Original article
Pancreas, biliary tract, and liver
Temporal Trends of Nonalcoholic Fatty Liver Disease–Related Hepatocellular Carcinoma in the Veteran Affairs Population

https://doi.org/10.1016/j.cgh.2014.08.013Get rights and content

Background & Aims

Nonalcoholic fatty liver disease (NAFLD) is a risk factor for hepatocellular carcinoma (HCC). However, no systemic studies from the United States have examined temporal trends, HCC surveillance practices, and outcomes of NAFLD-related HCC.

Methods

We identified a national cohort of 1500 patients who developed HCC from 2005 through 2010 from Veterans Administration (VA) hospitals. We reviewed patients’ full VA medical records; NAFLD was diagnosed based on histologic evidence for, or the presence of, the metabolic syndrome in the absence of hepatitis C virus (HCV) infection, hepatitis B, or alcoholic liver disease. We compared annual prevalence values for the main risk factors (NAFLD, alcohol abuse, and HCV), as well a HCC surveillance and outcomes, among HCC patients.

Results

NAFLD was the underlying risk factor for HCC in 120 patients (8.0%); the annual proportion of NAFLD-related HCC remained relatively stable (7.5%–12.0%). In contrast, the proportion of HCC cases associated with HCV increased from 61.0% in 2005 (95% confidence interval, 53.1%–68.9%) to 74.9% in 2010 (95% confidence interval, 69.0%–80.7%). The proportion of HCC cases associated with only alcohol abuse decreased from 21.9% in 2005 to 15.7% in 2010, and the annual proportion of HCC cases associated with hepatitis B remained relatively stable (1.4%–3.5%). A significantly lower proportion of patients with NAFLD-related HCC had cirrhosis (58.3%) compared with patients with alcohol- or HCV-related HCC (72.4% and 85.6%, respectively; P < .05). A significantly higher percentage of patients with NAFLD-related HCC did not receive HCC surveillance in the 3 years before their HCC diagnosis, compared with patients with alcohol- or HCV-associated HCC. A lower proportion of patients with NAFLD-related HCC received HCC-specific treatment (61.5%) than patients with HCV-related HCC (77.5%; P < .01). However, the 1-year survival rate did not differ among patients with HCC related to different risk factors.

Conclusions

NAFLD is the third most common risk factor for HCC in the VA population. The proportion of NAFLD-related HCC was relatively stable from 2005 through 2010. Although patients with NAFLD-related HCC received less HCC surveillance and treatment, a similar proportion survive for 1 year, compared with patients with alcohol-related or HCV-related HCC.

Section snippets

Data Sources

Data were obtained from VA administrative data files and a review of patient electronic medical records (EMRs). Administrative data included the Medical SAS (MedSAS) Outpatient and Inpatient files, and the VA Vital Status File. The MedSAS files contain patient demographic data as well as diagnoses according to the International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) and procedures according to Common Procedural Terminology (CPT) codes. We determined the date

Results

The study cohort comprised 1500 patients diagnosed with HCC during fiscal years 2005 to 2010. Their mean age at the time of diagnosis was 63.7 years (SD, 9.5 y), and the vast majority were men (99.8%). The greatest proportions of patients were as follows: white non-Hispanic (59.8%), followed by blacks (26.1%), and Hispanics (11.9%). A liver mass biopsy was available in 786 (52.4%) cases to confirm the diagnosis of HCC, and the remainder were diagnosed according to radiologic features. HCV

Discussion

Our study shows that in the VA population between 7.5% and 12.0% of HCC cases were related to NAFLD and this proportion remained stable over the study period. We observed that NAFLD-related HCC patients have a distinct phenotype: older age, more likely to be white, and with less severe liver dysfunction at diagnosis compared with HCC from other causes. These patients received less medical attention as shown by lower rates of surveillance and treatment.

An earlier study on risk factors in HCC in

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    Conflicts of interest The authors disclose no conflicts.

    Funding Supported in part by the National Cancer Institute (R01 CA160738 to J.A.D.), the facilities and resources of the Houston Veterans Affairs Health Services Research and Development Center of Excellence (HFP90-020), the Michael E. DeBakey Veterans Affairs Medical Center, and the Dan Duncan Cancer Center (Houston, TX).

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