Hepatocellular carcinoma in Pacific Islanders: comparison of Pacific Island-born vs. US-born

Abstract

Aim: To describe demographic, clinical, and outcome differences in Pacific Island-born (PI-born) compared to US-born hepatocellular carcinoma (HCC) patients of Pacific Island ancestry within a clinical cohort in Hawaii.

Methods: A prospectively collected database of 1608 patients diagnosed with HCC over a 30-year period (1993-2022) identified 252 patients of Pacific Islander ethnicity. Data collected: demographics, medical history, laboratory data, tumor characteristics, treatment, and survival. Patients were divided into two groups: PI-born and US-born. Categorical variables were analyzed using ANOVA and chi-square analysis. Odds ratios with 95% confidence intervals were calculated using univariate and multivariate logistic regression. Overall survival was evaluated using Kaplan-Meier analysis.

Results: PI-born patients were younger (57.3 vs. 61.8 years, P = 0.002) and more likely to have hepatitis B (OR 14.10, 7.50-26.50) and underlying cirrhosis (OR 2.28, 1.17-4.45). In comparison, US-born patients had a significantly higher likelihood of Hepatitis C, nonalcoholic steatohepatitis/nonalcoholic fatty liver disease, history of non-HCC cancer, and positive smoking history compared to PI-born patients. PI-born patients were more likely to forego treatment (OR 3.22, 1.77-5.87) and be lost to follow-up (OR 9.21, 1.97-43.03). Both groups were equally likely to have the opportunity for curative surgical treatment (liver resection or transplant). US-born status was associated with higher mortality risk, while transplantation was associated with lower mortality risk. The PI-born cohort demonstrated higher overall survival at 3 and 5 years compared to US-born.

Conclusion: HBV remains the primary risk factor for HCC in PI-born patients, whereas HCC in US-born patients is more associated with the adoption of a Westernized lifestyle.

Keywords

hepatocellular carcinoma / Pacific Islander / nativity / risk factors / liver resection / liver transplant

References

[1] National Cancer Institute, NIH. Liver cancer causes, risk factors, and prevention. Available from https://www.cancer.gov/types/liver/what-is-liver-cancer/causes-risk-factors [Last accessed 15 Mar 2023]

[2] Xie Y.Hepatitis B virus-associated hepatocellular carcinoma.Adv Exp Med Biol2017;1018:11-21

[3] Younossi ZM.Non-alcoholic fatty liver disease - a global public health perspective.J Hepatol2019;70:531-44

[4] Estes C,Loomba R,Sanyal AJ.Modeling the epidemic of nonalcoholic fatty liver disease demonstrates an exponential increase in burden of disease.Hepatology2018;67:123-33 PMCID:PMC5767767

[5] Wong LL,Kwee S,Okimoto G.Healthcare disparities in Asians and Pacific Islanders with hepatocellular cancer.Am J Surg2012;203:726-32 PMCID:PMC3524307

[6] Yang B,So SK.Disparities in hepatocellular carcinoma incidence by race/ethnicity and geographic area in California: implications for prevention.Cancer2018;124:3551-9 PMCID:PMC6436543

[7] Danos D,Gilliland A.Increased risk of hepatocellular carcinoma associated with neighborhood concentrated disadvantage.Front Oncol2018;8:375 PMCID:PMC6141716

[8] Shebl FM,Graubard BI,Altekruse SF.Socioeconomic status and hepatocellular carcinoma in the United States.Cancer Epidemiol Biomarkers Prev2012;21:1330-5 PMCID:PMC3647693

[9] Stewart SL,Bowlus CL.Racial/ethnic disparities in hepatocellular carcinoma treatment and survival in California, 1988-2012.World J Gastroenterol2016;22:8584-95 PMCID:PMC5064040

[10] Chang ET,Gomez SL.The burden of liver cancer in Asians and Pacific Islanders in the Greater San Francisco Bay Area, 1990 through 2004.Cancer2007;109:2100-8 PMCID:PMC2777532

