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 Table of Contents  
Year : 2022  |  Volume : 2  |  Issue : 4  |  Page : 152-155

Age cohort screening for hepatocellular carcinoma in an African population

1 Department of Internal Medicine, Jos University Teaching Hospital, Jos, Plateau, Nigeria
2 Department of Internal Medicine, Federal Teaching Hospital, Gombe, Nigeria
3 Department of Acute Medicine, Medway Maritime Hospital, Gillingham, Kent, England

Date of Submission05-Aug-2022
Date of Decision01-Sep-2022
Date of Acceptance01-Sep-2022
Date of Web Publication13-Oct-2022

Correspondence Address:
Pantong Mark Davwar
Jos University Teaching Hospital, Jos, Plateau
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ghep.ghep_23_22

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Background: Hepatocellular carcinoma (HCC) is a disease of global and public health significance. In Africa, HCC is the fourth most common cancer and sub-Saharan Africa is a hotbed for HCC due to high prevalence of hepatitis B (HBV) and hepatitis C (HCV) virus infections. The late presentation in African patients has been well documented with attendant bad prognosis. We undertook this study to determine if there is an age-related clustering of HCC based on etiology. Methods: This was a retrospective hospital-based study from records of 425 adult patients (18 years and above) with triphasic computed tomography confirmed HCC at the Jos university teaching hospital, Jos, Nigeria. Relevant data were extracted from the database into an Excel spreadsheet with subsequent analysis based on age and risk factors of HCC. Results: Of 425 patients included in this study, 323 (76%) were male. The overall mean (± standard deviation) age for the studied population was 48.8 ± 14.6 years: 48.8 + 14.5 years for females and 48.9 + 14.6 years for males. 44.7% had HBV and 28% had HCV. There was a significant difference in the mean age of those with HBV as against HCV (43.0 ± 12.5 years vs. 54.3 ± 14.2 years; P < 0.001). Among those who had HCV as a risk factor for HCC, the majority (31.9%) were in the age group of 51–60 years while most of those with HBV (32.1%) were in the 31–40 years of age group. Conclusion: In this African cohort, HBV-related HCC presented a decade earlier than HCV-related HCC. Targeted screening strategies for HCC may take this into account.

Keywords: Age cohort, hepatocellular carcinoma, liver cancer, screening

How to cite this article:
Davwar PM, David N P, Duguru M J, Makpu J D, Okwute A, McHenry S, Zawaya K, Sadiq I, Okeke E N. Age cohort screening for hepatocellular carcinoma in an African population. Gastroenterol Hepatol Endosc Pract 2022;2:152-5

How to cite this URL:
Davwar PM, David N P, Duguru M J, Makpu J D, Okwute A, McHenry S, Zawaya K, Sadiq I, Okeke E N. Age cohort screening for hepatocellular carcinoma in an African population. Gastroenterol Hepatol Endosc Pract [serial online] 2022 [cited 2022 Nov 27];2:152-5. Available from: http://www.ghepjournal.com/text.asp?2022/2/4/152/358475

  Introduction Top

Liver cancer is a disease with global and public health significance. Although it has well-known largely preventable risk factors, late presentation and very high mortality are still characteristic of patients who present with this tumor. The number of new cases of liver cancer mortality was 830,180 in 2020.[1] It is the sixth most common cancer worldwide: 5th in males and 9th in females;[2] With a 5-year survival rate of 18%, its lethality is second only to pancreatic cancer. On the African continent, hepatocellular carcinoma (HCC) is the fourth most common cancer.[3] where its prevalence and etiology show some differences between North and Sub-Saharan Africa (SSA). SSA has been described as a hotbed for HCC because of the high prevalence of HCC and presence of risk factors such as infection with hepatitis B virus (HBV) which is endemic in this region of the world and hepatitis C virus (HCV) which is gradually becoming an important risk factor approximating the impact of HBV as etiologic agent.[4]

