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  The Liver Meeting
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November 13 - 16 - 2021
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US Medicare Patients With NAFLD Get Less
HCC Surveillance and Curative Therapy

  AASLD, The Liver Meeting, November 12-15, 2021
Mark Mascolini
Nonalcoholic fatty liver disease (NAFLD) explained more than one third of hepatocellular carcinoma (HCC) cases among Medicare beneficiaries in the United States in 2011-2015, according to an 5098-person analysis [1]. The study linked NAFLD to lower HCC surveillance and thus later detection, lower chances of curative therapy, and worse overall survival.
NAFLD has begun outpacing other causes of HCC in many parts of the world, according to Cedars-Sinai Medical Center researchers and collaborators who conducted this study. Projections see incidence of NAFLD-related HCC jumping 122% from 2016 to 2030 in the United States. But the researchers said how big a role NAFLD plays in causing HCC in the US general population remains unclear. They aimed to address that question in a population-based US cohort and to examine differences between NAFLD patients and others in HCC surveillance, clinical presentation, and outcomes.
The study population came from the SEER-Medicare database of newly diagnosed (incident) cancers in 18 US cancer registries. This analysis focused on Medicare recipients at least 68 years old diagnosed with HCC from 2011 to 2015. The researchers identified NAFLD patients by ICD-9 or ICD-10 codes for obesity, diabetes, bariatric surgery, or both abnormal lipids and hypertension without HBV or HCV infection, alcohol abuse, or other known liver diseases. They identified cirrhosis by ICD-9 and -10 codes from Medicare claims, and they defined unrecognized cirrhosis as cirrhosis detected in the 6 months immediately before HCC diagnosis or any time after HCC diagnosis. HCC surveillance could be classified as consistent (one or more abdominal ultrasound, CT, or MRI scans per year), inconsistent (one or more abdominal scans during the study period but less than annually), or no surveillance.
The researchers counted 5098 diagnoses of HCC in Medicare beneficiaries 68 or older in the years 2011-2015. NAFLD caused 1813 (36%) of those cases, HCV 1715 (34%), alcoholic liver disease 895 (18%), HBV 246 (5%), and other conditions 429.
Only 15.2% of all people diagnosed with HCC received consistent surveillance for the cancer, and people with NAFLD received less consistent surveillance than people with HCV, HBV, or alcoholic liver disease whether the analysis considered all patients or only those with cirrhosis. People with NAFLD had about 80% lower odds of consistent HCC surveillance than other at-risk people (adjusted odds ratio [aOR] 0.22, 95% confidence interval [CI] 0.17 to 0.28).
Three quarters of all people with HCC had cirrhosis, but only 57.9% of those with NAFLD had cirrhosis. Among people with cirrhosis, it remained unrecognized in 57.5% overall and in 76.4% of people with NAFLD. The NAFLD group had more than 4-fold higher odds of having unrecognized cirrhosis (aOR 4.42, 95% CI 3.63 to 5.38).
The researchers estimated that 19% of HCC patients entered care with early-stage cancer, and 22.9% got potentially curative treatment. In contrast, only 13% of NAFLD patients entered care with early-stage HCC and only 17.7% received potentially curative therapy. People with NAFLD had half the chance of entering care with early-stage HCC (aOR 0.49, 95% CI 0.40 to 0.60) and 75% the chance of curative treatment (aOR 0.75, 95% CI 0.62 to 0.91).
Median overall survival stood at only 15 months for the entire cohort but was lower still-only 12 months--in people with NAFLD. Having NAFLD raised chances of worse overall survival 20% (adjusted hazard ratio 1.20, 95% CI 1.09 to 1.32).
The researchers cautioned that people in their study were at least 68 years old, so their findings may not apply to younger people in the United States. A better understanding HCC risk with NAFLD and earlier cirrhosis detection should lead to more aggressive HCC surveillance in the NAFLD population, the researchers proposed. In turn, earlier HCC detection should help more NAFLD patients receive curative therapy and survive longer.
1. Karim MA, Singal AG, Kum HC, et al. Clinical characteristics and outcomes of nonalcoholic fatty liver diseases associated hepatocellular carcinoma in the United States. AASLD, The Liver Meeting, November 12-15, 2021. Abstract 192.