Trends in mortality from primary liver cancer in Europe

Trends of cancer mortality in Xi'an City, China: 2005-2020

PURPOSE

Describe and predict the malignant tumor deaths in Xi'an so as to provide evidence for the government to formulate the prevention and treatment plans.

METHODS

Overall malignant tumor death in Xi'an in the past 16 years was described. The multi-decrease life table was used to calculate cumulative mortality risk by cause and life expectancy reduction years by cause of malignant tumors in 2020. The join point regression models were used to analyze the change trend of standard mortality of malignant tumors in Xi'an from 2005 to 2020. The appropriate gray models were selected to predict the death of malignant tumors in Xi'an in the next decade.

RESULTS

The mortality of total malignant tumors in Xi'an showed that men are higher than women and the elderly are higher than other groups. As for 2020, lung cancer had the highest risk of death for both men and women, while leukemia had the highest life expectancy reduction years by cause. From 2005 to 2020, standardized mortality of majority malignant tumors showed downward trends, which were particularly obvious in recent years. The prediction results of several major malignant tumors showed that in the next decade, the mortality of most malignant tumors had downward trends, but combined with the increase of population in the future, the number of malignant tumor deaths in Xi'an will continue to increase.

CONCLUSIONS

Malignant tumors in Xi'an have decreasing mortality trends in recent years, and effective measures to prevent and treat tumors should be strengthened in the future.

The survival rate of hepatocellular carcinoma in Asian countries: a systematic review and meta-analysis

Hepatocellular carcinoma or Liver cancer (LC) is the sixth most common cancer and the fourth cause of death worldwide in 2018. There has not been a comprehensive study on the survival rate of patients with LC in Asia yet. Therefore, the present study was conducted to evaluate the survival rate of patients with LC in Asian countries. The methodology of the present study is based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) statement. The researchers searched five international databases including Medline/PubMed, Scopus, Embase, Web of Knowledge and ProQuest until July 1, 2018. We also searched Google Scholar for detecting grey literature. The Newcastle-Ottawa Quality Assessment Form was used to evaluate the quality of selected papers. A total of 1425 titles were retrieved. 63 studies met the inclusion criteria. Based on the random-effect model one-year, three-year and five-year survival rate of LC were 34.8 % (95 % CI; 30.3-39.3), 19 % (95 % CI ; 18.2-21.8) and 18.1 % (95 % CI ;16.1-20.1) respectively. According to the results of our study, the LC survival rate in Asian countries is relatively lower than in Europe and North America.

Pravastatin combination with sorafenib does not improve survival in advanced hepatocellular carcinoma

BACKGROUND & AIMS

Sorafenib is the standard of care for advanced hepatocellular carcinoma (HCC). Combining sorafenib with another treatment, to improve overall survival (OS) within an acceptable safety profile, might be the next step forward in the management of patients with advanced HCC. We aimed to assess whether a combination of sorafenib and a statin improved survival in patients with HCC.

METHODS

The objective of the PRODIGE-11 trial was to compare the respective clinical outcomes of the sorafenib-pravastatin combination (arm A) versus sorafenib alone (arm B) in patients with advanced HCC. Child-Pugh A patients with advanced HCC who were naive to systemic treatment (n = 323) were randomly assigned to sorafenib-pravastatin combination (n = 162) or sorafenib alone (n = 161). The primary endpoint was OS; secondary endpoints were progression-free survival, time to tumor progression, time to treatment failure, safety, and quality of life.

RESULTS

After randomization, 312 patients received at least 1 dose of study treatment. After a median follow-up of 35 months, 269 patients died (arm A: 135; arm B: 134) with no difference in median OS between treatments arms (10.7 months vs. 10.5 months; hazard ratio = 1.00; p = 0.975); no difference was observed in secondary survival endpoints either. In the univariate analysis, the significant prognostic factors for OS were CLIP score, performance status, and quality of life scores. The multivariate analysis showed that the only prognostic factor for OS was the CLIP score. The main toxicity was diarrhea (which was severe in 11% of patients in arm A, and 8.9% in arm B), while severe nausea-vomiting was rare, and no toxicity-related deaths were reported.

CONCLUSION

Adding pravastatin to sorafenib did not improve survival in patients with advanced HCC.

LAY SUMMARY

Sorafenib has proven efficacy for the treatment of patients with advanced hepatocellular carcinoma. However, overall survival remains poor in these patients, so we were interested to see if the addition of a statin, pravastatin, improved outcomes in patients with advanced HCC. This randomized-controlled trial demonstrated that the sorafenib-pravastatin combination did not improve overall survival in this study population compared to sorafenib alone. Clinical trial number: NCT01075555.

The Incidence of Hepatocellular Carcinoma in Iran from 1996 to 2016: a Systematic Review and Meta-analysis

PURPOSE

Hepatocellular carcinoma or liver cancer (LC) is one of most important cancer around the world. There are several reports about LC incidence from various Iranian locations with conflicting results. The present study aimed to accomplish a systematic review to estimate the accurate incidence rate of LC among Iranian people.

METHODS

This systematic review was performed based on the preferred reporting items for systematic reviews and meta-analyses (PRISMA) checklist in 2018. A literature search was conducted using international databases (Medline/PubMed, Scopus, ScienceDirect, and Google Scholar) for English papers and national databases (Scientific Information Database, MagIran, IranMedex, and IranDoc) for Persian papers which estimated incidence rate of LC in any geographical area of Iran. The incidence rate of LC was calculated using random effect model.

RESULTS

Of 171 papers in the primary searches, 15 studies were included by advanced screening and refinement. The age-standardized rate (ASR) of LC was 1.66 (95% CI 1.49-1.83) for males and 1.25 (95% CI 1.12-1.38) for females.

CONCLUSIONS

The incidence rate of LC in Iran was lower in comparison to other countries. Afterwards, more studies are necessary to outline the accurate incidence rate and the trend of LC among Iranian population.

THE CHANGING TREND OF MORTALITY CAUSED BY GASTROINTESTINAL CANCERS IN IRAN DURING THE YEARS 2006-2010

BACKGROUND

Cancers are one of the most important causes of death in the world. According to their high incidence and mortality, gastrointestinal cancers have particular importance among other cancers.

OBJECTIVE

Therefore, this study was conducted to investigate the mortality change trends of gastrointestinal cancers in Iran.

METHODS

This study was performed by analyzing the reported mortality data in 29 provinces of Iran in 2006-2010. Mortality trend of gastrointestinal cancers was drawn for both sexes in the study years and disaggregated by age groups and their frequency distribution. The WinPepi software was used for analysis.

RESULTS

In the years 2006-2010, the mortality rate of, gastric, colorectal, liver and pancreatic cancers, has significantly increased. Totally, gastrointestinal mortality is higher in men than women. Also, the results showed that by increasing age, death from these cancers also increased.

CONCLUSION

The most important causes of death from gastrointestinal cancers were gastric, liver and colorectal cancers in Iran and because of their increasing trend in the country, performing preventive interventions for the cancers' risk factors is necessary.

Cancer Mortality in Italy, 1998

This short report provides data and statistics of cancer mortality in Italy in 1998, updating previous work on the issue. The material and methods of this report are similar to those previously described1,2. Briefly, cancer death certification numbers by cause and estimates of the resident population in 1998, stratified by sex and quinquennia of age, were abstracted from data provided by the Istituto Nazionale di Statistica (ISTAT)3. All cancers or groups of cancers, classified according to the standard International Classification of Diseases (ICD), Ninth Revision4, were grouped in 31 categories, besides total cancer mortality and other and unspecified sites. We grouped together all intestinal sites, melanomas and non-melanomatous skin neoplasms, all uterine neoplasms (cervix and corpus), all neoplasms of the brain and nerves (benign and malignant), all leukemias, and all non-Hodgkin's lymphomas.

