CHICAGO — Drinking even two or fewer alcoholic drinks per day nearly quadruples the risk of hepatocellular carcinoma in patients with cirrhosis due to both nonalcoholic steatohepatitis and hepatitis C infection, a prospective study has concluded.
The study is the first to confirm such a link in patients with nonalcoholic steatohepatitis (NASH), and emphasizes the need for proactive counseling among these patients, Dr. Nizar Zein said at the annual Digestive Disease Week.
“Physicians following these patients should counsel complete abstention of alcohol,” Dr. Zein said in an interview. “If we can get them to do that, we may in the future be able to lower the burden of cancer associated with this disease.”
About 20% of patients with NASH will develop cirrhosis, a proven risk factor for hepatocellular carcinoma (HCC), said Dr. Zein, chief of hepatology and medical director of liver transplants at the Cleveland Clinic. “Despite this link, there is a lack of large population studies regarding the risk of HCC in patients with cirrhosis due to NASH.”
To study this question, Dr. Zein and his colleagues performed a retrospective analysis of 510 patients with cirrhosis not related to alcohol intake, who were treated at the clinic from 2003 to 2007. Cirrhosis was due to NASH in 195 patients, and to hepatitis C viral infection in 315. Patients with NASH were significantly older than those with hepatitis C (57 vs. 45 years). They also had a significantly higher body mass index (35 vs. 28 kg/m2). The mean score on the Model for End-Stage Liver Disease (MELD) scale was 11 in the NASH group and 12 in the hepatitis group—not a significant difference.
Over the 3-year follow-up period, 18% of the entire study population developed HCC. The rate was significantly higher in the hepatitis group than in the NASH group (20% vs. 13%). The yearly HCC incidence was also significantly higher in the hepatitis C group than in the NASH group (4% per year vs. 3% per year).
A multivariate analysis examined risk factors associated with the development of HCC in those patients with NASH. Not surprisingly, older age at cirrhosis diagnosis was significantly associated with developing cancer, increasing the risk by 7%.
Even patients who drank only small amounts (fewer than two drinks per day) were almost four times more likely to develop HCC than were nondrinkers (hazard ratio 3.6). Heavy drinking (more than two drinks per day) increased HCC risk to the same extent as social drinking. Body mass index, smoking, diabetes, and MELD score were not significantly related to HCC in patients with NASH.
“This study shows for the first time that patients with NASH are at high risk for HCC, especially if they drink, and, as such, would probably benefit from a regular screening strategy,” Dr. Zein said.
No studies have addressed the optimum screening method. However, Dr. Zein said, a reasonable option might be ultrasound examination every 6 months.