Series
Hepatocellular carcinoma: measures to improve the outlook in sub-Saharan Africa

https://doi.org/10.1016/S2468-1253(22)00041-3Get rights and content

Summary

Hepatocellular carcinoma is a leading public health concern in sub-Saharan Africa, and it is most prevalent in young adults (median 45 years [IQR 35–57]). Overall, outcomes are poor, with a median survival of 2·5 months after presentation. Major risk factors for hepatocellular carcinoma are hepatitis B virus (HBV), hepatitis C virus, aflatoxin B1 exposure, and alcohol consumption, with metabolic dysfunction-associated fatty liver disease slowly emerging as a risk factor over the past few years. Crucially, these risk factors are preventable and manageable with effective implementation of the HBV birth-dose vaccination, treatment of chronic viral hepatitis, provision of harm reduction services, and by decreasing aflatoxin B1 exposure and harmful alcohol consumption. Primary prevention is central to the management of hepatocellular carcinoma, especially in poorly resourced environments. Effective screening and surveillance programmes with recall policies need to be implemented, because detection and curative management of hepatocellular carcinoma is possible if it is detected at an early stage, even in countries with minimal resources, with appropriate upskilling of medical personnel. The establishment of centres of excellence with advanced diagnostic and therapeutic capabilities within countries should improve hepatocellular carcinoma outcomes and assist in driving the implementation of much needed systematic data systems focused on hepatocellular carcinoma to establish the accurate burden in sub-Saharan Africa. Such data would support the public health importance of hepatocellular carcinoma and provide a strong basis for advocacy, programme development, resource allocation, and monitoring of progress in reducing mortality.

Introduction

Hepatocellular carcinoma is a cancer of substantial public health concern in sub-Saharan Africa; it is prevalent in young adults (median 45 years [IQR 35–57]),1 with a median survival after diagnosis of 2·5 months.2 The major causative factors that are preventable or manageable include viral hepatitis, aflatoxin B1, and alcohol. Effective implementation of the WHO global health sector strategy on viral hepatitis and the global strategy to reduce harmful use of alcohol would lead to a sustained reduction in the incidence of hepatocellular carcinoma.3, 4 Such a reduction can principally be achieved through primary prevention and improved surveillance programmes for high-risk individuals, because access to interventional radiology, surgical resection, liver transplantation, and new chemotherapeutic regimens is limited in sub-Saharan Africa.

Section snippets

Global hepatocellular carcinoma epidemiology

Globally, hepatocellular carcinoma is the sixth most prevalent cancer and accounted for 4·7% (n=905 677) of all new cancer diagnoses in 2020.5 In men, hepatocellular carcinoma is the fifth most common cancer, and in women the ninth most common cancer in adults. The number of cases has been underestimated because of inadequate reporting from 78 countries, including 34 in Africa.6 Hepatocellular carcinoma accounted for 8·3% (n=830 180) of all cancer deaths in 2020, ranking third for cancer

Demographic trends for hepatocellular carcinoma in sub-Saharan Africa

In sub-Saharan Africa, hepatocellular carcinoma is the second leading cancer in men and the third for women, with an estimated 38 629 incident cases and 36 592 hepatocellular carcinoma-related deaths in 2020 for both sexes.6 Ten African countries (Egypt, The Gambia, Guinea, Ghana, Liberia, Burkina Faso, Senegal, Guinea-Bissau, Mauritania, and Cape Verde) are among the 25 countries with the highest age-standardised rates of hepatocellular carcinoma per 100 000 population.8 After Egypt (34·1

Risk factors for hepatocellular carcinoma in sub-Saharan Africa

Cirrhosis is a crucial antecedent for hepatocellular carcinoma, with the annual incidence of hepatocellular carcinoma in patients with cirrhosis ranging from 1–8%. Almost a third of patients with cirrhosis are at risk of developing hepatocellular carcinoma during their lifetime. Older age (age >44 years), male sex, platelet counts of less than 100 000 per μL, and oesophageal varices are associated with hepatocellular carcinoma risk in patients with cirrhosis. Worsening liver stiffness, measured

Preventive strategies for reducing the burden of hepatocellular carcinoma in sub-Saharan Africa

Primary and secondary prevention strategies are pivotal in reducing mortality from hepatocellular carcinoma in sub-Saharan Africa. Primary prevention relies on infant HBV vaccination, viral hepatitis screening, education, and lifestyle adaptations. Secondary preventive and treatment measures in poorly resourced countries are inextricably reliant on existing medical, radiological, and surgical substructures. Effective interventional radiological or surgical treatment options are a prerequisite

Surveillance and screening guidance in sub-Saharan Africa: meeting the goals of secondary prevention

Several factors can compromise secondary prevention endeavours in sub-Saharan Africa. Financial constraints impair development of expertise and material resources required for optimal treatment. According to World Bank figures, there are 1·7 specialist surgical workforces per 100 000 population in sub-Saharan Africa, 42·2 per 100 000 in upper-middle-income countries, and 71·2 per 100 000 in high-income countries. Similarly, there are an estimated 0·2 physicians and 1·0 nurses and midwives per

Liver cancer registries

The GBD and GLOBOCAN estimates of hepatocellular carcinoma in sub-Saharan Africa are based on modelling frameworks that depend on the quality and quantity of available data.5, 7, 9 Accurate population-based data on incidence, survival, treatment, and outcomes of hepatocellular carcinoma from sub-Saharan Africa countries are scarce. Liver cancer registries still rely on histological confirmation of hepatocellular carcinoma, rather than on diagnostic radiological imaging.

There is an urgent need

Conclusions

The current status of hepatocellular carcinoma prevention and management in sub-Saharan Africa is no longer tolerable. Guidelines adopting a one-size-fits-all approach are neither realistic nor practical. Instead, guidance should be customised to existing situations and regional variances. Specific actions required to implement such guidelines are complex and require operational research. Minimising or eradicating inequalities will be a prerequisite for the successful implementation of

Search strategy and selection criteria

We searched for references for this Series paper through searches of PubMed with the search terms “hepatocellular carcinoma”, “risk factors”, “epidemiology”, “preventative strategies”, “screening and surveillance”, and “sub-Saharan Africa” from Jan 1, 2011, to Dec 31, 2021. We also identified articles through searches of the authors' own files. Only papers published in English were reviewed. The final reference list was generated on the basis of originality and relevance to the broad scope of

Declaration of interests

GD reports grants from Abbott Diagnostics for hepatitis B biomarker research; speaker honoraria from Cepheid and Clinical Care Options; participation on data safety monitoring boards for Aligos, Arbutus, Enanta, Gilead, GlaxoSmithKline, and Janssen; participation on advisory boards for Aligos, Antios, Arbutus, and Gilead; previously being medical director for Skipton Fund and research appraiser for Singapore National Medical Research Council. CK is chairman of the Gastroenterology Foundation of

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