GBD US Health Disparities Collaborators. Burden of liver cancer mortality by county, race, and ethnicity in the USA, 2000-19: a systematic analysis of health disparities

HCC surveillance in hepatitis C: A longitudinal algorithm improves alpha-fetoprotein screening

BACKGROUND

Surveillance for HCC remains important after hepatitis C cure. Improved sensitivity of screening with alpha-fetoprotein (AFP) by using a parametric empirical Bayes (PEB) algorithm, which incorporates an individual patient's longitudinal AFP measurements, was previously demonstrated in a retrospective analysis of clinical trial data prior to widespread hepatitis C cure.

METHODS

We analyzed de-identified data extracted from the medical records of participants in the Alaska Hepatitis C Study, which aims to enroll all Alaska Native persons living in Alaska with a history of hepatitis C.We compared the performance characteristics of AFP as a screening test using the PEB method versus a fixed cutoff (FC) method in an observational setting, separately for HCC surveillance in active and cured hepatitis C.

RESULTS

The PEB and FC methods were applied to AFP levels from participants with F3/F4 fibrosis who had active hepatitis C (173 no HCC, 14 HCC) or after they achieved hepatitis C cure (162 no HCC, 12 HCC). Compared to a fixed 20 ng/mL cutoff, demonstrating 91.2% specificity in active hepatitis C, PEB increased sensitivity from 64.3% to 71.4%. After cure, a fixed 7.2 ng/mL cutoff demonstrated 91.2% specificity, and PEB increased sensitivity from 58.3% to 91.7%.

CONCLUSIONS

The PEB algorithm can increase sensitivity and lead to earlier detection of HCC among patients with F3/F4 fibrosis, both in active and even more so in cured hepatitis C. Lower AFP levels after cure indicate that for either PEB or FC methods, screening parameters, such as cutoffs for a target specificity, should be specified separately by hepatitis C treatment status for HCC surveillance.

Exploring the association between chemotherapy and prognosis among patients less than 50 years old with hepatocellular carcinoma: a retrospective cohort study based on the SEER database

BACKGROUND/AIM

Hepatic carcinoma, including hepatocellular carcinoma (HCC), is one of the most common malignant tumors globally, with an increasing incidence among younger populations. While chemotherapy is effective for advanced HCC, its impact on the prognosis of younger patients, who typically have better physiological conditions, remains unclear. Younger patients may have different tumor biology and chemotherapy responses than older patients. This study aims to evaluate the impact of chemotherapy on the prognosis and survival rates of younger HCC patients.

METHODS

A retrospective analysis was conducted using the Surveillance, Epidemiology, and End Results Program (SEER) database, which provides information on cancer statistics among the US population. We selected patients diagnosed with primary HCC between 2010 and 2015. The patients were divided into two groups based on whether they received chemotherapy or not. Kaplan-Meier analyses were utilised to evaluate the impact of chemotherapy on prognosis by comparing the overall survival (OS) and cancer-specific survival (CSS) between the two groups. After performing 1:1 propensity score matching (PSM), the differences in OS and CSS were reassessed.

RESULTS

Before PSM, there were 1662 participants with primary HCC. After PSM, the sample was reduced to 1154 participants, with 577 individuals in each chemotherapy and non-chemotherapy group. Before PSM, there was no statistically significant difference in OS and CSS between the chemotherapy and non-chemotherapy groups (P = 0.25 and P = 0.06). After PSM, although the survival time in the chemotherapy group was slightly extended, the difference remained statistically insignificant (P = 0.09 and P = 0.38). Kaplan-Meier curves indicated no significant difference between the chemotherapy and non-chemotherapy groups, both before and after PSM, further supporting the conclusion that chemotherapy did not significantly improve survival in young patients with HCC.

CONCLUSION

Chemotherapy did not significantly improve survival for young patients with HCC. Treatment decisions should be approached cautiously, especially in cases with complex tumor characteristics. Future studies should explore the mechanisms of chemotherapy in younger patients and develop personalized treatment strategies to improve long-term outcomes.

Socioeconomic inequalities in diagnostics, care and survival outcomes for hepatocellular carcinoma in Sweden: a nationwide cohort study

Background

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality worldwide. This study evaluates how strongly socioeconomic factors associate with diagnostics, treatment, and survival among patients with HCC in Sweden.