In SSA, the incidence to mortality ratio approximates one with a very dismal survival outcome in all those affected. In one previous study, the survival from time of diagnosis to death was a dismal 2 months;[5] and over 90% of patients in that study did not have diseases that are amenable to any form of available treatment options. Data from other studies showed that only 8% of Ugandan and 1% of rural southern African black patients had resectable tumors at diagnosis, compared to resectability rates of 20% in Japan and even up to 37% in some western countries. Early diagnosis of HCC has been proposed as the key to improved outcomes in this group of patients. Because of this, a lot of research has been channeled toward the discovery of HCC while it is still amenable to curative therapy. The 5-year survival in HCC patients who have had a resection or a liver transplant is 70%–80%.[6] This makes early diagnosis an attractive intervention.

In the United States, the task force on screening has found a benefit of screening for HCV in people born between 1945–1965.[7] This one-time screening has been shown to be beneficial. In our cohort of patients presenting with HCC, we observed that older patients born before 1965 tend to have HCV as a risk factor for HCC while patients with HBV-related HCC tend to be born between 1970 and 1980.[8] This seems to be an unexplored window of opportunity for an age cohort screening for risk factors and early HCC diagnosis in this age group of patients. It may also be a more cost-effective strategy in low- and middle-income countries where interventions can be targeted at identifying risk factors in individuals within these age brackets.

This study was undertaken to confirm the validity of our impression regarding the age clustering of HCC based on etiology in the population served by our hospital.

  Methods Top

This was a retrospective hospital-based study which looked at the hospital records of all HCC patients from 2013 to 2019 in our database. The total number of HCC patients was 425 individuals confirmed by a triphasic computed tomography (CT) scan in which there was arterial phase characteristic enhancement of liver lesions with a washout in the portal and venous phases of the triple phase CT scan as recommended by the American Association of the study of liver disease. Hepatitis B and C were screened using rapid test that use the lateral flow method made by Lumiquick diagnostics USA. We performed Fibroscan for each patient using the medium probe of the mini Fibroscan by Echosens France. Baseline investigations such as the liver function test, full blood count, urea electrolyte, and creatine were also extracted from the patients' records.

The patients were adults 18 years and above were consented to two previous studies carried out in the Gastroenterology Unit of the Jos University Teaching Hospital.[9] Patients were sent for a triphasic CT scan based on suspicion of liver cancer on ultrasound scan of the liver which showed masses in the liver. HCC was diagnosed based on AASLD guidelines of 2020 using a triphasic CT scan with characteristics of arterial enhancement and washout in the portal venous stages.[10]

We extracted demographic, clinical, and laboratory data from the database into a spreadsheet. We cleaned the data and excluded all patients who had missing data from the parameters of interest, mainly age and associated risk factors. We grouped patients based on age and risk factors for HCC. We then looked at the age bracket with the highest number of cases for each risk factor and determined the year of birth to determine the age bracket of interest.

Statistical analysis

Data were captured in Excel and analyzed using Epi info version 7 CDC, Atlanta, USA 2021. Basic descriptive statistics were performed and displayed as frequency tables. Continuous data and categorical data were compared using Student's t-test, Chi-square test, and Fisher's exact test, where appropriate.

  Results Top

A total of 425 patients were included in this study.

Females were 102 (24%) and males 323 (76%) the mean ± standard deviation age for females was 48.8 ± 14.5 years while for males it was 48.91 ± 4.6 years and overall mean age for the studied population was 48.8 + 14.6 years. Ninety-nine percent of the population were employed in a formal setting.

Those with HCV were 119 (28%) while HBV were 190 (44.7%), those with HIV were 41 (9.6%), those who had HBeAg were 17 (4%), and those with a family history of liver cancer were 12.7%.

There was a difference in the mean age of those with hepatitis B compared to hepatitis C, 43.01 ± 2.5 years versus 54.3 ± 14.2 years P < 0.001. The mean fibrosis score was 57.5 ± 22.9 kpa.

