: carcinogenesis mechanisms and clinical implications in hepatocellular carcinoma

Liver cancer is the third leading cause of death globally, with hepatitis B virus (HBV) infection being identified as the primary risk factor for its development. The occurrence of HBV-related hepatocellular carcinoma (HCC) is attributed to various mechanisms, such as chronic inflammation and liver cell regeneration induced by the cytotoxic immune response triggered by the virus, abnormal activation of oncogenes arising from HBV DNA insertion mutations, and epigenetic alterations mediated by viral oncoproteins. The envelope protein of the HBV virus, known as hepatitis B surface antigen (HBsAg), is a key indicator of increased risk for developing HCC in HBsAg-positive individuals. The HBsAg seroclearance status is found to be associated with recurrence in HCC patients undergoing hepatectomy. Additional evidence indicates that HBsAg is essential to the entire process of tumor development, from initiation to advancement, and acts as an oncoprotein involved in accelerating tumor progression. This review comprehensively analyzes the extensive effects and internal mechanisms of HBsAg during the various stages of the initiation and progression of HCC. Furthermore, it highlights the importance and potential applications of HBsAg in the realms of HCC early diagnosis and personalized therapeutic interventions. An in-depth understanding of the molecular mechanism of HBsAg in the occurrence and development of HCC is provided, which is expected to develop more precise and efficient strategies for the prevention and management of HCC in the future.

Southeast Asia burden and trend of Gastrointestinal tract cancers from 1990 to 2021 and its prediction to 2050: findings from the Global Burden of Disease Study 2021

BACKGROUND

The burden of disease associated with gastrointestinal (GI) tract cancer in Southeast Asia has changed significantly in recent years. This study analyzes data from the Global Burden of Disease Study (GBD)-2021 to examine trends in the burden of GI tract cancers in Southeast Asia from 1990 to 2021, identifies key risk factors, and predicts future trends.

METHOD

First, this study obtained data on GI tract cancer by age, sex, etiology, incidence, prevalence, deaths, disability-adjusted life years (DALYs), and risk factor from the GBD-2021 study focused on Southeast Asia data from 1990 to 2021. Secondly, the study also examined the temporal trend of subtype-specific GI tract cancer disease burden in Southeast Asia from 1990 to 2021 using linear regression modeling to calculate estimated annual percentage change (EAPC) values. The autoregressive integrated moving average (ARIMA) model was also used to project the future disease burden from 2022 to 2050. Finally, risk factors for GI tract cancer of different etiologies were also analyzed.

RESULTS

In 2021, the number of deaths, DALYs, incidence, and prevalence cases of GI tract cancers in Southeast Asia were about 216,074, 5,955,050, 258,629, and 686,835, respectively, with colorectal cancer (CRC) associated with the most severe burden of disease. Between 1990 and 2021, the number of deaths and DALYs associated with CRC and pancreatic cancer (PC) and the corresponding age-standardized rates (ASRs) showed a significant upward trend, with the fastest growth being in PC. The total number of esophageal (EC), gastric (GC), liver (LC), and gallbladder and biliary tract (GBTC) cancer-related deaths and DALYs increased, but the age-standardized rates declined significantly. Predictive data suggest that age-standardized death rate (ASDR), ASR of DALYs, age-standardized incidence rate (ASIR), and age-standardized prevalence rate (ASPR) will continue to decline in EC, GC, and LC, with the most pronounced declines, especially in GC. Overall, ASRs will continue to rise in the cases of CRC, PC, and GBTC cancers. ASDRs associated with GI tract cancers are greatest among those over 90 years of age. The burden of disease is significantly greater in men than in women, and this gender-induced difference is most pronounced in LC.

CONCLUSION

While the disease burden of various types of gastrointestinal (GI) cancers in Southeast Asia is experiencing both increases and declines, the overall burden remains significant, with the total number of cases expected to rise in the coming years. To alleviate the impact of severe GI cancers, public health professionals and policymakers must proactively develop and adapt prevention and control strategies, ensuring they are aligned with the shifting disease trends and the evolving risk factors associated with each type of GI tumor.