Methods

All adult patients registered with a diagnosis of HCC in the Swedish quality register for liver cancer between 2011 and 2021 were included. Household income was classified as low (first quartile; poorest), medium (second or third quartile), or high (in fourth quartile; wealthiest) based on the overall distribution of household income across all household in Sweden. Outcomes included likelihood of diagnosis under surveillance, early-stage diagnosis (Barcelona Clinic Liver Cancer [BCLC] staging 0-A), and receipt of curative treatment (ablation, resection or liver transplantation), as well as mortality risk.

Findings

Among 5490 patients, a significant association was found between low household income and decreased likelihood of diagnosis while under surveillance (adjusted odds ratio [aOR] 0·63; 95% confidence interval [CI]: 0·50-0·80), early-stage diagnosis (aOR 0·58; 95% CI: 0·51-0·67), and curative treatment receipt (aOR 0·65; 95% CI: 0·50-0·85). After adjustments for all variables in the BCLC, other sociodemographic variables, comorbidities, and cirrhosis status, patients with low household income had an adjusted hazard ratio for mortality of 1·29 (95% CI: 1·15-1·45) compared to patients with high household income.

Interpretation

Socioeconomic disparities associate markedly with more advanced stage at HCC diagnosis, less curative treatment, and poorer survival in Sweden. Addressing these disparities through targeted public health interventions may improve HCC care and outcomes in socioeconomically disadvantaged populations.

Funding

The Swedish Cancer Society-Cancerfonden.

Metabolic dysfunction-associated steaotic liver disease self-management among the Hispanic/Latino population

Introduction

Hispanic/Latino populations in the U.S. have the highest prevalence of Metabolic Dysfunction-Associated Steaotic Liver Disease (MASLD), and diet and exercise management are crucial for controlling the disease. While quantitative research on general diet and physical activity within this population exists, studies specifically addressing the quantitative analysis of self-management behaviors in Hispanic/Latino individuals with MASLD are notably scarce. This gap underscores the need for our focused investigation into these specific behaviors under the framework of self-management.

Objectives

Our study aims to investigate how various factors such as age, gender, socioeconomic status, and cultural influences are associated with diet and exercise self-management behaviors in Hispanic/Latino individuals with MASLD. We specifically explore the impact of these demographic and cultural factors as independent variables on the dependent variables of diet and exercise self-management behaviors.

Methods

This study involved 94 participants who were recruited from the Fresno Clinical Research Center to participate in a cross-sectional analysis designed to explore diet and exercise self-management behaviors among Hispanic/Latino people with MASLD. Data were collected from January 2023 to February 2023 using a 54-item Qualtrics survey.

Results

The average age of the participants was 53 years. Among the participants, 68.1% self- identified as female, and 80.9% had an annual income of at least $35,000. Age b = 0.074, p ≤ 0.001, gender b = 1.242, p ≤ 0.05, and financial stress b = 1.887 p ≤ 0.01 were predictors for poor exercise self-management behaviors. Disease-related knowledge b = -2.264 p ≤ 0.001, and familism b = -0.344 p ≤ 0.05 were predictors for healthy exercise self-management behaviors. There were no significant predictors for diet self-management behaviors among the variables observed in this study.

Conclusion

Age, gender, and financial stress predicted poor exercise self-management behaviors, while disease-related knowledge and familism predicted healthy exercise self-management behaviors.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

The first international experience with histotripsy: a safety analysis of 230 cases

BACKGROUND

Histotripsy is a novel, noninvasive, nonionizing, and nonthermal approach that uses focused ultrasound waves to treat liver tumors. This technology received a de novo Food and Drug Administration grant in late 2023. This study aimed to provide the first report on post-trial real-world clinical safety data.

METHODS

Safety outcomes within 30 days of histotripsy were collected after obtaining Food and Drug Administration clearance (December 22, 2023 to July 26, 2024). All centers that performed histotripsy were invited to participate in this study. Complications requiring treatment were graded using the Clavien-Dindo classification and Comprehensive Complication Index (CCI).

RESULTS

A total of 295 patients underwent histotripsy for 510 tumors at 18 centers. The treated liver tumor types included colorectal metastases (n = 140), neuroendocrine tumors (n = 46), hepatocellular carcinomas (n = 31), pancreatic tumors (n = 30), and breast metastases (n = 26). The most common numbers of tumors treated per procedure were 1 (n = 170), 2 (n = 69), and 3 (n = 37). All 8 liver segments were treated for tumors. Safety data were available for 230 patients from 9 centers. Of note, 12 of 230 patients (5.2%) experienced complications of any grade. Most patients (9 [75%]) had minor cases (Clavien-Dindo grade ≤ II). The median and mean CCIs were 0.00 (IQR, 0.00-0.00) and 0.00 (95% CI, 0.00-0.75). All 3 major complications (Clavien-Dindo grade > II [1.3%]) were death due to disease progression. All 3 patients underwent histotripsy with palliative intent for known advanced intra- and extrahepatic diseases.

