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Hepatocellular Carcinoma. Thomas Hargrave M.D. January 16, 2009. HCC Is Common and Increasing. World Health Organization. Available at: http://www.who.int/whosis/en/. Accessed October 6, 2008. American Cancer Society. Cancer facts & figures 2008. Atlanta: American Cancer Society; 2008.

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hepatocellular carcinoma

Hepatocellular Carcinoma

Thomas Hargrave M.D.

January 16, 2009

hcc is common and increasing
HCC Is Common and Increasing

World Health Organization. Available at: http://www.who.int/whosis/en/. Accessed October 6, 2008. American Cancer Society. Cancer facts & figures 2008. Atlanta: American Cancer Society; 2008.

  • 662,000 deaths from liver cancer yearly worldwide
  • Age-adjusted US incidence has increased 2-fold: 1985-1998
  • American Cancer Society statistics for liver cancer in 2008
    • Estimation of new cases: 21,370
    • Estimation of deaths: 18,410
    • 5th leading cause of cancer deaths in males
slide3

HCC Epidemiology

Worldwide Incidence of Hepatocellular Carcinoma

High (> 30:100,000)

El-Serag HB,

Gastroenterology

2004

Intermediate (3-30:100,000)

Low or data unavailable (< 3:100,000)

recent changes in the incidence of hcc
Recent Changes in the Incidence of HCC

HCC Epidemiology

Changes in the Incidence of HCC 1978-1992

-30

Singapore, Chinese

-24

Spain, Zaragoza

-20

India, Bombay

-18

China, Shanghai

10

Switzerland, Geneva

12

Hong Kong

14

NewZealand, Maori

21

NewZealand, Non-Maori

46

Japan, Osaka

50

UK, So. Thames

71

Canada, Alberta

83

Italy, Varese

France, Bas-Rhin

90

Australia, NSW

108

20

40

60

80

100

120

-40

-20

0

McGlynn K, et al, Int J Cancer 2001

age adjusted incidence rates for hcc 1976 2002

HCC Epidemiology

Age-Adjusted Incidence Rates For HCC (1976-2002)

3.5

3.3

3.1

3

2.7

2.5

2.3

Rate

per 100,000

2.0

2

1.8

1.6

1.4

1.4

1.5

1

0.5

0

76-78

79-81

82-84

85-87

88-90

91-93

94-96

97-99

2000-02

Year

El-Serag HB, Mason A, N Engl J Med 1999

El-Serag HB et al, Ann Intern Med 2003

racial distribution of hcc in the united states

HCC Epidemiology

Racial Distribution of HCC in the United States

3000

Asian

2500

Black

2000

White

Number of Cases

1500

1000

500

0

75-77

78-80

81-83

84-86

87-89

90-92

93-95

96-98

Year

El-Serag HB, Mason A, N Engl J Med 1999

racial incidence rates for hcc in the united states

9

8

7

6

5

4

3

2

1

0

HCC Epidemiology

Racial Incidence Rates For HCCIn The United States

8.4

White

Black

Other (Asian)

8

7.9

7.2

7.2

6.6

6.3

6

5.2

5

Age-Adjusted Incidence Rate

per 100,000

4.6

3.9

3.7

3.4

2.9

2.6

2.5

2.5

2.5

2.3

1.9

1.7

1.4

1.3

1.1

1.1

1

76-78

79-81

82-84

85-87

88-90

91-93

94-96

97-99

2000-02

Year

El-Serag HB et al, Ann Intern Med 2003

temporal trends in the age distribution of hepatocellular carcinoma

20

18

16

14

12

10

8

6

4

2

0

HCC Epidemiology

Temporal Trends in The Age Distribution of Hepatocellular Carcinoma

1982 – 84

1991 – 93

2000 – 02

Incidence Rate

per 100,000 PY

20-24

30-34

40-44

50-54

60-64

70-74

80-84

25-29

35-39

45-49

55-59

65-69

75-79

85+

Age (years)

El-Serag HB, Mason A, N Engl J Med 1999

risk factors for hcc in us patients
Risk Factors for HCC in US Patients

Worldwide, 75% to 80% of HCC attributable to chronic HBV (50% to 55%) or HCV (25% to 30%)

Known Risk Factor in the US: Viral Hepatitis (N = 691)

100

80

60

47

Presence of Risk Factor Among HCC Patients (%)