Eight tables were produced, including the following statistics: 1) number of deaths, crude and age-standardized death certification rates, and percentages of all cancer deaths for population at all ages and truncated 35-64 years (Table 1 for males and Table 2 for females). Two different standards were used: i) the 1971 Italian census population, corrected for census undercount and subdivided into 16 quinquennia of age from 0-4 to 75-79, plus 80 and over, and ii) the world standard population, for purposes of comparison with other countries; 2) age-specific death certification rates for each sex and quinquennium of age from 0-4 to 75-79, plus 80 and over (Table 3 for males and Table 4 for females); 3) total number of registered deaths for each cancer or group of cancers, sex and age group (Table 5 for males and Table 6 for females); 4) percentage of all cancer deaths for each sex and age group (Table 7 for males and Table 8 for females).

A few comments are included, mainly in order to assist reading and interpretation of data for major cancer sites, and to recall underlying long-term tendencies. Any inference should in any case be based on age-standardized rates, and, essentially, on detailed inspection of age-specific rates.

Cancer Mortality in Italy, 1997: Quantifying the Fall in Rates in Women and Men

Aims and Background

To update data and statistics on cancer death certification in Italy to 1997.

Methods

Data and statistics for 1997 subdivided into 31 cancer sites are presented. Trends in age-standardized rates for major cancer sites are plotted from 1955 to 1997. Results: The age-standardized (world standard) death certification rates from all neoplasms steadily declined from the peak of 199.2/100,000 males in 1988 to 174.7 in 1997 and for females from 102.5 to 93.0. The decline was larger in truncated rates, by about 26% for males since 1983 and by 24% for females since the top rate of the early 1960′s. A major component of the favorable trend in males was lung cancer, which showed a 16% decline from the peak of 1987-88, to reach 50.6/100,000 in 1997, corresponding to about 5,000 avoided deaths. The decline in lung cancer was about 34% at age 35 to 64. For females, in contrast, both the absolute number of lung cancer deaths and the age-standardized rate of 7.9/100,000 were among the highest values ever registered, reflecting the different pattern of spread of the tobacco-related lung cancer epidemic in the two sexes. Intestinal cancer rates were stable for males but declined by approximately 10% for females, mostly in middle age, as did breast cancer mortality. Among neoplasms showing favorable trends, there were other tobacco-related neoplasms in men, plus the continuing fall in stomach and cervix uteri. Upward trends were observed for non Hodgkin's lymphomas.

Conclusions

The fall in cancer mortality observed over the last decade in Italy is attributable to a decline in lung and other tobacco-related neoplasms in males, together with a persistent fall in stomach and uterine (cervical) cancer. In women, there were also recent falls in intestinal and breast cancer rates, and declines in both sexes in rarer neoplasms influenced by therapeutic advancements.

Estimates of the Incidence and Prevalence of Hepatocellular Carcinoma in Italy in 2002 and Projections for the Years 2007 and 2012

Aims and background

Data on liver cancer incidence and prevalence in Italy are not available on a national and regional level.

Methods

We provided estimates of the number of incident and prevalent cases for hepatocellular carcinoma in Italy overall and in various regions in 2002 and gave projections for the years 2007 and 2012. We obtained annual numbers of incident cases of hepatocellular carcinoma by combining mortality data provided by the World Health Organization and information on survival for liver cancer, and subsequently derived five-year prevalence for hepatocellular carcinoma by combining incidence with information on survival.

Results

In 2002, there were about 5800 incident cases and 4300 prevalent cases of hepatocellular carcinoma in Italy. The most reliable estimate of hepatocellular carcinoma incident cases in Italy in 2007 is between 5500 and 6000, and this figure is likely to decline to 5000–5500 in 2012. The best estimate of prevalence is about 4000 cases in 2007, which is likely to decline to 3700 in 2012.

Conclusions

Incidence and prevalence of hepatocellular carcinoma are likely to remain approximately stable between 2002 and 2007 and slightly decrease in the subsequent quinquennia. These projections are, however, subject to large uncertainties because of the problems in diagnosis and death certification for this neoplasm, particularly for the elderly.

Global trends and predictions in hepatocellular carcinoma mortality

BACKGROUND & AIMS

Trends in hepatocellular carcinoma (HCC) mortality rates have increased over recent decades in most countries. It is also the third cause of cancer death worldwide. The aim of this study is to update global trends in HCC mortality to 2014, and predict trends in rates in the EU, USA and Japan to 2020.

METHODS

Death certification data for HCC over the 1990-2014 period from the World Health Organization database were analyzed. Sixteen European, five American countries, and six other countries worldwide were included, as well as the EU as a whole.

RESULTS

In European men, mortality rates were stable during the last decade (3.5/100,000). HCC mortality increased in Northern and Central Europe, and decreased in Southern Europe. In the USA, HCC mortality increased by 35% between 2002 and 2012, reaching 3.1/100,000 men in 2012; it is predicted to remain stable to 2020. Reduced mortality rates were observed in East Asia, although they remained around 10-24/100,000 men. In Japan, HCC mortality is predicted to decrease (5.4/100,000 men in 2020). Trends were favorable in the young, but unfavorable in middle aged, except in East Asia. Mortality rates were 3- to 5-fold lower in women than men in most regions, but trends were similar.

CONCLUSIONS

Control of hepatitis B (HBV) and hepatitis C virus (HCV) infections has contributed to the decrease in HCC-related mortality in East Asia and Southern Europe. Unfavorable trends in other regions can be attributed to HCV (and HBV) epidemics in the 1960s and 1980s, alcohol consumption, increased overweight/obesity, and diabetes. Better management of cirrhosis, HCC diagnosis and treatment are also influencing the mortality trends worldwide.

LAY SUMMARY

Mortality rates due to HCC have increased in many countries over recent decades. In this study, we updated worldwide mortality trends for HCC from 1990 to 2014, and predicted trends for some countries to 2020. We observed unfavorable trends in Northern and Central Europe, North and Latin America. East Asia showed an improvement, however mortality rates in this region were 2- to 5-fold higher than in most European countries and the Americas. Steady declines to 2020 are predicted for East Asia but not for Europe and the Americas.

Mean corpuscular volume levels and all-cause and liver cancer mortality

BACKGROUND

An elevated mean corpuscular volume (MCV) is associated with aging, nutrition, alcohol abuse and more, and it is known as a survival predictor in chronically ill patients. The aim of this study was to investigate the association between MCV levels and mortality from all-causes, cancer and site-specific cancer in a non-anemic healthy population.

METHODS

A total of 36,260 participants aged 40 years or older who underwent routine check-ups at Seoul National University Hospital Health Promotion Center between 1995 and 2008 were followed-up for mortality until December 31, 2008, retrospectively.

RESULTS

During an average follow-up of 8.0 years, 1107 deaths including 547 cancer deaths were observed. The adjusted hazard ratios (aHRs) of the subjects with the highest quartile of MCV ≥95.8 fL in men and MCV ≥94.2 fL in women for all-cause and cancer mortality were 1.44 [95% confidence interval (CI), 1.15-1.80] and 1.51 (95% CI, 1.10-2.07) for men and 1.55 (95% CI, 1.08-2.22) and 1.25 (95% CI, 0.74-2.11) for women, respectively, compared with those in the reference group (90.5 fL≤MC <93.0 fL in men and 89.2 fL≤MCV<91.6 fL in women). Elevated MCV level was related to an increased risk of liver cancer mortality in men (aHR, 3.55; 95% CI, 1.75-7.21).

CONCLUSIONS

This study suggests that the elevated MCV level in non-anemic cancer-free individuals was associated with increased all-cause mortality in both men and women, and with cancer mortality, in particular liver cancer mortality in men. Future prospective studies are required to consolidate our findings.

Meta-analysis of the prognostic and diagnostic significance of serum/plasma osteopontin in hepatocellular carcinoma

GOALS

The aim of this study was to perform a meta-analysis to evaluate the prognostic and diagnostic significance of serum/plasma osteopontin (OPN) in hepatocellular carcinoma (HCC).

BACKGROUND

The prognostic and diagnostic value of serum/plasma OPN) in HCC remain controversial.