CONCLUSION

To the best of our knowledge, this is the first study to report on the real-world therapeutic use of histotripsy for liver tumors. Histotripsy was well tolerated, with few overall complications and rare serious complications, indicating a safety profile that compares favorably with that of other liver-directed and surgical therapies for the treatment of liver tumors. Long-term follow-up data, including oncologic outcomes, were collected.

Global, regional and national burden of liver cancer 1990-2021: a systematic analysis of the global burden of disease study 2021

BACKGROUND

Liver cancer is a growing global health issue, with significant geographical disparities in prevalence and mortality. Understanding these differences is key to developing effective prevention and treatment strategies.

METHODS

We analyzed liver cancer trends from 1990 to 2021 across 204 countries using data from the Global Burden of Disease (GBD) study. We modeled mortality from vital registration data and estimated non-fatal burden using primary studies, hospital discharges, and claims data. We calculated prevalence, mortality, YLLs, YLDs, and DALYs, adjusting for age and reporting rates per 100,000 population with 95% UI.

FINDINGS

In 2021, there were 739,299 (673114-821948) cases of liver cancer worldwide. The age-standardized prevalence rate increased from (7.75 [6.91-8.43] per 100,000 people) in 1990 to (8.68[7.90-9.67] per 100,000 people) in 2021, while the mortality rate slightly decreased from(4.48 [4.10-4.93] per 100,000 people) to (6.13 [5.58-6.84] per 100,000 people). High-income North America had the highest prevalence rate, and Southern Latin America had the lowest. Mongolia had the highest prevalence and mortality rates, while Morocco had the lowest. The total YLDs attributed to liver cancer nearly tripled from 1990 to 2021, and the age-standardized DALY rate decreased. In the frontier analysis, countries or regions with higher SDI have greater potential for burden improvement. In the frontier analysis of SDI and age-standardized liver cancer DALY rates in 2021, countries with higher SDI (> 0.85) and higher effective differences relative to their level of development include America, Canada, Germany, Netherlands, etc., while frontier countries with lower SDI (< 0.5) and lower effective differences include Somalia, Papua New Guinea, Yemen, Lao People's Democratic Republic, etc. Countries with larger effective differences include Togo, Gambia, Australia, Norway, etc. CONCLUSION: The global burden of liver cancer is decreasing, but the prevalence of liver cancer is increasing, with significant differences across regions worldwide. These findings can inform health policy and research to address this global challenge.

INTERPRETATION

From 1990 to 2021, the incidence of liver cancer in many regions has increased significantly, which is expected to impose a huge social and economic burden on governments and health systems in the coming years. Our research findings may assist policymakers in devising strategies to combat liver cancer, including educating professionals to address the burden of this complex disease.

Hepatic Stellate Cells Functional Heterogeneity in Liver Cancer

Hepatic stellate cells (HSCs) are the liver's pericytes, and play key roles in liver homeostasis, regeneration, fibrosis, and cancer. Upon injury, HSCs activate and are the main origin of myofibroblasts and cancer-associated fibroblasts (CAFs) in liver fibrosis and cancer. Primary liver cancer has a grim prognosis, ranking as the third leading cause of cancer-related deaths worldwide, with hepatocellular carcinoma (HCC) being the predominant type, followed by intrahepatic cholangiocarcinoma (iCCA). Moreover, the liver hosts 35% of all metastatic lesions. The distinct spatial distribution and functional roles of HSCs across these malignancies represent a significant challenge for universal therapeutic strategies, requiring a nuanced and tailored understanding of their contributions. This review examines the heterogeneous roles of HSCs in liver cancer, focusing on their spatial localization, dynamic interactions within the tumor microenvironment (TME), and emerging therapeutic opportunities, including strategies to modulate their activity, and harness their potential as targets for antifibrotic and antitumor interventions.