33

40

15

20

5

0

HBV

HBV + HCV

Neither

HCV

Di Bisceglie AM, et al. Am J Gastroenterol. 2003;98:2060-2063. El-Serag HB. Gastroenterology. 2004;127:S27-S34. Bosch FX, et al. Gastroenterology. 2004;127:S5-S16.

risk factors for hcc

HCC Epidemiology

Risk Factors for HCC

Risk Factors for HCC
  • Cirrhosis from any cause (3-8%/yr)
    • HCV
    • HBV
    • Heavy alcohol consumption
    • Non-alcoholic fatty liver disease
  • HBV without cirrhosis (0.02-0.06%/yr)
  • Inherited metabolic diseases
    • Hemochromatosis
    • Alpha-1 antitrypsin deficiency
    • Glycogen storage disease
    • Porphyriacutaneatarda
    • Tyrosinemia
    • Autoimmune hepatitis
hcv cirrhosis and hcc
HCV Cirrhosis and HCC

HCC Epidemiology

HCV Cirrhosis and HCC

Multiple smallfoci of HCC

why hcc is rising

HCC Epidemiology

Why HCC is Rising?

Why is HCC Incidence Rising?

Increasing prevalence of patients with cirrhosis

  • Rising incidence of cirrhosis
    • HCV (main reason)
    • HBV
    • Other (?NAFLD/insulin resistance)
  • Improved survival of patients with cirrhosis

El-Serag HB, Gastroenterology 2004

prevalence of hcv in united states males 1999 2002
Prevalence of HCV in United States Males:1999-2002

Annals Internal Medicine 2006; 144:705

projected rates of hcv related cirrhosis and hcc
Projected Rates of HCV-Related Cirrhosis and HCC

Davis GL, et al. Liver Transpl. 2003;9:331.

alcohol intake and the risk of hcc

HCC Epidemiology

Alcohol Intake and the Risk of HCC

Alcohol Intake and the Risk of HCC

20

No HCV

with HCV

15

10

Odds Ratios

5

0

20

40

60

80

100

120

140

Grams of Alcohol / Day

Donato F, et al, Am J Epidemiol 2002

hbv dna associated with increased risk of hcc

HBV DNA Associated with Increased Risk of HCC in Non-Cirrhotics

HBV DNA Associated with Increased Risk of HCC
  • Likelihood of HCC in individuals with detectable HBV DNA is3.9 times more than those with undetectable HBV DNA
    • Risk associated with increasing HBV DNA levels
  • These data support possibility of preventing long-term risk of HCC by inducing sustained suppression of HBV replication

Yang HI, et al, N Engl J Med 2002

hbe antigen and risk of hcc
HBe Antigen and Risk of HCC

11,893 Noncirrhotic Taiwanese Males Followed 8 Yrs

12

HBsAg+, HBeAg+

(RR = 60.2)

10

8

Percent cumulative incidence

6

4

HBsAg+, HBeAg-

(RR = 9.6)

2

HBsAg-, HBeAg-

0

10

0

1

2

3

4

5

6

7

8

9

Year

Yang HI, et al, N Engl J Med 2002

hbv dna and risk of hcc untreated non cirrhotic hbeag
HBV DNA and Risk of HCC: Untreated Non-Cirrhotic HBeAg+

HBV DNA (copies/mL)

  • 3465 HBeAg (+) Non-cirrhotic Taiwanese Patients followed for a mean of 11.5years
  • 65% had HBV DNA > 100,000,000

Incidence of HCC

Per Year (%)

Chen et al. JAMA. 2006;295:65-73 (B).

risk factors for hcc in us patients1
Risk Factors for HCC in US Patients

Worldwide, 75% to 80% of HCC attributable to chronic HBV (50% to 55%) or HCV (25% to 30%)

Known Risk Factor in the US: Viral Hepatitis (N = 691)

100

80

  • (?NAFLD/insulin resistance?)