STUDY

Eligible studies were identified through a systematic literature search. A meta-analysis of 8 studies (4 for prognosis and 4 for diagnosis, 1399 patients) was performed to estimate the association between serum/plasma-based OPN elevation and overall survival (OS) and disease-free survival (DFS) in HCC patients, and to evaluate the accuracy of plasma OPN and α-fetoprotein (AFP) in the diagnosis of HCC. Subgroup analyses were also performed in the meta-analysis.

RESULTS

We found that serum/plasma-based OPN elevation was significantly associated with poor OS (HR, 1.96; 95% CI, 1.47-2.61; P<0.00001) and DFS (HR, 1.80; 95% CI, 1.43-2.26; P<0.00001) in HCC. The summary estimates for plasma OPN and AFP in diagnosing HCC in the studies included were as follows: sensitivity, 88% (95% CI, 84%-91%) versus 68% (95% CI, 63%-73%); specificity, 87% (95% CI, 83%-90%) versus 97% (95% CI, 94%-99%); diagnostic odds ratio, 62.87 (95% CI, 10.90-362.60) versus 49.09 (95% CI, 11.36-212.10); and area under SROS, 0.91 (95% CI, 0.85-0.97) versus 0.68 (95% CI, 0.45-1.03).

CONCLUSIONS

The current evidence indicates that serum/plasma-based OPN seems to have significant predictive ability for estimating survival in HCC, and plasma OPN has a comparable accuracy to AFP for the diagnosis of HCC, although the diagnostic value of plasma OPN for early or AFP-negative HCC remains to be assessed by further studies.

Hepatocellular carcinoma epidemiology

Primary liver cancer (namely hepatocellular carcinoma, HCC) is worldwide the fifth most common cancer in men and the seventh one in women, and it represents the third most frequent cause of cancer death. HCC rates are particularly high in eastern/south-eastern Asia and in Africa, intermediate in Southern Europe, and low in most high-income countries. Persistent infections by HBV or HCV are the main recognized risk factors for HCC. Aflatoxin exposure is also an important risk factor for HCC development in Africa and eastern Asia. In high-income countries heavy alcohol drinking, tobacco smoking, overweight, diabetes, familial/genetic factors, and selected dietary aspects, have a relevant role. Updated geographic patterns and time trends in mortality from HCC in Europe, USA, Japan, and Australia are provided in the present review, together with an overview of relevant etiologic factors for HCC and main measures for the prevention of this neoplasm.

Hepatic stellate cells and extracellular matrix in hepatocellular carcinoma: more complicated than ever

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and the third leading cause of cancer death. Recent epidemiological data indicate that the mortality rate of HCC will double over the next decades in the USA and Europe. Liver cancer progresses in a large percentage of cases during the clinical course of chronic fibro-inflammatory liver diseases leading to cirrhosis. Therefore, HCC development is regarded as the result of different environmental risk factors each involving different genetic, epigenetic- and chromosomal alterations and gene mutations. During tumour progression, the malignant hepatocytes and the activated hepatic stellate cells are accompanied by cancer-associated fibroblasts, myofibroblasts and immune cells generally called tumour stromal cells. This new and dynamic milieu further enhances the responsiveness of tumour cells towards soluble mediators secreted by tumour stromal cells, thus directly affecting the malignant hepatocytes. This results in altered molecular pathways with cell proliferation as the most important mechanism of liver cancer progression. Given this contextual complexity, it is of utmost importance to characterize the molecular pathogenesis of HCC, and to identify the dominant pathways/drivers and aberrant signalling pathways. This will allow an effective therapy for HCC that should combine strategies affecting both cancer and the tumour stromal cells. This review provides an overview of the recent challenges and issues regarding hepatic stellate cells, extracellular matrix dynamics, liver fibrosis/cirrhosis and therapy, tumour microenvironment and HCC.

Tetraspanin-enriched microdomains and hepatocellular carcinoma progression

As in many tumors, heterogeneity within the cell population is one of the main features of hepatocellular carcinoma (HCC). Heterogeneity results from the ability of tumor to produce multiple subpopulations of cells with diverse genetic, biochemical and immunological characteristics. Little is known about how heterogeneity emerges and how it is maintained. Fluctuations in single cells can be masked or completely misrepresented when cell populations are analyzed. It has become exceedingly apparent that the utility of measurement based on the analysis of bulk specimens is limited by intra-tumor genetic and epigenetic heterogeneity, as characteristics of the most abundant cell type might not necessarily predict the properties of cell populations. Yet, such non-uniformities often unveil molecular patterns that can represent mechanisms of tumor progression. Interestingly, variability among single cells in a population may arise from different responses to intrinsic and extrinsic perturbations mainly mediated by the plasma membrane. The association of certain proteins, including tetraspanins, and lipids in specific location on the plasma membrane constitutes specialized structure called tetraspanin-enriched microdomains (TEMs). TEMs organization in cancer may reveal essential clues for understanding pathogenic mechanisms underlying cancer progression. Along these lines, TEMs and HCC progression represent a valuable paradigm for gaining a deeper understanding of such mechanisms.

Roles of microRNAs in the hepatitis B virus infection and related diseases

The hepatitis B virus (HBV) is a small enveloped DNA virus that belongs to the Hepadnaviridae family. HBV can cause acute and persistent infection which can lead to hepatocellular carcinoma (HCC). MicroRNAs (miRNAs) play a crucial role in the main cellular events. The dysregulation of their expression has been linked to the development of the cancer as well as to viral interference. This chapter will describe the involvement of miRNAs in the case of HBV infection and their implication in the development of the HBV-related diseases.

A comparison of trends in mortality from primary liver cancer and intrahepatic cholangiocarcinoma in Europe

BACKGROUND

To update and compare mortality from primary liver cancer (PLC) and intrahepatic cholangiocarcinoma (ICC) in Europe in 1990-2010.

MATERIALS AND METHODS

We used data from the World Health Organization (WHO) to compute age-standardized (world population) mortality rates, and used joinpoint analysis to identify substantial changes.

RESULTS

Between 2002 and 2007, PLC rates in the European Union (EU) declined from 3.9 to 3.6/100,000 men. Around 2007, the highest male rates were in France (6.2/100,000), Spain (4.9), and Italy (4.0), while the lowest ones were in Sweden (1.1), the Netherlands (1.2), and the UK (1.8). In women, mortality was lower (0.8/100,000 in 2007 in the EU), and showed more favourable trends, with a decline of over 2% per year over the last two decades as compared with 0.4% in men, in the EU. In contrast, the EU mortality from ICC increased by around 9% in both sexes from 1990 to 2008, reaching rates of 1.1/100,000 men and 0.75/100,000 women. The highest rates were in UK, Germany, and France (1.2-1.5/100,000 men, 0.8-1.1/100,000 women).

CONCLUSIONS

PLC mortality has become more uniform across Europe over recent years, with an overall decline; in contrast, ICC mortality has substantially increased in most Europe.

Radiation dose dependent risk of liver cancer mortality in the German uranium miners cohort 1946-2003

An increased risk of mortality from primary liver cancers among uranium miners has been observed in various studies. An analysis of the data from a German uranium miner cohort (the 'Wismut cohort') was used to assess the relationship with ionising radiation. To that end the absorbed organ dose due to high and low linear energy transfer radiation was calculated for 58 987 miners with complete information on radiation exposure from a detailed job-exposure matrix. 159 deaths from liver cancer were observed in the follow-up period from 1946 to 2003. Relative risk models with either linear or categorical dependence on high and low linear energy transfer radiation liver doses were fitted by Poisson regression, stratified on age and calendar year. The linear trend of excess relative risk in a model with both low and high linear transfer radiation is -0.8 (95% confidence interval (CI): -3.7, 2.1) Gy(-1) and 48.3 (95% CI: -32.0, 128.6) Gy(-1) for low and high linear energy transfer radiation, respectively, and thus not statistically significant for either dose. The increase of excess relative risk with equivalent liver dose is 0.57 (95% CI: -0.69, 1.82) Sv(-1). Adjustment for arsenic only had a negligible effect on the radiation risk. In conclusion, there is only weak evidence for an increase of liver cancer mortality with increasing radiation dose in the German uranium miners cohort considered. However, both a lack of statistical power and potential misclassification of primary liver cancer are issues.