[11] McGlynn KA,El-Serag HB.Epidemiology of hepatocellular carcinoma.Hepatology2021;73 Suppl 1:4-13 PMCID:PMC7577946

[12] Harlan LC,Wiggins CL,Patt YZ.Treatment of hepatocellular carcinoma in the community: disparities in standard therapy.Liver Cancer2015;4:70-83 PMCID:PMC4439839

[13] Mathur AK,Lynch RJ,Dimick JB.Racial/ethnic disparities in access to care and survival for patients with early-stage hepatocellular carcinoma.Arch Surg2010;145:1158-63

[14] Howell J,Lemoine M,Hellard M.Overview of hepatitis B prevalence, prevention, and management in the Pacific Islands and Territories.J Gastroenterol Hepatol2014;29:1854-66

[15] National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Care Services; Committee on Health Care Utilization and Adults with Disabilities. Factors that affect health-care utilization. In: Health-care utilization as a proxy in disability determination. Washington (DC): National Academies Press (US); 2018. p. 21-38.

[16] U.S. Census Bureau. New census data show differences between urban and rural populations. Available from: https://content.govdelivery.com/accounts/USCENSUS/bulletins/1782904 [Last accessed on 14 Mar 2023]

[17] U.S. Department of Health and Human Services, Office of Minority Health. Minority population profiles: Native Hawaiian/Other Pacific Islander. Available from: https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=65 [Last accessed on 14 Mar 2023]

[18] Kaiser Family Foundation (KFF). Health care disparities among Asian, Native Hawaiian, and Other Pacific Islander (NHOPI) People. Available from: https://www.kff.org/racial-equity-and-health-policy/issue-brief/health-care-disparities-among-asian-native-hawaiian-and-other-pacific-islander-nhopi-people/ [Last accessed on 14 Mar 2023]

[19] NIH. State cancer profiles: liver and bile duct, 2014-2018. Available from: www.statecancerprofiles.cancer.gov [Last accessed on 14 Mar 2023]

[20] Heimbach JK,Finn RS et al.AASLD guidelines for the treatment of hepatocellular carcinoma.Hepatology2018;67:358-80

[21] Roberts LR,Zaiem F.Imaging for the diagnosis of hepatocellular carcinoma: a systematic review and meta-analysis.Hepatology2018;67:401-21

[22] U.S. Census Bureau. Population estimates, July 1, 2021 (V2021); quick facts. Available from https://www.supremecourt.gov/opinions/URLs_Cited/OT2021/19-1392/19-1392-7.pdf [Last accessed on 14 Mar 2023]

[23] Xie Y.Hepatitis b virus-associated hepatocellular carcinoma. In: Cai Q, Yuan Z, Lan K. (eds) Infectious agents associated cancers: epidemiology and molecular biology. advances in experimental medicine and biology, vol 1018. Singapore: Springer; 2017. p. 11-21

[24] CDC. People born outside of the United States and viral hepatitis. Available from: https://www.cdc.gov/hepatitis/populations/Born-Outside-United-States.htm [Last accessed on 14 Mar 2023]

[25] U.S. Department of Health and Human Services; National Institute of Diabetes and Digestive and Kidney Diseases. Hepatitis B. Available from: https://www.niddk.nih.gov/health-information/liver-disease/viral-hepatitis/hepatitis-b [Last accessed on 14 Mar 2023]

[26] Lasitani S,Elisara T.Assessing hepatitis B knowledge among Native Hawaiians and Pacific Islanders in San Diego.J Immigr Minor Health2021;23:1193-7 PMCID:PMC8599383

[27] Abara WE,Teshale EH.Impact of universal infant hepatitis B vaccination in the US-affiliated Pacific Islands, 1985-2015.Vaccine2017;35:997-1000

[28] Thursz M,Lemoine M.Global eradication of hepatitis B-feasible or fallacy?.Nat Rev Gastroenterol Hepato2012;9:492-4

