Hepatocellular carcinoma: A global view

Abstract

Hepatocellular carcinoma (HCC) is a global health problem, although developing countries are disproportionally affected: over 80% of HCCs occur in such regions. About three-quarters of HCCs are attributed to chronic HBV and HCV infections. In areas endemic for HCV and HBV, viral transmission occurs at an early age, and infected individuals develop HCC in mid-adulthood. As these are their most productive years of life, HCC accounts for a substantial burden on the health-care system and drain of productive capacity in the low-income and middle-income countries most affected by HCV and HBV infections. Environments with disparate resource levels require different strategies for the optimal management of HCC. In high-resource environments, guidelines from the American Association for the Study of Liver Diseases or European Association for the Study of the Liver should be applied. In intermediate-resource or low-resource environments, the fundamental focus should be on primary prevention of HCC, through universal HBV vaccination, taking appropriate precautions and antiviral treatments. In intermediate-resource and low-resource environments, the infrastructure and capacity for abdominal ultrasonography, percutaneous ethanol injection, radiofrequency ablation and surgical resection should be established. Programs to provide targeted therapy at low cost, similar to the approach used for HIV therapy in the developing world, should be pursued.

Figure 1

Global variations in age-adjusted incidence rates of liver cancer, prevalence of chronic HCV infection and chronic HBV infection. Maps were generated using incidence rates of liver cancer from GLOBOCAN 2002; prevalence of chronic HBV infection from US Centers for Disease Control and Prevention; and prevalence of chronic HCV infection from WHO International Travel and Health.

Figure 2

Age-specific incidence rates of hepatocellular carcinoma among men in China and Gambia (West Africa). Data from GLOBOCAN, 2002.

Figure 3

Estimated attributable fractions of primary hepatocellular cancers with a viral etiology in countries with different levels of medical resources (data from Bosch et al. [2004]). US and European countries were classified as having high-resource levels and Asian and African countries (except for Japan) were classified as having intermediate- or low-resource levels.

Figure 4

Change in the incidence rates of hepatocellular carcinoma between 1983 and 2004. This period spans the introduction of universal HBV vaccination in Taiwan (data from Chang et al. [2009]). The unvaccinated birth cohort consists of children born in Taiwan between July 1979 and June 1984. The vaccinated birth cohort consists of children born in Taiwan after July 1984.