Etiological and molecular profile of hepatocellular cancer from India

Hepatocellular carcinoma (HCC) cases are underreported in India. Our study was designed to investigate the etiological profile of HCC cases in India and compare with global incidence. The study included 348 HCC and 375 chronic liver disease cases without HCC as controls. Samples were screened for hepatitis B virus (HBV)/hepatitis C virus (HCV) infections using enzyme-linked immunosorbent assay and polymerase chain reaction (PCR). HBV-DNA and HCV-RNA genotyping was performed by PCR-restriction fragment length polymorphism. All cases were also assessed for other possible risk factors of HCC. Among HCC cases, 62.6% were positive for HBV, 26.7% for HCV and 3.2% had coinfection. Around 17% of HCC cases had aflatoxin-B1 exposure. HBV genotype D (odds ratio, OR = 1.76) and mixed genotypes (OR = 6.86) had higher risk of HCC development. The risk of HCC was twofold (OR = 2.26) in patients with high HBV-DNA levels. Moreover, our findings were unable to establish a clear differential effect of HCV genotype (OR = 1.48) and high viral load (OR = 1.21) on HCC development. In India, HBV is the major risk factors, whereas alcohol, smoking and diabetes are nonsignificantly associated. Asian countries such as Hong Kong and Taiwan also had high incidence of HBV-related HCC. Contrarily, countries from Europe and USA reported HCV as predominant cause of HCC. Further, aflatoxin could be a possible risk of HCC in the population. However, in comparison to the countries such as China and Taiwan (high Aflatoxin exposure), the aflatoxin level is relatively low in our patients. High HBV-DNA levels and HBV/D increased the risk of HCC. However, neither genotype nor virus loads of HCV affected prognosis of HCC patients in our study.

Single nucleotide polymorphisms and risk of hepatocellular carcinoma in cirrhosis

Liver carcinogenesis is a complex and multi-factorial process, in which both environmental and genetic features interfere and contribute to malignant transformation. Patients with cirrhosis are particularly exposed and justify periodical screenings in order to detect the early development of hepatocellular carcinoma (HCC). The risk of HCC is, however, not identical from one patient to another. The identification of host factors that may also play an important role in HCC development may improve our understanding of the implications of the various biological pathways involved in liver carcinogenesis; such progress may as well help refine the selection of patients who could benefit from specific preventative measures or could be given adapted screening policies. Numerous candidate-gene studies have reported associations between single nucleotide polymorphisms (SNPs) and the presence of HCC. Some of these publications unfortunately suffer from major methodological drawbacks because of their case-control, retrospective and monocentric aspect. Prospective cohort studies conducted in large homogeneous populations and comprising a sufficient number of events during follow-up may overcome these pitfalls, but require a long time to be conducted and are still scarce. More recently, the first Genome Wide Association studies (GWAs) have enabled the identification of unsuspected loci that may be involved in various steps implicated in liver tumourigenesis. Taken together, these studies highlight variants that modulate oxidative stress, iron metabolism, inflammatory and immune responses, DNA repair mechanisms or systems involved in cell-cycle regulation as genetic traits susceptible to modify the natural history of cirrhotic patients and partly explain the observed differences in the risk of HCC occurrence. However, large genetic epidemiology studies in the field of cancer diseases have suggested the limited ability of polymorphic traits, alone, to refine individual prognosis. The integration of various panels of genes into clinical scores may in the near future define a "genomic risk prediction" specific to liver cancer developed in cirrhotic patients.

Alterations of TP53 are associated with a poor outcome for patients with hepatocellular carcinoma: evidence from a systematic review and meta-analysis

BACKGROUND

The prognostic significance of p53 aberration in hepatocellular carcinoma (HCC) remains inconclusive. This systematic review and meta-analysis aimed to provide comprehensive evidence on the association of p53 alterations with recurrence-free survival (RFS) and overall survival (OS) in HCC patients.

METHODS

Systematic literature searches were conducted until July 2010. Meta-analysis was performed to estimate prognostic effects of p53 alterations on patient outcomes in HCC. Sensitivity and subgroup analyses were also conducted in the meta-analysis.

RESULTS

Thirty-seven studies (7 tumour p53 mutation, 23 tumour p53 expression and 7 serum anti-p53 antibodies) were included in the systematic review and meta-analysis. The average percentages of p53 mutation, p53 expression upregulation and anti-p53 antibody level elevation in HCC patients were 31.5%, 35.0% and 23.8%, respectively. Tumour p53 alterations were associated significantly with poor patient outcomes in HCC: the summary hazard ratio (HR) of mutant p53 versus wild type p53 phenotype was 2.58 [95% confidence interval (CI): 1.96-3.41] for OS and 3.19 [95% CI: 2.21-4.60] for RFS, respectively; and the summary HR of upregulated p53 expression versus low/undetectable p53 expression was 1.68 [95% CI: 1.49-1.90] for OS and 1.89 [95% CI: 1.34-2.66] for RFS, respectively. However, elevated serum anti-p53 antibody was only associated with poor OS in HCC group with a high proportion of (≥ 50%) of hepatitis C virus (HCV) infection [HR: 1.92; 95% CI: 1.30-2.85]. Moreover, sensitivity analyses showed that the results of meta-analyses were not altered.

CONCLUSION

HCC patients with p53 mutation and upregulated expression in tumour tissue have a shorter OS and RFS than patients with wild type p53 and low/undetectable p53 expression. However, the prognostic value of serum anti-p53 antibody is required to be further examined.

Effect of recombinant plasmid pEGFP-AFP-hTNF on liver cancer cells (HepG2 Cells) in vitro when delivered by PEG-PEI/Fe₃O₄ nanomagnetic fluid

BACKGROUND/PURPOSE

Gene delivery into liver cancer cells has been a problem. This study aimed to understand the effect of using PEGI/Fe₃O₄ nanomagnetic fluid as a gene vector for liver cancer gene therapy. An AFP enhancer aids in the expression of tumor-specific foreign genes in AFP-producing cancer cells like HepG2 cells, and was utilized in the delivery method in this study.

METHODS

We constructed recombinant plasmid PEGFP-AFP-hTNFα, which was transfected into AFP positive HepG2 cells and AFP negative Hela cells by PEG-PEI/Fe₃O₄ nanomagnetic fluid. Fluorescence microscopy was used to evaluate the transfection rate of the hTNFα gene in the HepG2 cells 12 hours after transfection. Reverse transcription polymerase chain reaction (RT-PCR) and western blot were used to detect expression of hTNFα gene in the HepG2 cells 48 hours after transfection. Methyl thiazolyl tetrazolium (MTT) assay was used to evaluate the inhibitory effect of hTNFα on the proliferation of HepG2 cells. Flow cytometry was used to analyze the apoptosis of HepG2 cells.

RESULTS

Plasmid PEGFP-AFP-hTNFα delivered by PEG-PEI/Fe₃O₄ nanomagnetic fluid was successfully transfected into HepG2 cells and expressed in the HepG2 cells. The transfection efficacy of hTNFα gene delivered by PEG-PEI/Fe₃O₄ nanomagnetic fluid was superior to that of hTNFα gene delivered by lipofectamine in HepG2 cells. RT-PCR and western blot demonstrated that hTNFα gene was expressed in HepG2 cells that were transfected with complexes of nanomagnetic fluid/PEGFP-AFP-hTNFα. MTT and flow cytometry showed that the hTNFα gene markedly exerted a cell killing effect.

CONCLUSION

PEG-PEI/Fe₃O₄ nanomagnetic fluid successfully transfected PEGFP-AFP-hTNFα into HepG2 cells and induced expression of hTNFα gene in the HepG2 cells, thus showing promise as a gene vector for liver cancer gene therapy. Furthermore, an AFP enhancer can specifically increase the expression of target genes in cells positive for AFP.