60

47

Presence of Risk Factor Among HCC Patients (%)

33

40

15

20

5

0

HBV

HBV + HCV

Neither

HCV

Di Bisceglie AM, et al. Am J Gastroenterol. 2003;98:2060-2063. El-Serag HB. Gastroenterology. 2004;127:S27-S34. Bosch FX, et al. Gastroenterology. 2004;127:S5-S16.

non alcoholic fatty liver disease nafld and hcc

HCC Epidemiology

Non-alcoholic Fatty Liver Disease (NAFLD) and HCC

Non-alcoholic Fatty Liver Disease (NAFLD) and HCC

Single center study, Univ. Michigan

  • 105 consecutive patients with HCC
    • 51% due to HCV-associated cirrhosis
    • Cryptogenic cirrhosis in 29%
      • Half had histologic features consistent with NASH
      • Estimated that 13% of HCC and cryptogenic cirrhosis may have NAFLD/NASH

Marrero J, et al, Hepatology 2002

prospective study cancer mortality in obese us adults n 900 053 1982 1998
Prospective Study Cancer Mortality in Obese US Adults (n=900,053):1982-1998

Men

Prostate (>35)

1.34

Non-Hodgkin’s Lymphoma(>35)

1.49

1.52

All Cancers (>40)

All Other Cancers (>30)

1.68*

Kidney (>35)

1.70

Type of Cancer

(Highest BMI Category)

Multiple Myeloma (>35)

1.71

Gall Bladder (>30)

1.76

Colon and Rectum (>35)

1.84

1.91*

Esophagus (>30)

Stomach (>35)

1.94

Pancreas (>35)

2.61*

4.52

Liver (>35)

0

1

2

3

4

5

6

7

Relative Risk of Death (95% Confidence Interval)

Calle EE, & et al, N Engl J Med 2003

obesity and liver cancer

Women

Men

0

10

20

30

40

50

60

HCC Epidemiology

Obesity and Liver Cancer

8

35 to 39.9

48

6

30 to 34.5

19

BMI

5

20 to 29.9

10

5

18.5 to 25

9

Death Rate per 100,000

Calle, et al, NEJM 2003

impact of diabetes and overweight on liver cancer occurrence in cirrhosis
Impact of Diabetes and Overweighton Liver Cancer Occurrence in Cirrhosis

771 Compensated ETOH or HCV Cirrhotics Prospectively Screened for HCC

1.0

.8

BMI <23.9, diabetes -

BMI <23.9, diabetes +

BMI 23.9-27.3 diabetes -

BMI 23.9-27.3 diabetes +

BMI >27.3, diabetes -

BMI >27.3, diabetes +

.6

Probability of HCC Free Survival

P<0.0001

.4

.2

N = 771

0

0

2

4

6

8

10

Time (Years)

N’Kontchou G, Clin Gastro Hepatol 2005

cancer and insulin resistance
Cancer and Insulin Resistance

Excess weight / adiposity

FFA , TNFa Resistin , Adiponectin

Tumor development

Insulin resistance

Insulin

IR

Target cellsApoptosis Cell proliferation

Blood and tissue: IGFBP 1 IGFBP2

IGF1R

IGF1 bioavailability

cost effectiveness of hcc surveillance

HCC Screening

Cost-Effectiveness of HCC Surveillance

Cost-Effectiveness of HCC Surveillance

  • Surveillance with bi-annual alpha-fetoprotein (AFP) and ultrasonography in Child class A cirrhotics had cost-effectiveness ratios between $26,000 and $55,000 per QALY
  • 2 other studies show cost-benefits of HCC surveillance

Sarasin FP, et al, Am J Med 1996

Arguedas MR, et al, Am J Gastroenterol 2003

Lin OS, et al, Aliment Pharmacol Ther 2004

alpha fetoprotein cross sectional studies

HCC Screening

Alpha-fetoprotein Cross-Sectional Studies

Specificity

%

Author

Cutoff

No. of HCC

Sensitivity

%

65

88

Peng

20

205

Trevisani

16

170

60

90

25

Cedrone

100

74

95

89

Soresi

30

197

65

53

Lee

200

54

79

79

Nguyen

20

163

63

Marrero JA, Clin Liver Dis 2005

specificity of afp surveillance for hcc ppv 9 46
Specificity of AFP Surveillance for HCC: PPV 9- 46%

*5% prevalence of HCC.

