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Three main changes characterize the secular trends in the incidence of hepatocellular carcinoma (HCC) in the United States. First, the overall incidence and mortality rates of HCC have been rising for the past 3 decades. Second, Hispanics are disproportionately affected by the HCC increase and have recently surpassed Asian Americans as the racial/ethnic group at highest HCC risk. Third, Southern and Western states have registered higher incidence rates of HCC than did the rest of the country, with Texas having the highest rates.
There are significant racial/ethnic differences in the population distribution of HCC risk factors, notably the disproportionately high prevalence of metabolic syndrome (e.g., obesity, abdominal obesity, and diabetes) and nonalcoholic fatty liver disease (NAFLD) in Hispanics. This observation may explain some of the findings in the secular trends of HCC described above. Most, but not all, studies have reported modest increases in relative risk of HCC in persons with obesity as measured by body mass index. However, studies investigating more specific obesity measures such as obesity in early adulthood or abdominal obesity reported higher and more consistent HCC risk than did those using body mass index. Hispanics have been shown to have a higher proportion of abdominal, especially visceral fat, than African Americans. The prevalence of NAFLD in the United States has doubled over the last 2 decades, and is estimated to affect 15%-20% of adults overall, but up to 30% in adult Texas Hispanics. Recently, a large cohort study including 296,707 patients with NAFLD and an equal number of matched controls without NAFLD from 130 facilities of the Department of Veterans Affairs found that patients with NAFLD had several-fold higher HCC risk than controls. The study also reported that HCC incidence rates for patients with NAFLD ranged from 1.6 to 23.7 per 1000 person-years, with the highest risk among older Hispanic patients with cirrhosis. Approximately 20% of patients with NAFLD and HCC had no evidence of cirrhosis. Lastly, type 2 diabetes, a condition that also is disproportionately higher in Hispanics than in other racial/ethnic groups in the United States has been consistently associated with an approximately twofold increase in the risk of HCC.
Risk factors for cirrhosis and HCC in contemporary clinical practice, and to a lesser extent, in the general population have shifted from active viral hepatitis to resolved hepatitis C infection or adequately suppressed hepatitis B infection as well as alcoholic liver disease and NAFLD. The shift from uncommon risk factors that carry a considerable increased risk of cirrhosis and HCC (active hepatitis C virus, hepatitis B virus) to more common but weaker risk factors (alcohol, NAFLD) is likely to result in a larger pool of chronic liver disease patients at risk for developing cirrhosis and HCC. However, given that the relative risk of HCC is lower with these emerging risk factors, it also will become increasingly difficult to define the highest-risk groups in need of interventions or monitoring. Therefore, there is a clear need for risk-stratification tools for cirrhosis and HCC in patients with HCV and a sustained virologic response, adequate HBV suppression, alcoholic liver disease, and NAFLD.
Dr. El-Serag is with the section of gastroenterology and hepatology, department of medicine, Baylor College of Medicine, Houston. Dr. El-Serag made these comments during the AGA Institute Presidential Plenary at the annual Digestive Disease Week®.
Three main changes characterize the secular trends in the incidence of hepatocellular carcinoma (HCC) in the United States. First, the overall incidence and mortality rates of HCC have been rising for the past 3 decades. Second, Hispanics are disproportionately affected by the HCC increase and have recently surpassed Asian Americans as the racial/ethnic group at highest HCC risk. Third, Southern and Western states have registered higher incidence rates of HCC than did the rest of the country, with Texas having the highest rates.
There are significant racial/ethnic differences in the population distribution of HCC risk factors, notably the disproportionately high prevalence of metabolic syndrome (e.g., obesity, abdominal obesity, and diabetes) and nonalcoholic fatty liver disease (NAFLD) in Hispanics. This observation may explain some of the findings in the secular trends of HCC described above. Most, but not all, studies have reported modest increases in relative risk of HCC in persons with obesity as measured by body mass index. However, studies investigating more specific obesity measures such as obesity in early adulthood or abdominal obesity reported higher and more consistent HCC risk than did those using body mass index. Hispanics have been shown to have a higher proportion of abdominal, especially visceral fat, than African Americans. The prevalence of NAFLD in the United States has doubled over the last 2 decades, and is estimated to affect 15%-20% of adults overall, but up to 30% in adult Texas Hispanics. Recently, a large cohort study including 296,707 patients with NAFLD and an equal number of matched controls without NAFLD from 130 facilities of the Department of Veterans Affairs found that patients with NAFLD had several-fold higher HCC risk than controls. The study also reported that HCC incidence rates for patients with NAFLD ranged from 1.6 to 23.7 per 1000 person-years, with the highest risk among older Hispanic patients with cirrhosis. Approximately 20% of patients with NAFLD and HCC had no evidence of cirrhosis. Lastly, type 2 diabetes, a condition that also is disproportionately higher in Hispanics than in other racial/ethnic groups in the United States has been consistently associated with an approximately twofold increase in the risk of HCC.