Among those who had HBV as a risk factor 32.1%, 26.8%, and 16.3% were between the age groups 31–40,41–50, <30, and 51–60, respectively [Figure 1]. Among those who had HCV as a risk factor for HCC, 31.9%, 21.8%, and 21.0% were in the age groups of 51–60, 41–50, and 61–70 years, respectively [Figure 2]. For patients who had HBV as a risk factor 75.2% of them were between the ages 30–50 years while among those who had HCV as a risk factor 74.7% of them were between the age groups of 41–70 years. The overlap between these two age groups with the maximum occurrence was ages 41–50 years, where 45.6% of all HCC caused by either hepatitis B or C occurred.
Figure 1: Simple Bar chart showing the different age groups of patients with HBV as a risk factor for HCC. HCC: Hepatocellular carcinoma, HBV: Hepatitis B virus

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Figure 2: Simple Bar chart showing the different age groups of patients with HCV as a risk factor for HCC. HCC: Hepatocellular carcinoma, HCV: Hepatitis C virus

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  Discussion Top

In this retrospective study of a total of 425 HCC patients with a mean age of 48 years, we were able to demonstrate the clustering of liver cancer between the age groups of 30–50 years for patients with hepatitis B as a risk factor and 41–70 years for those with chronic HCV infection. This, therefore, presents an important window of opportunity to target these age groups for public health interventions that will screen for risk factors of HCC in all people within this age group and active surveillance for HCC in those at risk. Age cohort screening has been employed in the United States of America against hepatitis C among people born during the baby boom era and this method has demonstrated dramatic life-saving impact, with an increase in detection and linkage to care.[11]

In the United States where birth cohort screening has been employed, HCC detection was significantly higher in the cohort born between 1945 and 1965.[12] The group also had considerably longer survival when they were diagnosed with HCC presumably due to early detection of liver cancer when it is amenable to treatment. This age-related clustering of HCC definitely presents an opportunity for targeted screening for HCC. One of the leading problems with HCC is late presentation as demonstrated from our data where a large percentage of the cohort presented with tumors that were either the Barcelona clinic liver cancer Stage C or D and the available treatment was at best sorafenib or palliative care. A study from Taiwan has demonstrated that late presentation with hepatitis B-related HCC can be mitigated by screening a cohort.[13] In their study, they found out that younger patients tend to present with late disease. In our previous study, we had a 100% mortality in all our HBV patients presenting with HCC, none received any form of definitive treatment except for comfort care.[14] Hepatitis B is a major risk factor for HCC in this setting. Almost half of the population of the HCC patients had HBV as a risk factor for cancer. This group of patients was also considerably younger in age when compared to those with HCV which has become an important risk factor. This, therefore, means that for this young population, a big opportunity for screening is the school environment. Preadmission screening for liver cancer and its risk factors should become incorporated into preadmission tests with linkage to care as a pathway. We have demonstrated previously that over 90% of our HCC patients have a tertiary education.[14] This suggests that the school setting presents itself as a good opportunity to identify risk factors and diseases early before they progress beyond treatment. On the other hand, the workplace is an important avenue for risk identification for those with HCV. Over 90% of this cohort with HCV who are considerably more elderly said they were employed. This could therefore mean that if screening of this particular age group is instituted as a preemployment requirement, a large number of these patients can be identified early and linked to care.

Currently, in Nigeria, there is neither clear recommendation for risk-based screening nor cohort-based screening for risk factors for hepatocellular cancer. Since we have been able to demonstrate that there is a clustering of the disease within particular age groups, it seems that considering an age cohort will be a feasible model to employ to address the problem associated with late presentation and diagnosis. This method has been proven to be more cost-effective and has been shown to improve survival among HCC patients.[15] Males have also been demonstrated in this study and previous studies from Africa and around the globe to have a higher risk of developing HCC when compared to females. Screening of an age cohort based on gender could also be a reasonable approach.