Trevisani F, et al. J Hepatol. 2001;34:570-575. Pateron D, et al. J Hepatol. 1994;20:65-71. Sherman M, et al. Hepatology. 1995;22:432-438. McMahon BJ, et al. Hepatology. 2000;32:842-846. Bolondi L, et al. Gut. 2001;48:251-259. Tong MJ, et al. J Gastroenterol Hepatol. 2001;16:553-559.

current serologic surveillance tests not sufficiently sensitive specific
Current Serologic Surveillance Tests Not Sufficiently Sensitive/Specific

100

85.9

84.8

84.8

80

73.7

72.7

67.7

61.6

60

Sensitivity (%)

40

20

0

AFP-L3%

DCP

AFP

AFP-L3%

+ DCP

AFP-L3%

+ AFP

DCP

+ AFP

AFP-L3%

+ DCP

+ AFP

Tumor Marker

Prospective analysis of 99 patients with histologically proven, unresectable HCC

Carr BI, et al. Dig Dis Sci. 2007;52:776-782.

ultrasound in hcc in cohort studies

HCC Screening

Ultrasound in HCC in Cohort Studies

Colli A, et al, Am J Gastro 2006

hcc surveillance by ultrasound npv 98 100
HCC Surveillance by Ultrasound: NPV 98-100%

Collier J and Sherman M. AASLD 1995. Morris Sherman, MB BCh, PhD, FRCP(C). Data on file.

Performance characteristics of ultrasound as a screening test

surveillance interval 6 vs 12 months
Surveillance Interval: 6 vs 12 Months

1. Trevisani F, et al. Am J Gastroenterol. 2002;97:734-744. 2. Santagostino E, et al. Blood. 2003;102:78-82. 3. Kim DY, et al. AASLD 2007. Abstract 368.

  • Trevisani et al[1]
    • Survival similar with 6-month vs 12-month surveillance
  • Santagostino et al[2]
    • Rate of detection of single nodules (vs multinodular HCC) similar with 6-month vs 12-month surveillance
  • Kim et al[3]
    • Survival improved with 6-month vs 12-month surveillance
aasld and nccn surveillance guidelines
AASLD and NCCN Surveillance Guidelines

AASLD Guidelines

Surveillance recommended in at-risk groups

Specific hepatitis B carriers

Nonhepatitis B cirrhosis

US preferred surveillance tool

AFP alone should not be used unless US unavailable

Patients should be screened at - 6 to 12-month intervals

NCCN Guidelines

US and AFP, AP, and albumin for surveillance in high-risk patients

Every 3-6 months

Continue screening every 3 months in those with high AFP but no evidence on imaging

NCCN, National Comprehensive Cancer

surveillance for hcc improves mortality a randomized controlled trial

HCC Screening

Surveillance for HCC Improves MortalityA Randomized Controlled Trial

Screened group Control group

Person-years in study 38,444 41,077

HCC occurrence

Cases 86 67

Total incidence (per 100,000) 223.7 163.1

Rate ratio (95% CI) 1.37 (0.99, 1.89)

Deaths from HCC

Deaths 32 54

Total mortality (per 100,000) 83.2 131.5

Rate ratio (95% CI) 0.63 (0.41, 0.98)

clinical features at presentation

HCC Diagnosis

Clinical Features at Presentation

Symptoms Percent of Patients

None 23%

Abdominal Pain 32%

Ascites 8%

Jaundice 8%

Anorexia/weight loss 10%

Malaise 6%

Bleeding 4%

Encephalopathy 2%

Gastroenterology 2002

guidelines for diagnosis of hcc

HCC Diagnosis

Guidelines for Diagnosis of HCC

Ultrasound findings

Typical features of HCC = vascular nodule on arterial phase

with washout in delayed phases

Bruix J, et al, Hepatology 2005

dual blood supply of liver

HCC Diagnosis

Dual Blood Supply of Liver
  • The vascular supply of HCC arises from the hepatic artery through neovascularization.
  • Normal hepatocytes receive 80% of blood flow from portal vein
  • Imaging of the liver has to be performed in a triple phase manner to account for the early arterial phase followed by the portal venous phase and the delayed phases

Yu JS, et al, Am J Roentgenol 1999

triple phase imaging of hepatocellular carcinoma

HCC Diagnosis: MRI

Triple Phase Imaging of Hepatocellular Carcinoma

Arterial Phase

Pre-contrast

Portal Venous Phase

5-min Delayed

dynamic mri spiral ct for diagnosis of hcc

HCC Diagnosis

Dynamic MRI Spiral CT for Diagnosis of HCC

Variables Dynamic MRI Spiral CT

Sensitivity 76% (58/76) 61% (43/70)

Specificity 75 % (18/24) 66% (12/18)

PPV 90% (58/64) 87% (43/49)

NPV 50% (18/36) 30% (12/39)

LR positive test 3.04 1.79

n= 55 cirrhotics (29 with HCC)

