Black patients with hepatitis C virus (HCV) were found to develop hepatocellular carcinoma (HCC) at an earlier stage of liver disease and present with a more aggressive tumor phenotype, according to study data presented at The Liver Meeting Digital Experience.
Although prior research has demonstrated that Black patients have an elevated risk for mortality after HCC diagnosis compared with patients of other races, the mechanisms behind this association are unclear. HCV infection is a known risk factor for HCC, and fibrosis progression is known to be slower in Black patients vs White patients with HCV exposure. However, at a given stage of fibrosis, it is unclear whether HCC risk is higher in Black patients compared with White patients, according to the study authors.
To assess the incidence of HCC in the absence of cirrhosis in Black patients with HCV exposure, the investigators conducted a retrospective study of patients with HCV who were diagnosed with HCC between 2003 and 2018 at the Icahn School of Medicine at Mount Sinai in New York, New York. Race and ethnicity were reported by the patients.
The study authors also evaluated the higher prevalence of HBV exposure in Black patients as a potential contributing factor to the elevated HCC-related mortality seen in this population. Chi-square and Mann-Whitney U tests were used to compare HCC phenotype and outcomes between Black patients and patients of other racial backgrounds.
The study cohort comprised 1195 patients with HCV and HCC, of whom 390 (33%) were Black. The proportion of patients of other races was as follows: 34% White; 18% Hispanic; 7% Asian/Pacific Islander; and 7% unknown. HBV/HIV exposure was observed in a significant proportion of the cohort, affecting nearly 60% and 50% of Black and non-Black patients, respectively.
Compared with patients of other racial backgrounds, Black patients had more severe cancer by nearly every parameter that the investigators evaluated, including tumor size and metastasis. For example, Black patients were found to have a significantly greater median tumor size (3.5 cm) than all other patients (3.1 cm; P <.01).
Although Black and non-Black patients were more closely aligned regarding the median number of tumors (1 [1-3] vs 1 [1-2]; P =.03), a greater proportion of Black vs non-Black patients had gross vascular invasion (21.2% vs 18.3%) and metastasis (10.6% vs 7.1%; both P <.01). Black patients were also more likely to have Fibrosis-4 (FIB-4) scores less than 3.25 at the time of HCC diagnosis, indicating the absence of cirrhosis (31.3% vs 17.8%; P <.01).
These trends persisted in analyses restricted to patients with HCV only, in which a FIB-4 score of less than 3.25 was still more prevalent among Black patients (26.5% vs 18.2%; P =.05). The Model for End-Stage Liver Disease (MELD) score at diagnosis was significantly lower among Black vs non-Black patients, indicating that HCC develops earlier in the course of liver disease among Black patients. Platelets, bilirubin, and the Internalized Normalized Ratio (INR) were all found to be lower in Black patients, again confirming the development of HCC earlier in the disease course.
These results assert that HCC has a unique profile in Black patients with HCV. That these findings remained consistent when patients with HBV and/or HIV were excluded from analyses, suggesting that HCV alone may drive the association.
Per these data, Black patients with HCV “may need to begin HCC surveillance long before they develop cirrhosis,” the study authors said. The investigators added that HCC screening programs solely focused on patients with cirrhosis may result in inadequate detection rates in the Black patient population; therefore, HCC screening should accommodate all patients with HCV exposure. The investigators’ recommendation contends with current guidance from the American Association for the Study of Liver Diseases (AASLD) suggesting that HCC screening should be offered to patients with HCV once cirrhosis develops.
Shaltiel T, Zheng S, Siderides C, et al. Hepatitis C-positive Black patients develop hepatocellular carcinoma at an earlier stage of liver disease and present with a more aggressive tumor phenotype. Poster presented at: The Liver Meeting Digital Experience; November 13-16, 2020. P22487.