Etiologic fractions in patients of Hepatocellular carcinoma in India with and without a background of cirrhosis - a multi-centric study

Abstract

Abstract Background: Hepatocellular cancer (HCC) typically arises in the background of cirrhosis. Its epidemiology has been changing due to availability of antivirals, changing life-styles and early detection. We undertook a multicentric national sentinel surveillance for liver cirrhosis and HCC to assess the attributable risk factors for development of HCC, both with and without a background of cirrhosis. Methods: Data from January 2017 till August 2022 from hospital-based records of eleven participating centres was included. Diagnosed cases of cirrhosis [radiological (multiphase and/or histopathological] and HCC [as per AASLD 2018] were included. History of significant alcohol intake was elicited by AUDIT-C questionnaire. Results: Altogether 5798 enrolled patients were assessed, of which 2664 patients had HCC. The mean age was 58.2±11.7 years and 84.3% (n=2247) were males. Diabetes was found in over a third of those with HCC (n=1032;39.5%). The most common etiology of HCC was NAFLD (n=927;35.5%) followed by viral hepatitis B and C and harmful levels of alcohol. Among those with HCC, 27.9% (n=744) had no cirrhosis. Higher proportion of cirrhotic HCC patients had alcohol as an etiological factor as compared to non-cirrhotic (17.5% Vs 4.7%, p= <0.001). NAFLD was an etiological factor for a higher proportion of non-cirrhotic HCC patients as compared to cirrhotic HCC (48.2% Vs 30.6%, p=< 0.001). Diabetics more commonly had non-cirrhotic HCC (50.5% vs 35.2%). The odds of having cirrhotic HCC was 1.409 times greater for >60 years, 1.372 times for males and 3.472 times for harmful alcohol consumption. Those with NAFLD were 1.553 times more likely to develop non-cirrhotic HCC. Conclusion: This large multi-centric study demonstrates that NAFLD is the most important risk factor for development of both cirrhotic and non-cirrhotic HCC in India and has overtaken viral hepatitis. Awareness campaigns and large-scale screening are required to reduce the high burden of NAFLD related HCC in India.