Burrel M, et al, Hepatology 2003

population based survival estimates in the united states
Population-based Survival Estimates in the United States

0

1

2

3

HCC Treatment

HCC Survival Estimates

in the United States

100

Median Survival 6-8 months

80

White

Hispanic

60

Black

Survival (%)

Asian

40

20

0

Years Following Diagnosis

Davila J, & El-Serag HB, Clin Gastroenterol Hepatol. 2006

key concepts in the management of hepatocellular cancer

HCC Treatment

Key Concepts in the Management of Hepatocellular Cancer

Key Concepts in the Management of Hepatocellular Cancer

  • Potentially Curative
    • Liver transplantation (75% 5-year survival)
    • Surgical resection
  • Palliative
    • Radiofrequency ablation (RFA)
    • Transarterial chemoembolization (TACE)
    • Percutaneous ethanol or acetic acid ablation
    • Cryoablation
    • Systemic Chemotherapy
key concepts in the management of hepatocellular cancer1

HCC Treatment

Key Concepts in the Management of Hepatocellular Cancer

Key Concepts in the Management of Hepatocellular Cancer

  • Liver transplantation achieves the best outcome in HCC patients with decompensated cirrhosis who meet criteria
  • Surgical resection is most effective for non-cirrhotic patients or those with cirrhosis and preserved liver function and can be followed by salvage OLT
  • Patients with small tumors are best stratified for resection or OLT by the presence of clinically-significant portal hypertension and/or increased serum bilirubin
  • Local ablative methods are an option for small solitary nodules and those who are not surgical candidates
  • Transarterial chemoembolization improves survival in intermediate-advanced HCC
management of hepatocellular carcinoma requires a multidisciplinary approach

HCC Treatment

Management of Hepatocellular Carcinoma Requires a Multidisciplinary Approach

Hepatobiliary Surgery

Hepatology

Oncology

Pathology

Radiology

Liver Transplant Program

liver transplantation for hcc milan criteria stage 1 and 2
Liver Transplantation for HCC:Milan Criteria (Stage 1 and 2)

Single tumor, not > 5 cm

Up to 3 tumors, none > 3 cm

+

Absence of macroscopic vascular invasion,

absence of extrahepatic spread

Mazzaferro V, et al. N Engl J Med. 1996;334:693-699.

surgical resection of hcc outcome in a us cancer center

HCC Pts Evaluated

1989 – 2001

611 pts

Unresectable

385 pts (70%)

Resected

180 pts (30%)

Transplant Eligible

Transplant Ineligible

74 pts (80%)

36 pts (20%)

78% with cirrhosis

HCC Treatment

Surgical Resection of HCC:Outcome in a US Cancer Center

Ann Surg. 2003; 238:315-21.

treatment of hcc in us at non federal hospitals in 2000
Treatment of HCC in US atNon-Federal Hospitals in 2000

2 databases evaluated for trends in HCC

48,349 HCC deaths 1980-1998

15

11.0

10

Treatment (%)

5.5

4.9

5

3.5

1.8

0

Surgical

Resection

Liver

Transplant

Local

Ablation

Embolization

Chemotherapy

Kim WR, et al. Gastroenterology. 2005;129:486-493.

treatment for hcc often suboptimal
Treatment for HCC Often Suboptimal
  • Proportion of patients receiving potentially curative therapy (N = 2963)
    • 34.0% of patients with single lesions
    • 34.0% of patients with lesions < 3 cm
    • 19.2% of patients with lesions > 10 cm
    • 4.9% of patients with metastatic disease
  • 11.5% of patients ideal for transplantation received it
  • 12.9% of patients ideal for surgical resection received it

El-Serag HB, et al. J Hepatol. 2006;44:158-166.

slide52

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

Outcomes of HCC Treatment:

Observational Population-based study

2,963 patients with HCC diagnosed between 1992 and 1999 in SEER-Medicare datasets

1

Median Age:74

0.8

0.6

Survival

(Kaplan Meier Estimate)

Transplant

Resection

0.4

Ablation

TACE

0.2

0

Follow up Duration (Years)

El-Serag HB, et al, J Hepatology 2006 44:158

summary of nccn treatment guidelines
Summary of NCCN Treatment Guidelines

Potentially resectable, inoperable mass

Unresectable/ Denies Surgery

Inoperable by PS, comorbidity (local disease)