Longevity in the 21st Century

The main objective of this paper is to offer a detailed analysis of mortality change in the United Kingdom at the beginning the 21st century. Starting from an exploration of 20th century mortality trends, focusing in particular on the 1990s, underlying forces driving trends in longevity are discussed. These include the ‘cohort effect’ and the ‘ageing of mortality improvement’. International mortality statistics and trends are also analysed. The pace of medical advances is discussed, with specific focus on research into the ageing process and a potential treatment for cardiovascular disease. The paper also discusses the potential threat from infectious diseases.

The analysis of underlying trends suggests that life expectancy in retirement in the U.K. is likely to increase rapidly in the early part of the 21st century. Some scientists are also claiming that we will be seeing the fruits of anti-ageing research within just a few decades.

A core theme of the paper is that future projections should be grounded in as good an understanding of the past as possible. Different methods for projecting future rates of mortality are discussed, and it is noted that emphasis should be placed on the uncertainty surrounding projections.

The financial impact of using different assumptions for future mortality is explored. Significant differences in the cost of an annuity or pension arise from the use of the various projection bases.

Life assurance companies have already declared significant losses as a result of strengthening reserves on annuity portfolios. Taken together, future increases in life expectancy, increasing awareness of the risk of providing longevity insurance, changes in legislation and shortages in market capacity and capital, may well lead to worsening annuity rates.

It is difficult to assess the precise impact of future changes in life expectancy on final salary pension schemes. There is a lack of readily available information on the mortality assumptions being used in practice. It is therefore suggested that more disclosure in this area would be helpful. Employers sponsoring final salary schemes are making promises to their employees that extend up to 70 or 80 years into the future. Actuaries should be clear in spelling out to employers and trustees the nature of the risks behind the promises they are making. Future scheme design should reflect the possibility of substantial increases in life expectancy.

An over-riding implication of the anticipated increases in life expectancy is that people will remain in work for longer in the future. The age at which people retire will inevitably have to increase, and this trend will necessarily drive changes in all aspects of our society. As actuaries we have a vital role in helping to inform the wider debate.

Combination therapy of intra-arterial 5-fluorouracil and systemic pegylated interferon α-2b for advanced hepatocellular carcinoma

BACKGROUND

This study evaluated the efficacy of combined 5-fluorouracil (5-FU) and pegylated interferon (PEG-IFN) α-2b in patients with advanced hepatocellular carcinoma (HCC).

METHODS

Fifty patients with portal vein tumor thrombosis were enrolled. Of these, 21 patients were treated using subcutaneous administration of PEG-IFNα-2b and intra-arterial infusion of 5-FU (5-FU/PEG-IFN group), 12 patients were treated using intramuscular administration of IFNα-2b and intra-arterial infusion of 5-FU (5-FU/IFN group), and 17 patients received intra-arterial infusion chemotherapy with lipiodol-cisplatin (CDDP) suspension (CDDP group).

RESULTS

The objective early response rate was significantly higher in the 5-FU/PEG-IFN group than in the 5-FU/IFN or CDDP groups (71.4 vs. 8.3% and 17.6%, respectively; P < 0.0001). Cumulative survival rates at 6 and 12 months were 83.8 and 77.8% in the 5-FU/PEG-IFN group, 60.8 and 16.2% in the 5-FU/IFN group, and 58.4 and 12.5% in the CDDP group, respectively. The cumulative survival rate was significantly higher in the 5-FU/PEG-IFN group than in the other 2 groups (P = 0.0272). Serious complications and treatment-related deaths were not observed in any of the 3 groups.

CONCLUSION

Although a prospective randomized controlled trial using a larger population of patients with advanced HCC is needed to evaluate combination therapy with 5-FU and PEG-IFNα-2b, this new combination therapy may be useful for patients with advanced HCC.

Serum microRNA profiles serve as novel biomarkers for HBV infection and diagnosis of HBV-positive hepatocarcinoma

Diagnosis of hepatitis B virus (HBV)-positive hepatocellular carcinoma (HCC), particularly HCC independent of cirrhosis etiology, presents a great challenge because of a lack of biomarkers. Here we test the hypothesis that expression profiles of microRNAs (miRNAs) in serum can serve as biomarkers for diagnosis of HBV infection and HBV-positive HCC. We recruited 513 subjects (210 controls and 135 HBV-, 48 hepatitis C virus (HCV)-, and 120 HCC-affected individuals) and employed a strategy of initial screening by Solexa sequencing followed by validation with TaqMan probe-based quantitative reverse transcription-PCR assay. First, because of a close link between chronic hepatitis B and HCC, we compared miRNA expression profiles in HBV serum with that in control serum and successfully obtained 13 miRNAs that were differentially expressed in HBV serum. This 13-miRNA-based biomarker accurately discriminated not only HBV cases from controls and HCV cases, but also HBV-positive HCC cases from control and HBV cases. Second, we directly compared miRNA expressions in HCC serum with those in controls and identified 6 miRNAs that were significantly upregulated in HCC samples. Interestingly, 2 of these miRNAs, miR-375 and miR-92a, were also identified by our first approach as HBV specific. When we employed 3 of these miRNAs (miR-25, miR-375, and let-7f) as biomarkers, we could clearly separate HCC cases from controls, and miR-375 alone had an ROC of 0.96 (specificity: 96%; sensitivity: 100%) in HCC prediction. In conclusion, our study demonstrates for the first time that serum miRNA profiles can serve as novel and noninvasive biomarkers for HBV infection and HBV-positive HCC diagnosis.

Impact of viral load of hepatitis C on the incidence of hepatocellular carcinoma: A population-based cohort study (JPHC Study)

Impact of viral load of HCV on the incidence of hepatocellular carcinoma was investigated using a population-based cohort consisting of 20,794 Japanese. A total of 114 newly arising cases of hepatocellular carcinoma were diagnosed during follow-up. Compared to the hepatitis virus-negative group, the hazard ratio (HR) of developing hepatocellular carcinoma was 35.8-fold higher in HCV monoinfection (95% confidence interval [CI], 20.7-62.7). A titer-dependent increase in risk was not identified. The risk was 3.86-fold higher (CI; 1.73-8.62) for genotype 1 than genotype 2. Our findings suggest that HCV viremia strongly influences the occurrence of hepatocellular carcinoma without titer-dependence.

Transcatheter arterial chemoembolization with a fine-powder formulation of cisplatin for hepatocellular carcinoma

AIM: To evaluate the efficacy of transcatheter arterial chemoembolization (TACE) using a suspension of a fine-powder formulation of cisplatin (DDPH) for hepatocellular carcinoma (HCC).

METHODS: The study population was comprised of 164 patients who were treated by TACE alone. Of these patients, 76 underwent TACE using a suspension of DDPH in lipiodol (LPD) (DDPH group), and the remaining 88 underwent TACE with an emulsion of doxorubicin (ADM) with LPD (ADM group). We compared the DDPH group with the ADM group in terms of the objective early response rate, progression free survival (PFS) and overall survival (OS).

RESULTS: The objective early response rate in the DDPH group was significantly higher than that in the ADM group (54% vs 24%, P < 0.001). The PFS rate in the DDPH group was also significantly higher than that in the ADM group (P < 0.001). Moreover, the OS in the DDPH group was significantly longer than that in the ADM group (P = 0.002). Although the incidence rate of nausea or vomiting in the DDPH group was higher than that in the ADM group, the ADM group showed a higher incidence rate of the adverse events of hepatic arterial damage and leucopenia. No other serious complications were observed in either group.

CONCLUSION: We conclude that TACE using a suspension of DDPH in LPD could be a useful treatment for HCC.

Dietary glycemic load and hepatocellular carcinoma with or without chronic hepatitis infection

BACKGROUND

Hepatitis B virus (HBV) and hepatitis C virus (HCV) are the major risk factors for hepatocellular carcinoma (HCC). The association of diabetes mellitus with HCC suggests that dietary glycemic load (GL) may influence HCC risk. We have examined the association between dietary GL and HCC.