Metabolic dysfunction-associated steatotic liver disease in adults

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the umbrella term that comprises metabolic dysfunction-associated steatotic liver, or isolated hepatic steatosis, through to metabolic dysfunction-associated steatohepatitis, the progressive necroinflammatory disease form that can progress to fibrosis, cirrhosis and hepatocellular carcinoma. MASLD is estimated to affect more than one-third of adults worldwide. MASLD is closely associated with insulin resistance, obesity, gut microbial dysbiosis and genetic risk factors. The obesity epidemic and the growing prevalence of type 2 diabetes mellitus greatly contribute to the increasing burden of MASLD. The treatment and prevention of major metabolic comorbidities such as type 2 diabetes mellitus and obesity will probably slow the growth of MASLD. In 2023, the field decided on a new nomenclature and agreed on a set of research and action priorities, and in 2024, the US FDA approved the first drug, resmetirom, for the treatment of non-cirrhotic metabolic dysfunction-associated steatohepatitis with moderate to advanced fibrosis. Reliable, validated biomarkers that can replace histology for patient selection and primary end points in MASH trials will greatly accelerate the drug development process. Additionally, noninvasive tests that can reliably determine treatment response or predict response to therapy are warranted. Sustained efforts are required to combat the burden of MASLD by tackling metabolic risk factors, improving risk stratification and linkage to care, and increasing access to therapeutic agents and non-pharmaceutical interventions.

Alcohol-Related Liver Disease, Followed by Metabolic Dysfunction-Associated Steatotic Liver Disease, Emerges as the Fastest-Growing Aetiologies for Primary Liver Cancer in the United States

OBJECTIVE

Primary liver cancer (PLC) is projected to be the third leading cause of cancer mortality in the United States in 2040. We examine the burden of PLC in the United States, stratified by sex, state and aetiological risk factors.

METHODS

Data on PLC prevalence, incidence, death and disability-adjusted life years (DALYs) were extracted from the Global Burden of Disease Study 2021. Changes in these parameters were calculated using the Joinpoint regression model.

RESULTS

There were 47,970 cases, 31,450 incident cases, 24,770 deaths and 576,920 DALYs from PLC in the United States. The highest prevalence (16,980), incidence (12,040), death (9840) and DALYs (213,410) from PLC were due to chronic hepatitis C virus infection. From 2000 to 2021, PLC incidences increased by 141%, and PLC deaths increased by 136%. Age-standardised incidence rates (ASIRs) and death rates (ASDRs) per 100,000 population for PLC increased, primarily driven by alcohol-related liver disease (ALD) (ASIR: annual percent change [APC]: +2.40%; ASDR: APC: +2.22%) and metabolic dysfunction-associated steatotic liver disease (MASLD) (ASIR: APC: +2.32%; ASDR: APC: +2.04%).

CONCLUSION

The burden of PLC in the United States has risen in the past two decades, driven mainly by ALD and followed by MASLD. These findings offer policymakers an accurate assessment of the PLC burden and emphasise the need for targeted risk factor mitigation, especially regarding alcohol related policy.

Persisting challenges in the early detection of hepatocellular carcinoma

INTRODUCTION

Prognosis in patients with HCC is largely determined by stage at diagnosis, highlighting the importance of effective early detection strategies. HCC surveillance is associated with increased early detection and reduced HCC-related mortality and is currently recommended in patients with cirrhosis or chronic HBV infection.

AREAS COVERED

We performed a targeted literature review to identify limitations of current HCC surveillance practices and strategies for improvement.