Metastatic

Transplant if appropriate candidate

Not transplant candidate/has cancer-related symptoms

Surgical eval/ biopsy

No cancer-related symptoms

Cancer-related symptoms

Extensive/ no cancer-related symptoms

  • Sorafenib
  • Chemo-embolization
  • Clinical trial
  • Ablation
  • Chemo + RT
  • RT
  • Radio-embolization
  • Supportive care
  • Systemic/intra-arterial chemo
  • Sorafenib
  • Ablation
  • Clinical trial
  • Chemo-embolization
  • RT
  • Radio-embolization
  • Supportive care

Resectable

  • Sorafenib
  • Clinical trial
  • Sorafenib
  • Clinical trial
  • Supportive care
  • Sorafenib
  • Ablation
  • Clinical trial
  • Ablation
  • Transplant
  • Transplant

NCCN. Available at: http://www.nccn.org/professionals/physician_gls/PDF/hepatobiliary.pdf. Accessed October 23, 2008.

hcc summary
HCC: Summary
  • HCC is one the most rapidly increasing cancers in the US
  • The 5-year survival is 8-12%
  • Less than 20% are candidates for surgery/transplant at diagnosis
  • Treatment is mainly palliative
  • Referral to a tertiary center indicated
  • Screening to detect early HCC is the main priority of primary care physicians
hepatitis b carriers suitable for hcc surveillance
Hepatitis B Carriers Suitable for HCC Surveillance

Hepatitis B carriers

Asian males > ~ 40 years (incidence ~ 0.4% to 0.6% per year)

Asian females > ~ 50 years (incidence ~ 0.2% per year)

Africans older than 20 years of age (incidence unknown but likely > 0.2% per year)

Cirrhosis (HCC incidence: 3% to 5%/year)

Family history of HCC: Screen from the time of diagnosis (mainly Asian and African)

aasld and nccn surveillance guidelines1
AASLD and NCCN Surveillance Guidelines

AASLD Guidelines

Surveillance recommended in at-risk groups

Specific hepatitis B carriers

Nonhepatitis B cirrhosis

US preferred surveillance tool

AFP alone should not be used unless US unavailable

Patients should be screened at - 6 to 12-month intervals

NCCN Guidelines

US and AFP, AP, and albumin for surveillance in high-risk patients

Every 3-6 months

Continue screening every 3 months in those with high AFP but no evidence on imaging

NCCN, National Comprehensive Cancer

focus screening efforts on patients under age 65
Focus Screening Efforts on Patients Under Age 65

20

18

16

14

12

10

8

6

4

2

0

1982 – 84

1991 – 93

2000 – 02

Incidence Rate

per 100,000 PY

20-24

30-34

40-44

50-54

60-64

70-74

80-84

25-29

35-39

45-49

55-59

65-69

75-79

85+

Age (years)

El-Serag HB, Mason A, N Engl J Med 1999

hcc preventative measures
HCC: Preventative Measures?
  • Although unproven, data suggest that maximal suppression of HBV DNA may reduce the annual incidence of HCC
    • Obscenely expensive
  • Eradication of HCV significantly reduces the risk of HCC
  • Minimize ETOH
  • Minimize risk factors for hyperinsulinemia
  • Statins?
  • Coffee
hcc after ifn therapy for hcv

HCC Epidemiology

HCC After IFN Therapy for HCV

30

25

20

No Response

Cumulative Incidence

of HCC (%)

15

10

Relapse

5

Sustained

Response

0

0

1

2

3

4

5

6

7

Follow-up (yr)

Imai Y, et al, Ann Intern Med 1998

statins vs hcc
Statinsvs HCC

Retrospective, case-controlled study

VA database >1,400.000 veterans

14,021 HVC positive

34% on statins

HCC diagnosed in 409

After controlling for age, genotype, statin use was associated with a significant reduction in risk for HCC

  • V. Khurana et al. “Statins Are Protective Against HCC in HCV Infection”DDW 2005. May 14-14 Abstract S1535
don t forget your coffee
Don’t Forget Your Coffee

Hepatology 2007 Aug;46(2):430-5

Meta-analysis of published studies on HCC that included quantitative information on coffee consumption

Ten studies were retrieved: 2,260 HCC cases

The overall summary RR for low or moderate coffee drinkers was 0.70 (95% CI 0.57-0.85), and that for high drinkers was 0.45 (95% CI 0.38-0.53)