[29] Mast EE,Margolis HS.Strategies to prevent and control hepatitis B and C virus infections: a global perspective.Vaccine1999;17:1730-3

[30] Papatheodoridis GV,Manolakopoulos S.Incidence of hepatocellular carcinoma in chronic hepatitis B patients receiving nucleos(t)ide therapy: a systematic review.J Hepatol2010;53:348-56

[31] Wong RJ,Therapondos G,Kshirsagar O.Antiviral therapy reduces risk of cirrhosis in noncirrhotic HBV patients among 4 urban safety-net health systems.Am J Gastroenterol2021;116:1465-75

[32] Thursz M,Hall AJ.Hepatitis B treatment in resource poor settings: time for action.Trop Med Int Health2010;15:2-4

[33] Hanafiah K,Flaxman AD.Global epidemiology of hepatitis C virus infection: new estimates of age-specific antibody to HCV seroprevalence.Hepatology2013;57:1333-42

[34] Howard J.Injecting drug use among young people in Pacific Island countries and territories: a review of the evidence.Drug Alcohol Rev2013;32:631-3

[35] Ali H.Prevalence of injecting drug use among youth in the Pacific Island countries and territories: what is the evidence?.Asia Pac J Public Health2011;23:112-4

[36] Islanders pay heavy price for abandoning traditional diet.Bull World Health Organ2010;88:484-5 PMCID:PMC2897991

[37] Pattison RJ,Sempokuya T.Nonalcoholic fatty liver disease: an important consideration for primary care providers in Hawai'i.Hawaii J Health Soc Welf2020;79:180-6 PMCID:PMC7281344

[38] Setiawan VW,Porcel J,Le Marchand L.Prevalence of chronic liver disease and cirrhosis by underlying cause in understudied ethnic groups: the multiethnic cohort.Hepatology2016;64:1969-77 PMCID:PMC5115980

[39] Sliz E,Würtz P.NAFLD risk alleles in PNPLA3, TM6SF2, GCKR and LYPLAL1 show divergent metabolic effects.Hum Mol Genet2018;27:2214-23 PMCID:PMC5985737

[40] Lee J,Friso S.Epigenetics in non-alcoholic fatty liver disease.Mol Aspects Med2017;54:78-88

[41] Rasanathan K.Tobacco smoking prevalence in Pacific Island countries and territories: a review.N Z Med J2007;120:U2742

[42] Kessaram T,Girin N.Tobacco smoking in islands of the Pacific Region, 2001-2013.Prev Chronic Dis2015;12:E212 PMCID:PMC4675401

[43] CDC. Asian, Native Hawaiian, and Pacific Islander people experience a health burden from commercial tobacco. Available from: https://www.cdc.gov/tobacco/health-equity/anhpi/health-burden.html [Last accessed on 14 Mar 2023]

[44] Kessaram T,Girin N.Alcohol use in the Pacific region: results from the STEPwise approach to surveillance, Global School-Based Student Health Survey and Youth Risk Behavior Surveillance System.Drug Alcohol Rev2016;35:412-23 PMCID:PMC5049666

[45] Subica AM,Aitaoto N,Iwamoto D.Hazardous drinking, alcohol use disorders, and need for treatment among Pacific Islander young adults.Am J Orthopsychiatry2020;90:557-66 PMCID:PMC9048751

[46] Floyd A.Healthcare access for refugee women with limited literacy: layers of disadvantage.Int J Equity Health2017;16:195 PMCID:PMC5681803

[47] Morisako AK,Ambrose AJH.Beyond the ability to pay: the health status of Native Hawaiians and Other Pacific Islanders in relationship to health insurance.Hawaii J Med Public Health2017;76 (3 Suppl 1):36-41 PMCID:PMC5375012

[48] Shindoh J,Watanabe G.Surgical approach for hepatitis C virus-related hepatocellular carcinoma.World J Hepatol2015;7:70-77 PMCID:PMC4295196