EXPERT OPINION

Semi-annual ultrasound continues as the cornerstone modality for HCC surveillance but has limited sensitivity for detecting early-stage HCC, particularly in patients with obesity and non-viral etiologies. Although sensitivity for early-stage HCC can be improved by using ultrasound with alpha fetoprotein, this strategy misses over one-third of HCC at an early stage. Emerging imaging and biomarker-based surveillance strategies currently remain in varying stages of validation and are not yet ready for routine use in practice. The cost-effectiveness of surveillance in patients with non-cirrhotic liver disease related to hepatitis C or metabolic dysfunction-associated steatotic liver disease continues to be debated, although subgroups with advanced fibrosis may warrant surveillance. Finally, the effectiveness of surveillance is diminished by underuse in clinical practice, particularly in racial minority and low-income groups, highlighting a need for interventions to increase utilization.

Global burden of burns among children and adolescents: a trend analysis from the global burden of disease study 2019

Precise

This study investigates global trends in burns among children and adolescents using data from the Global Burden of Disease Study 2019. Analyzing incidence and YLD rates across 204 countries from 1990 to 2019 reveals a general decline in burn-related injuries, with age and sex influencing trends. Notably, in high-SDI regions, incidence rates initially increased before reversing. These findings highlight the need for targeted public health policies and resource allocation to reduce burn-related risks in vulnerable populations.

Background

Given the lack of long-term trend studies on global burns among children and adolescents, this study examined trends in the global burden of burns among children and adolescents.

Methods

The Global Burden of Disease (GBD) Study 2019 provided the statistical data. Sex, age, region, and SDI were used as stratification variables in the study to evaluate the prevalence of burns injuries among kids and teenagers across 204 nations and territories between 1990 and 2019. YLD rates per 100,000 people and incidence rates together with their respective average annual percentage changes (AAPC) were computed to evaluate burden trends. Furthermore, AAPC in YLD rates and incidence rates spanning various age cohorts were analyzed using the Joinpoint software.

Results

The worldwide burns incidence and YLD rates of burns among kids and teenagers exhibited a general declining trend between 1990 and 2019. Concerning the general trend in new cases, incidence rates, and YLD rates, age was positively associated. In 2019, the incidence rate for females surpassed that of males, while YLD rates for females were consistently higher than those of males. New Zealand, Czechia, and Australia rank as the top three among the 204 countries studied. Interestingly, in the high SDI range, the expected values based on incidence rates reversed after first rising with the SDI.

Conclusion

Overall, the incidence and YLD rates of burns among children and adolescents have declined globally, though significant disparities exist across age groups, sexes, regions, and countries. These findings could help guide the development of more targeted strategies to reduce the burn burden in this population.

Pifithrin-μ sensitizes mTOR-activated liver cancer to sorafenib treatment

TSC2, a suppressor of mTOR, is inactivated in up to 20% of HBV-associated liver cancer. This subtype of liver cancer is associated with aggressive behavior and early recurrence after hepatectomy. Being the first targeted regimen for advanced liver cancer, sorafenib has limited efficacy in HBV-positive patients. In this study, we observed that mTOR-activated cells, due to the loss of either TSC2 or PTEN, were insensitive to the treatment of sorafenib. Mechanistically, HSP70 enhanced the interaction between active mTOR-potentiated CREB1 and CREBBP to boost the transcription of the antioxidant response regulator SESN3. In return, elevated SESN3 enhanced cellular antioxidant capacity and rendered cells resistant to sorafenib. Pifithrin-μ, an HSP70 inhibitor, synergized with sorafenib in the induction of ferroptosis in mTOR-activated liver cancer cells and suppression of TSC2-deficient hepatocarcinogenesis. Our findings highlight the pivotal role of the mTOR-CREB1-SESN3 axis in sorafenib resistance of liver cancer and pave the way for combining pifithrin-μ and sorafenib for the treatment of mTOR-activated liver cancer.

