Assessment of Risk Factors, and Racial and Ethnic differences in Hepatocellular Carcinoma

Abstract

Despite improved screening and surveillance guidelines, significant race/ethnicity‐specific disparities in hepatocellular carcinoma (HCC) continue to exist and disproportionately affect minority and disadvantaged populations. This trend indicates that social determinants, genetic, and environmental factors are driving the epidemic at the population level. Race and geography had independent associations with risk of mortality among patients with HCC. The present review discusses the risk factors and issues related to disparities in HCC. The underlying etiologies for these disparities are complex and multifactorial. Some of the risk factors for developing HCC include hepatitis B (HBV) and hepatitis C (HCV) viral infection, nonalcoholic fatty liver disease, nonalcoholic steatohepatitis, smoking and alcohol consumption. In addition, population genetics; socioeconomic and health care access; treatment and prevention differences; and genetic, behavioral, and biological influences can contribute to HCC. Acculturation of ethnic minorities, insurance status, and access to health care may further contribute to the observed disparities in HCC. By increasing awareness, better modalities for screening and surveillance, improving access to health care, and adapting targeted preventive and therapeutic interventions, disparities in HCC outcomes can be reduced or eliminated. 

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Keywords: alcohol intake, diabetes, ethnic disparities, hepatitis B (HBV) infection, hepatitis C (HCV) infection, hepatocellular carcinoma, metabolic syndrome, nonalcoholic fatty liver disease, obesity, smoking

Abstract

Population genetics, socioeconomic and health care access, treatment and prevention differences, dietary composition, and genetic, behavioral and biological influences can contribute to hepatocellular carcinoma (HCC). Acculturation of ethnic minorities, insurance status and access to healthcare may further contribute to the observed disparities in HCC. By increasing awareness and better modalities for screening and surveillance, targeted preventive and therapeutic interventions for reducing disparities can be successfully improved.

Introduction

According to Rakesh Srivastava Hepatocellular carcinoma (HCC) is one of the primary liver cancers predicted to be the sixth most commonly diagnosed cancer, and the third leading cause of cancer death worldwide in 2019, with about 841 000 new cases and 782 000 deaths annually. The worldwide HCC incidence is 10.1 cases per 100 000 person‐years.¹, ² Globally, 80% of HCC cases occur in sub‐Saharan Africa and eastern Asia. The burden of HCC in 2012 was 14 million and is expected to rise to 22 million in the next two decades.³ HCC has an average 5‐year survival of <15%.³

In the United States, HCC is the fifth leading cause of cancer‐related deaths among men and ranks seventh among women.⁴ In 2019, approximately 42 030 adults (29 480 men and 12 550 women) in the United States were diagnosed with primary liver cancer. The incidence of HCC in the United States has tripled over the last four decades. Between 2006 and 2015, the number of people diagnosed with the disease increased by approximately 3% annually. According to American Cancer Society, approximately 31 780 deaths (21 600 men and 10 180 women) from this disease has occurred in 2019. The overall death rate has more than doubled from 1980 to 2016.

Prominent risk factors for HCC vary depending on the region. Noticeably, the HCC incidence rates depend on the factors including race/ethnicity, gender, age, and geo‐/demographic regions⁵ and also by several risk factors such as cirrhosis, hepatitis B (HBV) infection, hepatitis C (HCV) infection, excessive alcohol consumption, nonalcoholic fatty liver disease (NAFLD), obesity, diabetes, glucose overload, metabolic syndrome, and environmental toxic intake (Fig. ​(Fig.11).⁶, ⁷, ⁸ The development of HCC is complex, involving sustained inflammatory damage leading to hepatocyte necrosis, regeneration, and fibrotic deposition. A deeper understanding of the mechanisms and expanding access to high‐quality prevention, early detection, and treatment for individuals will be required to reduce or prevent HCC disparities. The present review provides an overview of the risk factors and issues related with HCC disparities in epidemiology, detection, treatment, or outcomes.

Figure 1

Risk factors of hepatocellular carcinoma (HCC) and factors regulating HCC disparities. Risk factors of HCC include chronic viral hepatitis (HBV, HCV), cirrhosis, NAFLD/NASH, metabolic disease (obesity and diabetes mellitus), environment toxins (Aflatoxin), genetic and heredity disorders, lifestyle factors, (alcohol consumption and smoking), and dietary factors. HCC disparities can be regulated by Socioechonomic status, health care access, government policies and population dynamics.

Gender, Race, and Ethnicity

Gender, racial, and ethnic disparities in the survival of patients with HCC continue to exist.⁹ HCC cases are two to four times more common in males than in females. Liver cancer is the fifth most common cause of cancer death in men, whereas it is the seventh most common cause of cancer death in women. Clinical studies revealed that men have a higher risk of developing HCC by the progression of HBV and HCV, and elevated level of inflammatory cytokines (IL‐6 and IL‐1β) compared with the women worldwide.¹⁰ This gender disparity is the result of different behavioral risk factors, such as smoking and drinking alcohol. Glutathione S‐Transferase P1 (GSTP1) exon 6 polymorphism genotype was associated with an increase in the risk of HCC in male patients.¹¹

HCC rates are two times higher in Asian Americans than African Americans (AA). HCC rates in AA are two times higher than those in Caucasian Americans (CAs).¹² In California, during 2009–2013, the age‐adjusted HCC incidence was the highest in Asians/Pacific Islanders (APIs) and Hispanics (>100% higher than whites), especially those living in more ethnic neighborhoods (20–30% higher than less ethnic neighborhoods). In the United States, the HCC incidence was highest in Asians, followed by AA, Hispanics, and non‐Hispanic whites. However, a recent observation noted the highest percent increase in HCC incidence among Hispanics, whereas its incidence decline in Asians.⁴ The age‐adjusted HCC incidence in the United States has increased in both men from 6.9 per 100 000 in 2000 to 10.8 in 2012 and women from 2.3 per 100 000 in 2000 to 3.2 in 2012, suggesting the majority (73%) of cases occur in men according to an average annual percentage change (APC) rate.¹³ Hispanics and non‐Hispanic whites have a severity of liver disease than Native Americans in the New Mexico region.¹⁴ Blacks have a high occurrence of HCC than Hispanics and whites based on tumor stage and liver function.¹⁵ These studies clearly suggest the existence of gender, racial, and ethnic disparities in HCC incidence.

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Created on Dec 6th 2021 11:06. Viewed 75 times.

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