  Conclusion Top

In this African cohort, HBV-related HCC presented a decade earlier than HCV-related HCC. Targeted screening strategies for HCC may take this into account.

  References Top

Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2021;71:209-49.  Back to cited text no. 1
Ladep NG, Lesi OA, Mark P, Lemoine M, Onyekwere C, Afihene M, et al. Problem of hepatocellular carcinoma in West Africa. World J Hepatol 2014;6:783-92.  Back to cited text no. 2
Okeke E, Davwar PM, Roberts L, Sartorius K, Spearman W, Malu A, et al. Epidemiology of liver cancer in Africa: Current and future trends. Semin Liver Dis 2020;40:111-23.  Back to cited text no. 3
Tognarelli J, Ladep NG, Crossey MM, Okeke E, Duguru M, Banwat E, et al. Reasons why West Africa continues to be a hotbed for hepatocellular carcinoma. Niger Med J 2015;56:231-5.  Back to cited text no. 4
[PUBMED]  [Full text]  
Yang JD, Mohamed EA, Aziz AO, Shousha HI, Hashem MB, Nabeel MM, et al. Characteristics, management, and outcomes of patients with hepatocellular carcinoma in Africa: A multicountry observational study from the Africa liver cancer consortium. Lancet Gastroenterol Hepatol 2017;2:103-11.  Back to cited text no. 5
Altekruse SF, McGlynn KA, Dickie LA, Kleiner DE. Hepatocellular carcinoma confirmation, treatment, and survival in surveillance, epidemiology, and end results registries, 1992-2008. Hepatology 2012;55:476-82.  Back to cited text no. 6
Asrani SK, Davis GL. Impact of birth cohort screening for hepatitis C. Curr Gastroenterol Rep 2014;16:381.  Back to cited text no. 7
Yan M, Ha J, Aguilar M, Bhuket T, Liu B, Gish RG, et al. Birth cohort-specific disparities in hepatocellular carcinoma stage at diagnosis, treatment, and long-term survival. J Hepatol 2016;64:326-32.  Back to cited text no. 8
Okeke E, Mark Davwar P, Mullen B, Duguru M, Agbaji O, Sagay A, et al. The impact of HIV on hepatocellular cancer survival in Nigeria. Trop Med Int Health 2021;26:335-42.  Back to cited text no. 9
Heimbach JK, Kulik LM, Finn RS, Sirlin CB, Abecassis MM, Roberts LR, et al. AASLD guidelines for the treatment of hepatocellular carcinoma. Hepatology 2018;67:358-80.  Back to cited text no. 10
Williams J, Miners A, Harris R, Mandal S, Simmons R, Ireland G, et al. Cost-Effectiveness of one-time birth cohort screening for hepatitis C as part of the national health service health check program in England. Value Health 2019;22:1248-56.  Back to cited text no. 11
McGarry LJ, Pawar VS, Panchmatia HR, Rubin JL, Davis GL, Younossi ZM, et al. Economic model of a birth cohort screening program for hepatitis C virus. Hepatology 2012;55:1344-55.  Back to cited text no. 12
Sinn DH, Kang D, Kang M, Paik SW, Guallar E, Cho J, et al. Late presentation of hepatitis B among patients with newly diagnosed hepatocellular carcinoma: A national cohort study. BMC Cancer 2019;19:286.  Back to cited text no. 13
Davwar PM, Duguru MJ, Okorie MC, Ameh O, Okeke EN. Clinical pattern of hepatocellular cancer, a two year study. In: EASL Monothematic Conference 29/15/15. Romania: EASl Liver Tree; 2021. p. 22.  Back to cited text no. 14
Zaman A. Is birth cohort screening effective for identifying HCV cases. NEJM J Watch 2017;2017. Available from: https://www.jwatch.org. [Last accessed on 2021 May 22].  Back to cited text no. 15


  [Figure 1], [Figure 2]


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