Global, Regional, and National Burden of Primary Liver Cancer Attributable to Metabolic Risks: An Analysis of the Global Burden of Disease Study 1990-2021

INTRODUCTION

The global burden of metabolic diseases is increasing, but estimates of their impact on primary liver cancer are uncertain. We aimed to assess the global burden of primary liver cancer attributable to metabolic risk factors, including high body mass index (BMI) and high fasting plasma glucose (FPG) levels, between 1990 and 2021.

METHODS

The total number and age-standardized rates of deaths and disability-adjusted life years (DALYs) from primary liver cancer attributable to each metabolic risk factor were extracted from the Global Burden of Disease Study 1990-2021. The metabolic burden trends of liver cancer across regions and countries by sociodemographic index (SDI) and sex were estimated. The annual percentage changes in age-standardized DALYs rate were also calculated.

RESULTS

Globally, in 2021, primary liver cancer attributable to high BMI and/or high FPG was estimated to have caused 59,970 deaths (95% uncertainty interval [UI] 20,567-104,103) and 1,540,437 DALYs (95% UI 540,922-2,677,135). The age-standardized rates of death and DALYs were 0.70 (95% UI 0.24-1.21) and 17.64 (95% UI 6.19-30.65) per 100,000 person-years. A consistent global rise in liver cancer attributable to metabolic risks was observed from 1990 to 2021, with high BMI identified as the major contributing risk factor. The highest burden of deaths and DALYs of liver cancer consistently occurred in high SDI countries, while the fastest growth trends were observed in low-middle SDI countries. The burdens of high levels of BMI and FPG were higher in men than in women.

DISCUSSION

Primary liver cancer attributable to high BMI and/or high FPG imposes an increasingly substantial clinical burden on global public health, particularly in high SDI countries. Rapid growth trends are also found in middle SDI countries.

Latent Archetypes of the Spatial Patterns of Cancer

The cancer atlas edited by several countries is the main resource for the analysis of the geographic variation of cancer risk. Correlating the observed spatial patterns with known or hypothesized risk factors is time-consuming work for epidemiologists who need to deal with each cancer separately, breaking down the patterns according to sex and race. The recent literature has proposed to study more than one cancer simultaneously looking for common spatial risk factors. However, this previous work has two constraints: they consider only a very small (2-4) number of cancers previously known to share risk factors. In this article, we propose an exploratory method to search for latent spatial risk factors of a large number of supposedly unrelated cancers. The method is based on the singular value decomposition and nonnegative matrix factorization, it is computationally efficient, scaling easily with the number of regions and cancers. We carried out a simulation study to evaluate the method's performance and apply it to cancer atlas from the USA, England, France, Australia, Spain, and Brazil. We conclude that with very few latent maps, which can represent a reduction of up to 90% of atlas maps, most of the spatial variability is conserved. By concentrating on the epidemiological analysis of these few latent maps a substantial amount of work is saved and, at the same time, high-level explanations affecting many cancers simultaneously can be reached.

Sequential Use of Sorafenib and Regorafenib in Hepatocellular Cancer Recurrence After Liver Transplantation: Treatment Strategies and Outcomes

BACKGROUND AND AIMS

During liver transplantation, hepatocellular carcinoma (HCC) recurrence remains a critical challenge for patient survival. Targeted therapies, such as sorafenib and regorafenib, have been utilized to manage relapsed HCC in this unique setting. This study aimed to assess the efficacy of Sorafenib and Regorafenib in patients with HCC who experienced recurrence after liver transplantation. We focused on survival outcomes, treatment responses, and the management of side effects in this patient group.

METHODS

We conducted a retrospective analysis of 73 patients who experienced HCC recurrence post-liver transplantation between 2012 and 2022 across 11 oncology centers in Turkey. Patients were categorized according to Child-Pugh classification and treated with sorafenib as first-line therapy and Regorafenib in case of progression. Survival rates were analyzed using the Kaplan-Meier method, and risk factors were evaluated using Cox regression analysis.

RESULTS

Of the 73 patients included in the study, 62 were male (84.9%), and 11 were female (15.1%), with a mean age of 61.5 ± 10.9 years. All patients received sorafenib as first-line treatment. Among patients who experienced progression with sorafenib or discontinued treatment due to toxicity, 45.2% (n = 33) continued treatment with regorafenib. The median progression-free survival (PFS1) time with sorafenib was 5.6 months, and the one-year survival rate was 24.3%. The median progression-free survival (PFS2) time with regorafenib, which was administered as second-line treatment, was also calculated as 5.9 months. Overall survival (OS) duration was determined as 35.9 months. The most common side effects associated with both drugs included fatigue, hand and foot syndrome, and hypertension. Significantly better survival outcomes were shown in the Child-Pugh A group compared to other patients.