NAFLD to MAFLD: collaboration, not confusion - rethinking the naming of fatty liver disease

The recent shift from “non-alcoholic fatty liver disease” (NAFLD) and “metabolic associated fatty liver disease” (MAFLD) to “metabolic dysfunction-associated steatotic liver disease” (MASLD) has raised questions about its scientific basis and impact on patient understanding. This renaming may create confusion rather than clarity. A collaborative approach involving healthcare professionals, researchers, and patients to establish terminology that balances scientific accuracy with accessibility is needed. Effective disease naming should be accurate, unique, consistent, objective, and accessible - qualities essential for clear communication in healthcare. Disease name is more than scientific correctness because naming conventions for public use, especially anything related to health, must be a matter of convenience, ethics, and cultural and social acceptance. Education and straightforward communication should take precedence over renaming, helping patients and healthcare providers fully understand the complexities and implications of liver disease for treatment. After all, from a scientific and public health perspective, MAFLD has clear advantages over MASLD.

An Integrated Analysis of the Role of Gut Microbiome-Associated Metabolites in the Detection of MASH-Related Cirrhosis

BACKGROUND AND AIM

The prevalence and adverse outcomes of metabolic dysfunction associated with steatotic liver disease (MAFLD) are increasing. The changes in the gut microbiota and metabolites associated with metabolic dysfunction-associated steatohepatitis (MASH) are regarded as an essential part of the progression of MAFLD. This study aimed to identify the gut microbiota and metabolites involved in the development of MAFLD in patients.

METHOD

This study enrolled 90 patients (healthy controls, HC: n = 30; MASH: n = 30; MASH-related cirrhosis, MC: n = 30), and their fecal samples were collected for 16S rRNA sequencing and non-targeted LC-MS/MS metabolomics analysis. Data preprocessing and statistical analyses were performed using QIIME2 software, Pynast, QIIME2 package, Progenesis QI, and R program.

RESULTS

The abundance of Prevotellaceae at the family level and Prevotella at the genus level was lower in the MASH and NC samples than in the HC samples. Both Prevotellaceae and Prevotella showed the strongest correlation with MASH progression via random forest analysis. Untargeted metabolomics was used to quantitatively screen for discrepant metabolites in the stool samples from the three groups. Linolenic acid (LA)-related metabolite levels were significantly lower in MASH and NC samples. Associations between Prevotella- or LA-related metabolites and liver function were discovered. A high abundance of Prevotella was associated with LA-related metabolites and MASH.

CONCLUSION

This study identified that gut microbiota and metabolites are associated with MASH-related metabolic dysfunction. LA and Prevotella are depleted during MASH progression, and additional supplementation with Prevotella may be a potential strategy for the future treatment of MAFLD.

Beyond the Liver: A Comprehensive Review of Strategies to Prevent Hepatocellular Carcinoma

BACKGROUND/OBJECTIVES

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality worldwide, primarily developing in the context of chronic liver disease. Traditional prevention has focused on liver-specific interventions like antiviral therapies and surveillance. However, extrahepatic factors also significantly contribute to HCC risk. This review explores comprehensive strategies for HCC prevention, including both hepatic and extrahepatic factors.

METHODS

An extensive literature search of peer-reviewed articles up to October 2024 was conducted, focusing on studies addressing HCC prevention strategies. Studies that focused on both hepatic and extrahepatic factors were included. Data were extracted and synthesized to provide an overview of current prevention strategies and their effectiveness in reducing HCC incidence.

RESULTS

Hepatitis B vaccination and antiviral treatments for hepatitis B and C significantly reduce HCC incidence. Lifestyle modifications-such as reducing alcohol consumption, maintaining a healthy weight through diet and exercise, and smoking cessation-are crucial in lowering HCC risk. Environmental measures to limit exposure to aflatoxins and other hazards also contribute to prevention. Regular surveillance of high-risk groups enables early detection and improves survival rates. Emerging strategies like immunotherapy and gene therapy show potential for further reducing HCC risk.

CONCLUSIONS

A comprehensive approach combining medical interventions, lifestyle changes, and environmental controls is essential for effectively decreasing HCC incidence globally. Implementing these combined measures could significantly reduce the global burden of HCC.