Risk factors for cirrhosis and HCC in contemporary clinical practice, and to a lesser extent, in the general population have shifted from active viral hepatitis to resolved hepatitis C infection or adequately suppressed hepatitis B infection as well as alcoholic liver disease and NAFLD. The shift from uncommon risk factors that carry a considerable increased risk of cirrhosis and HCC (active hepatitis C virus, hepatitis B virus) to more common but weaker risk factors (alcohol, NAFLD) is likely to result in a larger pool of chronic liver disease patients at risk for developing cirrhosis and HCC. However, given that the relative risk of HCC is lower with these emerging risk factors, it also will become increasingly difficult to define the highest-risk groups in need of interventions or monitoring. Therefore, there is a clear need for risk-stratification tools for cirrhosis and HCC in patients with HCV and a sustained virologic response, adequate HBV suppression, alcoholic liver disease, and NAFLD.
Dr. El-Serag is with the section of gastroenterology and hepatology, department of medicine, Baylor College of Medicine, Houston. Dr. El-Serag made these comments during the AGA Institute Presidential Plenary at the annual Digestive Disease Week®.
Three main changes characterize the secular trends in the incidence of hepatocellular carcinoma (HCC) in the United States. First, the overall incidence and mortality rates of HCC have been rising for the past 3 decades. Second, Hispanics are disproportionately affected by the HCC increase and have recently surpassed Asian Americans as the racial/ethnic group at highest HCC risk. Third, Southern and Western states have registered higher incidence rates of HCC than did the rest of the country, with Texas having the highest rates.
There are significant racial/ethnic differences in the population distribution of HCC risk factors, notably the disproportionately high prevalence of metabolic syndrome (e.g., obesity, abdominal obesity, and diabetes) and nonalcoholic fatty liver disease (NAFLD) in Hispanics. This observation may explain some of the findings in the secular trends of HCC described above. Most, but not all, studies have reported modest increases in relative risk of HCC in persons with obesity as measured by body mass index. However, studies investigating more specific obesity measures such as obesity in early adulthood or abdominal obesity reported higher and more consistent HCC risk than did those using body mass index. Hispanics have been shown to have a higher proportion of abdominal, especially visceral fat, than African Americans. The prevalence of NAFLD in the United States has doubled over the last 2 decades, and is estimated to affect 15%-20% of adults overall, but up to 30% in adult Texas Hispanics. Recently, a large cohort study including 296,707 patients with NAFLD and an equal number of matched controls without NAFLD from 130 facilities of the Department of Veterans Affairs found that patients with NAFLD had several-fold higher HCC risk than controls. The study also reported that HCC incidence rates for patients with NAFLD ranged from 1.6 to 23.7 per 1000 person-years, with the highest risk among older Hispanic patients with cirrhosis. Approximately 20% of patients with NAFLD and HCC had no evidence of cirrhosis. Lastly, type 2 diabetes, a condition that also is disproportionately higher in Hispanics than in other racial/ethnic groups in the United States has been consistently associated with an approximately twofold increase in the risk of HCC.
Risk factors for cirrhosis and HCC in contemporary clinical practice, and to a lesser extent, in the general population have shifted from active viral hepatitis to resolved hepatitis C infection or adequately suppressed hepatitis B infection as well as alcoholic liver disease and NAFLD. The shift from uncommon risk factors that carry a considerable increased risk of cirrhosis and HCC (active hepatitis C virus, hepatitis B virus) to more common but weaker risk factors (alcohol, NAFLD) is likely to result in a larger pool of chronic liver disease patients at risk for developing cirrhosis and HCC. However, given that the relative risk of HCC is lower with these emerging risk factors, it also will become increasingly difficult to define the highest-risk groups in need of interventions or monitoring. Therefore, there is a clear need for risk-stratification tools for cirrhosis and HCC in patients with HCV and a sustained virologic response, adequate HBV suppression, alcoholic liver disease, and NAFLD.
Dr. El-Serag is with the section of gastroenterology and hepatology, department of medicine, Baylor College of Medicine, Houston. Dr. El-Serag made these comments during the AGA Institute Presidential Plenary at the annual Digestive Disease Week®.
