Large study finds risks of liver cancer low for certain PSC patients
Hepatocellular carcinoma relative rare for those without liver scarring
Hepatocellular carcinoma (HCC), the most common type of liver cancer, is relatively rare among people with primary sclerosing cholangitis (PSC) who do not have cirrhosis, or permanent liver scarring, according to an international study involving more than 3,000 patients.
HCC risk was also low for those younger than 50, with or without cirrhosis, the data showed — though the risks of this liver cancer increased with age for both men and women.
Overall, the research team concluded that “cirrhosis and age are key determinants of HCC risk in individuals with primary sclerosing cholangitis.”
As such, “our findings indicate that HCC monitoring for patients with PSC can be tailored based on their age and cirrhosis status,” the researchers wrote.
Still, the team noted that additional study is needed to determine guidelines for starting HCC-specific monitoring in individuals with PSC.
The study, “Cirrhosis and age are key determinants of HCC risk in individuals with primary sclerosing cholangitis: A multicenter longitudinal cohort study,” was published in the journal Hepatology by a team in Europe.
In PSC, inflammation of the bile ducts, the tubes that carry the digestive fluid bile from the liver to the intestines, slows the flow of bile, a condition called cholestasis. Over time, bile builds up in the liver and promotes tissue damage, organ dysfunction, and eventually, cirrhosis.
“Within 15 years of the time of diagnosis, 41% of patients with PSC develop cirrhosis,” the researchers wrote.
Scant data on risks of liver cancer in primary sclerosing cholangitis
People with PSC also have an elevated risk of developing cancer of the bile ducts, known as cholangiocarcinoma, and the gallbladder, which is the organ where bile is stored. Both of these cancers can occur without underlying liver cirrhosis.
The researchers noted that “this contrasts with chronic liver disease in general, for which the most common malignancy is HCC, predominantly occurring in cirrhotic livers.”
While the risk of cholangiocarcinoma is well established in PSC, the frequency of HCC in this patient population remains unclear, according to the researchers.
However, “despite this, current guidelines recommend biannual ultrasounds for early HCC detection for all patients with cirrhosis and PSC,” the team wrote.
Now, a team led by scientists at the Karolinska Institutet in Sweden sought to fill in this knowledge gap. To that end, the researchers assessed HCC risk in 3,071 people diagnosed with PSC between January 2000 and February 2024 at 12 hospitals in Finland, Germany, Italy, the Netherlands, Norway, and Sweden.
“The aim of this study is to bring new evidence that describes the risk of HCC development for patients with PSC to better decide when patients with PSC, with or without cirrhosis, benefit from regular HCC surveillance,” the team wrote.
20% of PSC patients diagnosed with liver scarring, or cirrhosis
The patients in the study had a mean age at PSC diagnosis of 36.2, and nearly two-thirds (63%) were men. The mean follow-up was 12.5 years, and there was a total observation time of 38,264 person-years, a measurement that combines the number of study participants and the length of time they were observed.
In terms of inflammatory bowel disease, a group of conditions that cause gastrointestinal tract inflammation and that are common among people with PSC, ulcerative colitis — inflammation of the colon and rectum — was the most common. The condition was present in 58% of people before their PSC diagnosis or during follow-up. About 1 in 7, or 14%, had Crohn’s disease, or inflammation of any part of the digestive tract.
One-fifth were diagnosed with cirrhosis, and one-sixth (16.2%) underwent a liver transplant.
During follow-up, 39 patients (1.3%) developed HCC, at a mean age of 59.5, and a mean of 16.4 years after their PSC diagnosis. Two-thirds were detected through surveillance, and about the same percentage had cirrhosis at the time of the HCC diagnosis.
More than half (61.5%) received a potentially curable treatment: liver transplant, ablation, which is a minimally invasive procedure to kill the cancer, or resection, meaning surgery to remove the tumor. Six of these patients died during follow-up, with a mean survival time of slightly less than four years after the HCC diagnosis.
Eight other patients received palliative treatment or best supportive care, and their mean survival was nearly one year after the diagnosis of HCC.
Presence of cirrhosis boosted HCC risk tenfold over long term
Overall, the long-term risk of this liver cancer in people with PSC was 1.01 cases per 1,000 person-years. The presence of cirrhosis boosted the HCC risk by 10 times, and for each year of life, the risk increased 5%. Being a woman tended to be associated with a lower risk of HCC, but this link was not statistically significant.
Among those without cirrhosis, and between the ages of 50 and 70, the annual rate of new HCC cases rose from 0.08 to 0.21 per 1,000 person-years for men, and from 0.04 to 0.12 per 1,000 person-years for women. In those with cirrhosis, the annual HCC rate rose from 0.81 to 2.22 per 1,000 person-years for men, and from 0.47 to 1.29 for women, over the same age range.
We conclude that the risk of HCC development is low in noncirrhotic patients with PSC and in cirrhotic patients with PSC [younger than] the age of 50 years.
When researchers excluded all people diagnosed with PSC before age 18, they found that the HCC risk was still significantly associated with cirrhosis and age.
“We conclude that the risk of HCC development is low in noncirrhotic patients with PSC and in cirrhotic patients with PSC [younger than] the age of 50 years,” the researchers wrote.
According to the team, these findings suggest that “HCC surveillance may be less cost-effective in young patients with PSC and cirrhosis compared to those aged 50 years or older.” However, the scientists noted that “further research is needed to determine appropriate age thresholds for initiating HCC-specific surveillance in patients with PSC.”
About the Author