PATIENTS AND METHODS

We conducted a hospital-based case-control study in Italy in 1999-2002, including 185 HCC cases and 412 controls who answered a validated food frequency questionnaire and provided blood samples. Odds ratios (ORs) and corresponding 95% confidence intervals (CIs) were computed using unconditional multiple logistic regression.

RESULTS

We observed a positive association between GL and HCC overall, with an OR of 3.02 (95% CI 1.49-6.12) for the highest quintile of GL compared with the lowest and a significant trend. The OR among HCC cases with evidence of chronic infection with HBV and/or HCV was 3.25 (95% CI 1.46-7.22), while the OR among those with no evidence of infection was 2.45 (95% CI 0.69-8.64), with no significant trend. The association was not explained by the presence of cirrhosis or diabetes.

CONCLUSIONS

High dietary GL is associated with increased risk for HCC. The positive association was most pronounced among HCC cases with HBV and/or HCV markers.

The impact of obesity and diabetes mellitus on the risk of hepatocellular carcinoma

BACKGROUND

Obesity has been associated to increased hepatocellular carcinoma (HCC) risk, but studies on the topic do not fully account for hepatitis B virus (HBV) and hepatitis C virus (HCV) infections. Likewise, an increased risk has been reported for diabetes mellitus (DM) but whether DM is an independent risk factor has not been established yet. To evaluate the association of obesity and DM with HCC risk, we conducted a hospital-based, case-control study in two Italian areas.

PATIENTS AND METHODS

From 1999 to 2003, 185 HCC cases and 404 hospital controls were enrolled. Blood samples were obtained for HBV and HCV screening.

RESULTS

After allowance for known risk factors, body mass index >/=30 kg/m(2) [odds ratio (OR) = 1.9, 95% confidence interval (CI) 0.9-3.9] and DM (OR = 3.7, 95% CI 1.7-8.4) were associated to HCC risk. These associations persisted (OR = 3.5, 95% CI 1.6-7.7 for obesity; OR = 3.5, 95% CI 1.3-9.2 for DM) among subjects without HBV and/or HCV infection. Overall, 23% of HCC cases seemed attributable to these conditions, and this figure rose to 37% among subjects without HBV and/or HCV infections.

CONCLUSIONS

The present study provides further evidence that obesity and DM increase HCC risk and that these factors may explain a relevant proportion of cases among subjects without markers of HBV/HCV infection.

Alcohol and tobacco use, and cancer risk for upper aerodigestive tract and liver

This study reviews the association between alcohol, tobacco, and the risk of cancers of the upper digestive and respiratory tract (i.e. oral cavity and pharynx, larynx, and esophagus) and liver. Alcohol drinking and tobacco smoking are the major risk factors for upper aerodigestive tract cancers, accounting for a large proportion (i.e. about three-quarters) of cases in developed countries. Consumption amount is the strongest alcohol-related determinant of risk, whereas the pattern of alcohol-related risk with duration is inconsistent. Both dose and duration of smoking have important effects on the risk of upper aerodigestive tract cancers. The combined exposure to alcohol and tobacco has a multiplicative effect on carcinogenesis of this tract. Alcohol and tobacco consumption are also causally related to liver cancer, although the associations are moderate and a lower fraction of neoplasms is attributable to these factors as compared with cancers of the upper aerodigestive tract. An interaction between alcohol drinking and tobacco smoking has been reported, but the issue is not adequately assessed.

Trends in mortality from hepatocellular carcinoma in Europe, 1980-2004

Upward trends in mortality from hepatocellular carcinoma (HCC) were recently reported in the United States and Japan. Comprehensive analyses of most recent data for European countries are not available. Age-standardized (world standard) HCC rates per 100,000 (at all ages, at age 20-44, and age 45-59 years) were computed for 23 European countries over the period 1980-2004 using data from the World Health Organization. Joinpoint regression analysis was used to identify significant changes in trends, and annual percent change were computed. Male overall mortality from HCC increased in Austria, Germany, Switzerland, and other western countries, while it significantly decreased over recent years in countries such as France and Italy, which had large upward trends until the mid-1990s. In the early 2000s, among countries allowing distinction between HCC and other liver cancers, the highest HCC rates in men were in France (6.8/100,000), Italy (6.7), and Switzerland (5.9), whereas the lowest ones were in Norway (1.0), Ireland (0.8), and Sweden (0.7). In women, a slight increase in overall HCC mortality was observed in Spain and Switzerland, while mortality decreased in several other European countries, particularly since the mid-1990s. In the early 2000s, female HCC mortality rates were highest in Italy (1.9/100,000), Switzerland (1.8), and Spain (1.5) and lowest in Greece, Ireland, and Sweden (0.3). In most countries, trends at age 45-59 years were consistent with overall ones, whereas they were more favorable at age 20-44 years in both sexes.

CONCLUSION

HCC mortality remains largely variable across Europe. Favorable trends were observed in several European countries mainly over the last decade, particularly in women and in young adults.

Chromosome instability in human hepatocellular carcinoma depends on p53 status and aflatoxin exposure

Hepatocellular carcinoma (HCC) is a heterogeneous disease triggered by various risk factors and frequently characterized by chromosome instability. This instability is considered to be caused primarily by Hepatitis B virus (HBV), although aflatoxin B1 (AFB1), a potent fungal mutagen is also suspected to influence chromosomal repair. We studied 90 HCCs from Italy, the country with the highest incidence of hepatocellular carcinoma in Europe, 81 samples from France and 52 specimens from Shanghai, in a region where intake of AFB1 via the diet is known to be high. All 223 tumours were characterized for 15 different genomic targets, including allelic loss at 13 chromosome arms and mutations of beta-catenin and p53 genes. Despite disparity in risk-factor distribution, Italian and French cases did not significantly differ for 14 of the 15 targets tested. beta-Catenin and p53 displayed moderate and similar mutation rates (18-29% of cases) in European series. By contrast, tumours from Shanghai were significantly different, with a lower mutation rate for beta-catenin (4% vs. 26%, p<0.0003) and a higher mutation rate for p53 (48% vs. 22%, p<0.0001) when compared with tumours of European origin. The Arg249Ser mutation, hallmark of exposure to AFB1, represented half of the changes in p53 in Shanghai. Furthermore, when stratified for the presence of HBV or p53 mutations, chromosome instability was always higher in Chinese than in European patients. This difference was particularly strong in p53-wildtype tumours (fractional allelic loss, 29.4% vs. 16.7%, p<0.0001). We suggest that AFB1-associated mutagenesis represents a plausible cause for the higher chromosome instability observed in Chinese HCCs, when compared with European primary liver carcinomas.

Epidemiology of viral hepatitis infections in an area of southern Italy with high incidence rates of liver cancer

Southern Italy shows the highest rates of liver cancer for Europe, mainly related to infection with hepatitis viruses. We thus described incidence rates of liver cancer and investigated prevalence and determinants of HCV and HBV infections in 4496 individuals randomly selected from the general population of the province of Naples. 7.5% was infected with HCV and 27.6% with HBV (2.2% was HBsAg-positive). Prevalence of both infections increased with age, 23.2% of those aged 65 years or older was HCV-positive and 47.9% were HBV-positive. Intravenous drug use (odds ratio (OR)=16.4 for anti-HCV and 4.7 for anti-HBc), history of blood transfusions (OR=2.8 and 1.5, respectively) and surgery, and household contacts with infected people (OR=2.1 and 1.6, respectively) increased risks for both infections. Sexual intercourse with HCV-positive individuals conveyed a 3-fold higher risk of HCV infection. This study quantified the spread of HCV and HBV in the population of southern Italy heavily affected by liver cancer.

Glutathione S-transferases pi 1, alpha 1 and M3 genetic polymorphisms and the risk of hepatocellular carcinoma in humans

INTRODUCTION

Glutathione S-transferases pi1, alpha1 and micro3 are members of an enzymatic superfamily involved in the conjugation and detoxification of carcinogens. Polymorphisms affecting the genes encoding these enzymes may modify their ability to neutralize carcinogens. Our aim was to investigate whether these polymorphisms affect the risk of developing hepatocellular carcinoma in humans.

