GLASGOW — Both the incidence and mortality rates of hepatocellular carcinoma (HCC) have risen dramatically in England in the 20 years up to 2016, say UK experts who found that patients often do not receive potentially curative treatment.
Anya Burton, a cancer epidemiologist at Public Health England, and colleagues examined national cancer data on HCC epidemiology, including diagnosis, treatment and survival, in almost 30,000 cases between 1997 and 2016.
The results, presented at the NCRI Cancer Conference 2019, showed that, while rates of HCC remain starkly higher in men than women, population-adjusted incidence and mortality rates rose approximately three-fold in both sexes.
Rising Global Cases
The study follows previous research reported by Medscape Medical News showing that the incidence of liver cancer has increased across much of the world in the past 25 years, although the causes vary by region and partially by income.
Anya Burton said in a news release: "Our findings highlight the urgent need to address prevention strategies for both liver disease generally and hepatocellular carcinoma specifically."
She pointed out that the "presence of cirrhosis, particularly advanced cirrhosis, in many patients means treatment options are severely limited".
While not addressed directly in the current analysis, she pointed to the need for further research into HCC risk factors, including high alcohol consumption and obesity.
Hassan Malik is chair of the NCRI Hepatobiliary workstream of the Upper Gastrointestinal Group and a consultant hepatobiliary surgeon at the University Hospital Aintree, Liverpool.
Commenting, he said: "The tripling of liver cancer in the past 20 years is extremely worrying and these data are a wake-up call to policy-makers and health providers that better prevention strategies are urgently needed."
He noted that the findings apply only to England and the figures could be higher in Scotland, where "we know that alcohol, drug abuse and the resulting liver cirrhosis are even worse problems".
The results were underlined by the release of data at the beginning of the month suggesting that there was a 50% increase in liver cancer deaths in the 10 years up to 2017.
Helen Reeves, at Newcastle University, is Cancer Research UK's liver cancer expert.
She said in a news release that progress in treating liver cancer has been "painfully slow and we desperately need more options for patients".
"Another problem is the rise in the number of people being diagnosed, which has meant we are losing more people to this disease than ever before."
While she emphasised the need to tackle the well-known preventable risk factors, she said that there is "good news" on the horizon with the "potentially game-changing" research into treatments such as immunotherapy.
Anya Burton began by noting that, to facilitate research into HCC, a partnership was formed between Hepatocellular Carcinoma UK and the National Cancer Registration and Analysis Service (NCRAS).
For the current study, this partnership, which was funded by the British Association for the Study of the Liver, used data from NCRAS to examine the incidence, diagnosis, treatment and survival of HCC in England.
They gathered data on tumour- and patient-specific variables, linking individual-level data to multiple databases on diagnosis and treatment, including Hospital Episode Statistics (HES), which was also used to identify the presence and severity of cirrhosis.
The results showed that there were 29,906 HCC cases diagnosed between 1997 and 2016, which accounted for 48% of all primary liver cancer cases, while a further 38% were intrahepatic cholangiocarcinoma.
The mean age at diagnosis was 68.4 years, with diagnosis in males being 3.4 times more than in females. Fifty-eight per cent of patients had a HES code of cirrhosis, which was decompensated in 42% of cases.
It was also shown that 25% of HCC cases occurred in the most deprived fifth of the population.
Anya Burton said that the incidence of HCC increased rapidly during the study period in both men and women, from 2.7 per 100,000 in 1997 to 8.8 per 100,000 in 2016 in men, and an increase from 0.8 per 100,000 to 2.2 per 100,000 in women.
The data showed that there were regional variations in the incidence of HCC, with the highest rates seen in London and in the north of England in both men and women.
Mortality rates also increased over the study period, from 1.9 to 6.0 per 100,000 between 1997 and 2016 in men, and from 0.5 to 1.4 per 100,000 in women over the same period.
There were, however, improvements in 1-year survival with HCC in both men and women over the study period, from 37% to 51.3% and from 34.9% to 61.1%, respectively.
Anya Burton said that the most common route to being diagnosed with HCC was via emergency presentation in 35.2% of cases, followed by via the GP in 31.1%.
Just 21.3% of patients received potentially curative treatment, with the majority receiving only best supportive care, rather than specific curative or palliative anticancer treatment.
There was, again, regional variation in the treatment of HCC, even after taking into account factors such as patient and cirrhosis stage.
Anya Burton told the audience that the presence of cirrhosis "can make treatment particularly difficult and complicated, and we urgently need to address prevention strategies for those with liver disease and hepatocellular carcinoma specifically".
A spokesperson for Public Health England told Medscape News UK that treatment was classified as "potentially curative" because a lack of data on disease stage means they "cannot be sure" whether patients were given treatments such as resection, ablation, and transplantation, with the specific aim of achieving a cure.
He nevertheless said that the presence of, particularly decompensated, cirrhosis precludes liver resection and "many clinicians would not offer ablation".
"However, there may be other reasons why a patient may not be suitable, including other co-morbidities, late cancer stage at presentation, and or the patient is too frail."
He noted that, "earlier diagnosis would reduce the cancer stage at presentation and increase the proportion of patients suitable for potentially curative treatment".
Overweight, Obesity, and Smoking
The data from Cancer Research UK covered a shorter timeframe, from 2007 to 2017, and were not population-adjusted.
They nevertheless showed that deaths from liver cancer increased by approximately 50% over the 10-year period, from around 3200 in 2007 to 5700 in 2017.
Experts from the charity noted that this was mirrored by a 60% increase in the number of diagnoses of liver cancer. Previous studies have suggested that 23% of cases can be linked to overweight or obesity and 20% to smoking.
Michelle Mitchell, chief executive of Cancer Research UK, commented in the news release that, "a lot of progress has been made saving lives from cancer, but it's worrying to see deaths from liver cancer increasing at such an alarming rate".
"Far too many lives are being lost, which is why we're funding more research into this area, and aiming to understand more about the biology of the disease to develop better treatments."
The study was supported by the British Association for the Study of the Liver, which received an unrestricted and unconditional educational grant from BTG International Ltd (now Biocompatibles UK).
No conflicts of interest declared.
NCRI Cancer Conference 2019: e-Poster 2661. Presented 4th November.
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Cite this: Liam Davenport. Liver Cancer Rates Tripled Over 20 Years in England - Medscape - Nov 05, 2019.