Race and Medicine

Race and Medicine

Disclosures: The authors report no relevant financial disclosures.
February 25, 2021
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Current liver cancer screening protocols may miss at-risk Black individuals with HCV

Disclosures: The authors report no relevant financial disclosures.
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Despite having better liver function at diagnosis, Black patients with hepatitis C virus tended to have more aggressive hepatocellular carcinoma tumors compared with other racial groups, according to a study published in Cancer.

Thus, established guidelines that use the presence of liver cirrhosis to initiate screening for HCC may miss at-risk Black individuals with HCV, according to the researchers.

Despite having better liver function at diagnosis, Black patients with HCV tended to have more aggressive hepatocellular carcinoma tumors compared with other racial groups.

“Black individuals are more likely to develop liver cancer than white individuals and are more likely to die [of] it. Black patients also have more advanced liver cancer at the time of diagnosis than white patients,” Umut Sarpel, MD, associate professor of surgery and medical education, and Andrea D. Branch, PhD, professor of medicine and liver diseases and associate professor of surgery, both of Icahn School of Medicine at Mount Sinai, said in a joint statement to Healio.

Umut Sarpel, MD
Umut Sarpel

“We aimed to identify factors that distinguish liver cancer in African Americans, focusing on patients with HCV infection, the most common chronic liver disease in people who die [of] liver cancer in the United States,” they added. “About 90% of people who develop liver cancer have cirrhosis (advanced liver scarring) due to a chronic underlying liver disease.”

Sarpel, Branch and colleagues compared liver function and the presence of cirrhosis at the time of HCC diagnosis between Black patients and those of other racial groups with a history of HCV infection. They also investigated whether HCC in these Black patients was associated with a more aggressive phenotype, potentially driving the increased mortality seen in that group.

The analysis included 1,195 patients with HCC and a history of HCV who were treated at Mount Sinai between 2003 and 2018.

Of them, 390 patients (median age, 62 years; 73.6% men) self-identified as non-Hispanic Black. The other 805 patients (median age, 59 years; 77.1% men) identified as white (n = 406), Hispanic (n = 221), Asian/Pacific Islander (n = 80), other (n = 16) and unknown (n = 82).

In addition to being older, Black patients had a lower BMI (median, 26.3 kg/m2 vs. 26.9 kg/m2) and were less likely to have commercial insurance (25.9% vs. 40%; P < .01 for all).

Black patients had better liver function at the time of HCC diagnosis than patients of other racial or ethnic groups. Specifically, a greater proportion of Black patients had Child-Pugh class A cirrhosis (69.4% vs. 58.5%) and fewer had class C cirrhosis (5.9% vs. 12.9%: P < .01 for both). Also, Black patients had lower median Model of End-Stage Liver Disease (9 vs. 10) and fibrosis-4 (FIB-4; 4.66 vs. 6.54; P < .01 for both) scores.

Thirty-one percent of Black patients had FIB-4 scores of less than 3.25 compared with 17.8% of all other patients (P < .01). Because a FIB-4 score greater than 3.25 typically indicates advanced fibrosis and cirrhosis, triggering HCC surveillance, researchers noted about one-third of Black patients with HCV exposure may be missed for such surveillance by their providers.

Imaging data also suggested Black patients had less advanced liver disease, with fewer having nodular contour (49.7% vs. 78.5%), altered morphology and portal hypertension (20% vs. 55%; P < .01 for all), other characteristics than can trigger HCC screening.

Still, tumors of Black patients were more advanced in stage and had worse pathologic prognostic features than those of all other racial groups. Black patients had larger tumors (median, 3.5 cm; interquartile range [IQR], 2.2-6.2 vs. 3.1 cm; IQR, 2.1-5.1; P < .01), and they more frequently had multiple tumors (median, 1; IQR, 1-3 vs. 1; IQR, 1-2; P = .03), poorly differentiated tumors (30.3% vs. 20.5%; P < .05) and microvascular invasion (67.2% vs. 56.5%; P < .05). A smaller proportion of Black patients presented with early-stage HCC (20.2% vs. 32.3%; P < .05).

A survival analysis conducted among 780 patients with at least 5 years of follow-up showed Black patients had shorter median OS than other groups (18 months; IQR, 6-67 vs. 30 months; IQR, 9-90; P < .01). Moreover, the 5-year survival rate was 21% for Black patients vs. 28.4% for the remainder of the cohort.

Overall, the findings suggest Black patients with HCV develop HCC at earlier stages of liver disease than other racial groups, and that HCC in Black patients often has characteristics associated with a more aggressive disease course.

Andrea D. Branch, PhD
Andrea D. Branch

“Hepatocellular carcinoma in Black patients had a distinctive profile with two features,” Sarpel and Branch told Healio. “The tumors were more aggressive and the cancers were more advanced. Tumors were larger and more likely to be multifocal, poorly differentiated and to show microvascular invasion. Counterintuitively, however, liver function was significantly better in Black patients — in fact nearly one-third of them did not have liver cirrhosis.

“In short, hepatocellular carcinoma developed in Black patients even though many of them lacked the strongest risk factor for progression to liver cancer, ie, liver cirrhosis,” they added. “Because current guidelines generally use the presence of liver cirrhosis to initiate screening, these guidelines appear to not serve the African American community as well.”

Sarpel and Branch recommended additional research to determine whether the distinctive profile of liver cancer they observed can be found among Black patients with other chronic liver diseases, such as those associated with alcohol; identify possible mutations and immunological features in HCC tumors of Black patients that could be targeted with precision interventions; and improve strategies for liver cancer prevention.

“Our findings indicate that hepatitis C-exposed Black patients may benefit from participation in liver cancer surveillance even though their liver function is relatively well-preserved and they do not have cirrhosis,” Sarpel and Branch told Healio. “This could increase the likelihood that liver cancer would be diagnosed at an early and curable stage.”

For more information:

Umut Sarpel, MD, can be reached at Department of Surgery, Box 1259, The Mount Sinai Medical Center, 1 Gustave L. Levy Place, New York, NY 10029-6574; email: umut.sarpel@mountsinai.org.

Andrea D. Branch, PhD, can be reached at Department of Medicine, Division of Liver Diseases, Icahn School Medicine at Mount Sinai, Icahn (East) Building, 11th Floor, Room 11-26, 1425 Madison Ave., New York, NY 10029; email: andrea.branch@mssm.edu.