Global disparities in hepatocellular carcinoma outcomes: a multicentre study

Sub-Saharan Africa carries a disproportionate burden of hepatocellular carcinoma (HCC), yet clinical guidelines used on the African subcontinent are extrapolated from high-income countries (HICs). The presentation, treatment, and outcomes of HCC were compared between liver referral centres in South Africa and Sweden to examine the limitations of applying HIC-derived guidelines to sub-Saharan Africa.

This was a comparative cohort study of adult patients with HCC treated from 2012 to 2023 in a referral centre in South Africa and in a referral centre in Sweden. The main and secondary outcomes were overall survival (OS) and treatment-specific survival respectively.

Of 959 patients included, 455 and 504 were treated in South Africa and Sweden respectively. Patients in South Africa were younger (median 50 versus 71 years, P < 0.001) and predominantly had hepatitis B virus (HBV)-related HCC (60% versus 3.6%, P < 0.001). They presented with more advanced liver dysfunction, more frequent metastases, and more advanced Barcelona Clinic Liver Cancer (BCLC) stage. Curative-intent therapies (ablation, liver resection, or liver transplantation) were offered to 9.2% and 42.5% of patients respectively (P < 0.001). OS rates at 1 year, 3 years, and 5 years were 17.8%, 7.7%, and 5.3% versus 59.3%, 35.3%, and 27.0% respectively (P < 0.001). Survival was consistently lower for 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.