METHODS

A total of 184 white Spanish patients diagnosed with hepatocellular carcinoma and 248 healthy control subjects from the same ethnic origin were included. GSTA1*B promoter allele, GSTM3*B 3-bp-deleted allele and GSTP1 Ile105Val SNP were identified.

RESULTS

No differences were found between the distribution of the studied polymorphisms, or in the allele frequencies for variant alleles in patients and controls: 0.411 and 0.371 for GSTA1, 0.116 and 0.131 for GSTM3, and 0.285 and 0.309 for GSTP1, respectively. Among patients the GSTP1 mutated allele was more frequent in those drinking more than 50 g ethanol/day (odds ratio: 2.00; 95% confidence intervals: 1.06-3.78). Age at diagnosis, gender, tobacco use and hepatitis B and C viral status did not influence these results.

CONCLUSION

We conclude that the studied polymorphisms affecting GSTP1, GSTA1 and GSTM3 genes are probably not related to the risk of developing hepatocellular carcinoma in the studied population.

Cancer mortality in the European Union, 1970-2003, with a joinpoint analysis

BACKGROUND

Cancer mortality peaked in the European Union (EU) in the late 1980s and declined thereafter.

MATERIALS AND METHODS

We analyzed EU cancer mortality data provided by the World Health Organization in 1970-2003, using join point analysis.

RESULTS

Overall, cancer mortality levelled off in men since 1988 and declined in 1993-2003 (annual percent change, APC = -1.3%). In women, a steady decline has been observed since the early 1970s. The decline in male cancer mortality has been driven by lung cancer, which levelled off since the late 1980s and declined thereafter (APC = 2.7% in 1997-2003). Recent decreases were also observed for other tobacco-related cancers, as oral cavity/pharynx, esophagus, larynx and bladder, as well as for colorectal (APC = -0.9% in 1992-2003) and prostate cancers (APC = -1.0% in 1994-2003). In women, breast cancer mortality levelled off since the early 1990s and declined thereafter (APC = -1.0% in 1998-2003). Female mortality declined through the period 1970-2003 for colorectal and uterine cancer, while it increased over the last three decades for lung cancer (APC = 4.6% in 2001-2003). In both sexes, mortality declined in 1970-2003 for stomach cancer and for a few cancers amenable to treatment.

CONCLUSION

This update analysis of the mortality from cancer in the EU shows favorable patterns over recent years in both sexes.

Time trends in incidence and prognosis of primary liver cancer and liver metastases of unknown origin in a Danish region, 1985-2004

OBJECTIVES

Changes, over the last 20 years, in the diagnostic procedures and treatment of primary liver cancer (PLC) and liver metastases of unknown origin (LMUO) may have affected the clinical course of both cancers. Few longitudinal studies examined this issue. In a population-based setting, we studied changes in the incidence and prognosis of PLC and LMUO over time.

METHODS

Between 1985 and 2004, we identified 2675 patients with PLC and LMUO in three Danish counties, with a population of 1.4 million. We computed the standardized incidence rate (SIR), ratio of PLC to LMUO diagnoses, median survival, and estimated mortality rate ratio adjusted for age, sex, and comorbidity.

RESULTS

The SIR of PLC increased from 3.2 in 1985 to 5.0 in 2003, and the SIR of LMUO increased from 3.7 to 6.4. No increase was noted in the PLC-to-LMUO ratio over time (P=0.1 for trend). From 1985 to 2004, the median survival of PLC patients increased from 1.6 to 2.9 months whereas that of LMUO patients decreased from 1.7 to 1.3 months. Adjusting for age, sex, and comorbidity did not affect the mortality rate ratio estimates.

CONCLUSIONS

The incidence of both PLC and LMUO increased over time, whereas the PLC-to-LMUO ratio remained unchanged. Median survival of PLC patients has increased whereas that of LMUO patients remained practically unchanged.

Molecular pathogenesis of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer and the third leading cause of cancer death worldwide. Hepatocarcinogenesis is a multistep process evolving from normal through chronic hepatitis/cirrhosis and dysplastic nodules to HCC. With advances in molecular methods, there is a growing understanding of the molecular mechanisms in hepatocarcinogenesis. Hepatocarcinogenesis is strongly linked to increases in allelic losses, chromosomal changes, gene mutations, epigenetic alterations and alterations in molecular cellular pathways. Some of these alterations are accompanied by a stepwise increase in the different pathological disease stages in hepatocarcinogenesis. Overall, a detailed understanding of the underlying molecular mechanisms involved in the progression of HCC is of fundamental importance to the development of effective prevention and treatment regimes for HCC.

Activity and safety of pegylated liposomal doxorubicin, 5-fluorouracil and folinic acid in inoperable hepatocellular carcinoma: A phase II study

AIM: To improve the results of New therapeutic strategies in hepatocellular carcinoma (HCC). We have conducted a phase II study with pegylated liposomal doxorubicin (PLD), 5-fluorouracil (5FU) and folinic acid (FA).

METHODS: Thirty-one patients with hystologically-confirmed, inoperable HCC, received combination chemotherapy with PLD 25 mg/mq on d 1, 5FU 1200 mg/mq in 48 h continuous infusion, and oral FA 30 mg on d 1 and 2 every 3 wk until disease progression or intolerable toxicity.

RESULTS: The median age was 65 years (range 41-82) and 28 patients were hepatitis C virus seropositive (90%). The majority of patients were Child-Pugh Class B (55%). Two patients showed a partial response (PR), and 16 had stable disease (SD). With a median follow-up of 14 mo, the median time to progression of all evaluable patients was 4 mo (95% CI 1.7-7). Median overall survival was 9 mo (95% CI 3-24 mo). After 1 year, 9 of 18 PR/SD patients were alive. Chemotherapy was well tolerated.

CONCLUSION: PLD/FU/FA combination seems capable of achieving durable stabilization of HCC. The manageable toxicity supports a role for combination with other anticancer agents.

Incidence of primary liver cancer in Italy between 1988 and 2002: an age-period-cohort analysis

We conducted in Italy a study to evaluate trends of primary liver cancer (PLC) and to disentangle the period from birth-cohort effects on PLC incidence. Cases aged<80 years and diagnosed between 1988 and 2002 in 20 areas covered by population-based Cancer Registries were included. Age-standardised incidence rates and age-period-cohort effects were estimated. In 1998-2002, incidence rates of PLC were 21.1/100,000 men and 6.0/100,000 women. In both genders, incidence rates increased slightly between 1988-1992 and 1993-1997 but did not rise thereafter. Amongst men, PLC risk increased in every cohort born after 1913 and the rise became steeper for cohorts born in 1948. In women, an upward trend appeared only in the cohorts born after 1953. Incidence of PLC over the last two decades in Italy did not substantially change but huge geographical variability emerged, mainly due to different times and modalities of spread of hepatitis C virus.

The cost-effectiveness of the new protocol reflecting rapid virologic response to peginterferon alpha-2b and ribavirin for chronic hepatitis C

OBJECTIVE

Recent studies have reported the effectiveness of shorter courses of treatment with peginterferon alpha-2b plus ribavirin for patients with chronic hepatitis C, who achieved a rapid virologic response (RVR), defined as undetectable hepatitis C virus (HCV-) RNA at week 4. The aim of this study was to evaluate the cost-effectiveness of the new protocol for treatment, from the perspective of RVR.

METHODS

A cost-effectiveness analysis based on the rate of sustained virologic response was performed. A Markov cohort model of hepatitis C was constructed to demonstrate the clinical states on the basis of the assigned transition probabilities over 30 years. The treatment strategies were classified into five subgroups taking into consideration the viral genotypes, viral load, and RVR. The lifetime costs and quality-adjusted life years (QALYs) were compared between the new and standard protocols for treatment.

RESULTS

Genotype 1-infected patients in the new protocol for treatment compared with the standard one could prolong QALYs by 0.33 and reduce lifetime cost by euro 5993. Genotype 2 or 3-infected patients in the new protocol for treatment compared with the standard one could prolong QALYs by 0.02 and reduce lifetime cost by euro2851.