CONCLUSIONS

These results suggest that Sorafenib and Regorafenib treatments offer a survival advantage in patients with relapsed HCC post-transplantation. However, individualized treatment strategies and close follow-up are crucial for optimizing outcomes. Further studies are needed to refine therapeutic protocols and enhance the care of this specific patient group.

Global burden of benign prostatic hyperplasia in males aged 60-90 years from 1990 to 2019: results from the global burden of disease study 2019

BACKGROUND

Benign prostatic hyperplasia (BPH) is a prevalent urological disease in elderly males. However, few studies have estimated the temporal and spatial distributions of the BPH burden in male adults aged 60 years and over at the global, national, and regional scales.

METHODS

Leveraging the Global Burden of Disease, Injuries, and Risk Factors Study, we estimated the global epidemiological trends in the prevalence, incidence, and disability-adjusted life-years (DALYs) of BPH in 204 countries and 21 regions and 5 sociodemographic index (SDI) regions in males aged 60 years and over between 1990 and 2019. The average annual percentage changes (AAPCs) in age-specific rates were estimated to quantify overall trends. We estimated the contribution of population aging and epidemiological alterations in disease burden via composition analysis.

RESULTS

Over the past three decades, the global prevalent cases, incident cases and DALYs of BPH have increased, ranging from 118.78 to 121.22%. The global number of prevalent BPH cases reached 79 million in people aged 60 years and older in 2019. The prevalence, incidence, and DALYs rates gradually increased, with AAPCs of 0.02, 0.02, and 0.01, respectively. Low-middle, middle, and low SDI regions experienced rapid increases in the number of prevalent cases of BPH. In 2019, China, India, and United States of America bore the largest burden of prevalent cases among people aged 60 years and over. The three regions with the highest prevalence rates of BPH were Eastern Europe, Central Latin America, and Andean Latin America. The increased prevalence was attributed to population growth (94.93%), epidemiological changes (3.45%), and aging (1.62%), globally.

CONCLUSIONS

BPH is a global health issue that imposes substantial economic burdens on most countries, particularly males aged 60 years and over. Effective health decisions are imperative for BPH prevention and treatment.

Clinical Nomogram Model for Pre-Operative Prediction of Microvascular Invasion of Hepatocellular Carcinoma before Hepatectomy

Background and Objectives: Microvascular invasion (MVI) significantly impacts recurrence and survival rates after liver resection in hepatocellular carcinoma (HCC). Pre-operative prediction of MVI is crucial in determining the treatment strategy. This study aims to develop a nomogram model to predict the probability of MVI based on clinical features in HCC patients. Materials and Methods: A total of 489 patients with a pathological diagnosis of HCC were enrolled from our hospital. Those registered from 2012-2015 formed the derivation cohort, and those from 2016-2019 formed the validation cohort for pre-operative prediction of MVI. A nomogram model for prediction was created using a regression model, with risk factors derived from clinical and tumor-related features before surgery. Results: Using the nomogram model to predict the odds ratio of MVI before hepatectomy, the AFP, platelet count, GOT/GPT ratio, albumin-alkaline phosphatase ratio, ALBI score, and GNRI were identified as significant variables for predicting MVI. The Youden index scores for each risk variable were 0.287, 0.276, 0.196, 0.185, 0.115, and 0.112, respectively, for the AFP, platelet count, GOT/GPT ratio, AAR, ALBI, and GNRI. The maximum value of the total nomogram scores was 220. An increase in the number of nomogram points indicated a higher probability of MVI occurrence. The accuracy rates ranged from 55.9% to 64.4%, and precision rates ranged from 54.3% to 68.2%. Overall survival rates were 97.6%, 83.4%, and 73.9% for MVI(-) and 80.0%, 71.8%, and 41.2% for MVI(+) (p < 0.001). The prognostic effects of MVI(+) on tumor-free survival and overall survival were poor in both the derivation and validation cohorts. Conclusions: Our nomogram model, which integrates clinical factors, showed reliable calibration for predicting MVI and provides a useful tool enabling surgeons to estimate the probability of MVI before resection. Consequently, surgical strategies and post-operative care programs can be adapted to improve the prognosis of HCC patients where possible.