Global disparities in hepatocellular carcinoma outcomes: multicentre study.

Abstract

Sub-Saharan Africa carries a disproportionate burden of hepatocellular carcinoma, yet clinical guidelines used on the African sub-continent are extrapolated from high-income countries. The presentation, treatment and outcomes of hepatocellular carcinoma between liver referral centres in South Africa and Sweden were compared to examine the limitations of applying high-income countries-derived guidelines in sub-Saharan Africa. This was a comparative cohort study of adult patients with hepatocellular carcinoma treated from 2012 to 2023 in a referral centre in South Africa and Sweden respectively. Main outcome was overall survival. Secondary outcome was treatment-specific survival. Of 959 patients included 455 and 504 were treated in South-Africa and Sweden respectively. Patients in South Africa were younger (median 50 vs. 71 years, P<0.001) and predominantly had hepatitis B virus-related hepatocellular carcinoma (60% vs. 3.6%, P<0.001). They presented with more advanced liver dysfunction, more frequent metastases and had more advanced BCLC stages. Curative-intended therapies (ablation, liver resection, liver transplantation) were offered to 9.2% and 42.5% of patients respectively (P<0.001). One, three, and five-year survival were 17.8%, 7.7% and 5.3%, respectively versus 58.9%, 35.3% and 26.2% respectively (P<0.001). Survival was consistently lower in the patients in South Africa when comparing treatment-specific cohorts. Marked disparities in disease presentation, access to treatment and survival were observed between regions. Tailored regional guidelines are urgently needed to address these inequities and improve outcomes.