CONCLUSION

Treatment strategies that consider viral load and RVR for patients with a low viral load infected with genotype 1 and those infected with genotype 2 or 3 are more cost-effective compared with the standard protocol for treatment.

Comparison of two techniques of transarterial chemoembolization before liver transplantation for hepatocellular carcinoma: a case-control study

Supraselective transarterial chemoembolization (STACE) more efficiently targets chemotherapy delivered via the feeding arterial branches of the tumor than does conventional transarterial chemoembolization (TACE). However, the hypothesis of its greater efficacy compared with the latter is subject to controversy. The aim of the present study was to compare STACE to conventional TACE in a controlled study of candidates for liver transplantation (LT) for hepatocellular carcinoma (HCC). Patients were matched for factors associated with HCC recurrence and survival. Sixty patients were included: 30 who were treated with STACE and 30 treated with conventional TACE. The 2 groups were similar in terms of matched criteria. In the overall population (uni- and multinodular HCC), there was no marked difference between the 2 groups in 5-year disease-free survival: 76.8% vs. 74.8%. In sensitivity analysis of patients considered to be the best candidates for TACE (uninodular HCC < or =5 cm), there was a trend toward significance between STACE and TACE in 5-year disease-free survival: 87% vs. 64% (P = 0.09). The only factor associated with complete tumor necrosis was STACE in the overall population (30.8% vs. 6.9%, P = 0.02), with a similar trend in the subgroup of patients with a single nodule (33.3% vs. 6.7%, P = 0.06), whereas the mean number of procedures was similar in the 2 groups (mean, 1.3 procedures; range 1-5 procedures; P = NS). STACE is more efficient at inducing complete tumor necrosis in the liver. This study observed trends toward improvement in the disease-free survival of patients with uninodular HCC < or =5 cm. Future studies focusing on such patients are warranted.

Fatigue experiences in hepatocellular carcinoma patients during six weeks of stereotactic radiotherapy

PURPOSE

To compare fatigue experiences and related factors during the first 6 weeks of stereotactic radiotherapy (SRT) for liver cancer patients with and without fatigue before SRT.

PATIENTS AND METHODS

Subjects (n = 91) were liver cancer patients receiving SRT at two teaching hospitals in northern Taiwan. Data were collected at seven times: the week before SRT (T0) and the end of each of the first 6 weeks of SRT (T1, T2, T3, T4, T5, and T6). Study variables were fatigue intensity, fatigue interference (with patients' daily life), functional status, symptom distress, sleep disturbance, depressive status, radiation dose, stage of cancer, and selected laboratory data.

RESULTS

Subjects were divided at T0 into two groups by fatigue level: those without (group 1, n = 32) and with (group 2, n = 59) pretreatment fatigue distress. Patients in group 2 had higher levels of fatigue intensity and interference than did patients in group 1. Both groups had similar patterns of fatigue interference, peaking at T5. However, patterns of average fatigue intensity differed slightly. In group 2, fatigue intensity remained constant until T3 and then increased to a peak at T5. In group 1, fatigue intensity increased to a peak between T4 and T5. Generalized estimating equation analysis showed significant differences between groups in fatigue intensity and interference across 6 weeks. Examination of factors related to fatigue after SRT indicated that sleep disturbance significantly predicted both fatigue intensity and interference in group 1, but depressive status, overall symptom distress, and education level predicted fatigue intensity and interference for group 2.

CONCLUSION

Liver cancer patients with or without fatigue before treatment had different fatigue experiences across 6 weeks of radiation therapy. Fatigue experiences of liver cancer patients receiving SRT can be better understood through future studies exploring patients' long-term fatigue changes and responses to fatigue-management interventions.

Rising costs and hospital admissions for hepatocellular carcinoma in Portugal (1993-2005)

AIM: To determine, for hepatocellular carcinoma (HCC), the patient demographic profile and costs of their admissions to the hospitals of the Portuguese National Health System from 1993 to 2005.

METHODS: The National Registry (ICD-9CM, Inter-national Classification of Diseases, 155.0) provided data from the 97 Hospitals in Portugal.

RESULTS: We studied 7932 admissions that progres-sively rose from 292 in 1993 to 834 in 2005, having a male predominance of 78% (6130/7932). The global rate of hospital admissions for HCC rose from 3.1/10⁵ in 1993 to 8.3/10⁵ in 2005. The average length of stay decreased from 17.5 ± 17.9 d in 1993 to 9.3 ± 10.4 d in 2005, P < 0.001. The average hospital mortality for HCC remained high over these years, 22.3% in 1993 and 26.7% in 2005. Nationally, hospital costs (in Euros - €) rose in all variables studied: overall costs from €533 000 in 1993, to €4 629 000 in 2005, cost per day of stay from €105 in 1993, to €597 in 2005, average cost of each admission from €1828 in 1993, to €5550 in 2005. In 2005, 1.8% (15/834) of hospital admissions for HCC were related to liver transplant, and responsible for a cost of about €1.5 million, corresponding to one third of the overall costs for HCC admissions in that same year.

CONCLUSION: From 1993 to 2005 hospital admissions in Portugal for HCC tripled. Overall costs for these admissions increased 9 times, with all variables related to cost analysis rising accordingly. Liver transplant, indicated in a small group of patients, showed a disproportionate increase in costs.

Coffee and tea consumption and risk of hepatocellular carcinoma in Italy

The role of coffee in the aetiology of hepatocellular carcinoma has raised great interest. In Italy, coffee consumption is high, thus allowing the investigation of the topic over a broad range of consumption. A hospital-based case-control study was conducted in Italy in 1999-2002, including 185 incidents, histologically confirmed cases of hepatocellular carcinoma aged 43-84 years. Controls were 412 subjects admitted to the same hospitals' networks for acute, non-neoplastic diseases unrelated to diet. Coffee and tea consumption were assessed using a validated food-frequency questionnaire. Odds ratios (ORs) and corresponding the 95% confidence intervals (CI) were computed using unconditional multiple logistic regression, adjusting for hepatitis viruses seropositivity, alcohol intake, smoking habits and other potential confounding factors. Compared to people who drunk <14 cups/week of coffee, the risk of hepatocellular carcinoma decreased for increasing levels of consumption (OR=0.4, 95% CI: 0.2-1.1 for >or=28 cups/week, p for trend = 0.02). In the present study, inverse relations were observed across strata of hepatitis C and, B virus infections and alcohol drinking. No significant association emerged with consumption of decaffeinated coffee (OR=0.7, 95% CI=0.2-2.5) or tea (OR=1.4, 95% CI=0.8-2.7). The present study supports the hypothesis of a favourable effect of coffee, though not decaffeinated coffee and tea, on the risk on hepatocellular carcinoma.

Food groups and risk of hepatocellular carcinoma: A multicenter case-control study in Italy

The role of diet, except for alcohol drinking and aflatoxin contamination, in the etiology of hepatocellular carcinoma (HCC) is unclear. A hospital-based case-control study was conducted in Italy in 1999-2002, including 185 incident, histologically-confirmed cases of HCC. Controls were 412 subjects admitted to hospitals for acute, nonneoplastic diseases unrelated to diet. Dietary habits were assessed using a validated food-frequency questionnaire. Odds ratios (ORs) and the corresponding 95% confidence intervals (CI) were computed using unconditional multiple logistic regression, adjusting for hepatitis B (HBV) and hepatitis C (HCV) virus infection and alcohol drinking. Energy adjustment was carried out by means of the residual model. A significant inverse relation was found between intakes of milk and yoghurt (OR = 0.28; 95% CI: 0.13-0.61), white meats (OR = 0.44; 95% CI: 0.20-0.95), eggs (OR = 0.31; 95% CI: 0.14-0.69), and fruits (OR = 0.48; 95% CI: 0.22-1.05) and HCC risk. The favourable effect of high intakes of milk and yoghurt, white meats, eggs and fruits was consistent across strata of HBV and HCV infections. The present study supports the hypothesis of a role of diet in HCC aetiology. Dietary modifications may be indicated in subjects at high-risk for HCC.