title: Temporal trends of nonalcoholic fatty liver disease-related hepatocellular carcinoma in the veteran affairs population.
abstract: OBJECTIVE
  Nonalcoholic fatty liver disease (NAFLD) is a risk factor for hepatocellular carcinoma (HCC). However, no systemic studies from the United States have examined temporal trends, HCC surveillance practices, and outcomes of NAFLD-related HCC.
  
  
  METHODS
  We identified a national cohort of 1500 patients who developed HCC from 2005 through 2010 from Veterans Administration (VA) hospitals. We reviewed patients' full VA medical records; NAFLD was diagnosed based on histologic evidence for, or the presence of, the metabolic syndrome in the absence of hepatitis C virus (HCV) infection, hepatitis B, or alcoholic liver disease. We compared annual prevalence values for the main risk factors (NAFLD, alcohol abuse, and HCV), as well a HCC surveillance and outcomes, among HCC patients.
  
  
  RESULTS
  NAFLD was the underlying risk factor for HCC in 120 patients (8.0%); the annual proportion of NAFLD-related HCC remained relatively stable (7.5%-12.0%). In contrast, the proportion of HCC cases associated with HCV increased from 61.0% in 2005 (95% confidence interval, 53.1%-68.9%) to 74.9% in 2010 (95% confidence interval, 69.0%-80.7%). The proportion of HCC cases associated with only alcohol abuse decreased from 21.9% in 2005 to 15.7% in 2010, and the annual proportion of HCC cases associated with hepatitis B remained relatively stable (1.4%-3.5%). A significantly lower proportion of patients with NAFLD-related HCC had cirrhosis (58.3%) compared with patients with alcohol- or HCV-related HCC (72.4% and 85.6%, respectively; P < .05). A significantly higher percentage of patients with NAFLD-related HCC did not receive HCC surveillance in the 3 years before their HCC diagnosis, compared with patients with alcohol- or HCV-associated HCC. A lower proportion of patients with NAFLD-related HCC received HCC-specific treatment (61.5%) than patients with HCV-related HCC (77.5%; P < .01). However, the 1-year survival rate did not differ among patients with HCC related to different risk factors.
  
  
  CONCLUSIONS
  NAFLD is the third most common risk factor for HCC in the VA population. The proportion of NAFLD-related HCC was relatively stable from 2005 through 2010. Although patients with NAFLD-related HCC received less HCC surveillance and treatment, a similar proportion survive for 1 year, compared with patients with alcohol-related or HCV-related HCC.
authors.affiliation: Center of Innovation, Effectiveness and Quality, Sections of Health Services Research, Section of Gastroenterology and Hepatology, Houston, Texas; Baylor College of Medicine, Houston, Texas. Electronic address: smittal@bcm.edu.
authors.forename: Sahil
authors.initials: S
authors.lastname: Mittal
authors.affiliation: Center of Innovation, Effectiveness and Quality, Sections of Health Services Research, Section of Gastroenterology and Hepatology, Houston, Texas.
authors.forename: Yvonne H
authors.initials: YH
authors.lastname: Sada
authors.affiliation: Center of Innovation, Effectiveness and Quality, Sections of Health Services Research, Section of Gastroenterology and Hepatology, Houston, Texas; Baylor College of Medicine, Houston, Texas; Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.
authors.forename: Hashem B
authors.initials: HB
authors.lastname: El-Serag
authors.affiliation: Center of Innovation, Effectiveness and Quality, Sections of Health Services Research, Section of Gastroenterology and Hepatology, Houston, Texas; Baylor College of Medicine, Houston, Texas; Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.
authors.forename: Fasiha
authors.initials: F
authors.lastname: Kanwal
authors.affiliation: Center of Innovation, Effectiveness and Quality, Sections of Health Services Research, Section of Gastroenterology and Hepatology, Houston, Texas.
authors.forename: Zhigang
authors.initials: Z
authors.lastname: Duan
authors.affiliation: Center of Innovation, Effectiveness and Quality, Sections of Health Services Research, Section of Gastroenterology and Hepatology, Houston, Texas.
authors.forename: Sarah
authors.initials: S
authors.lastname: Temple
authors.affiliation: Center of Innovation, Effectiveness and Quality, Sections of Health Services Research, Section of Gastroenterology and Hepatology, Houston, Texas.
authors.forename: Sarah B
authors.initials: SB
authors.lastname: May
authors.affiliation: Center of Innovation, Effectiveness and Quality, Sections of Health Services Research, Section of Gastroenterology and Hepatology, Houston, Texas.
authors.forename: Jennifer R
authors.initials: JR
authors.lastname: Kramer
authors.affiliation: Center of Innovation, Effectiveness and Quality, Sections of Health Services Research, Section of Gastroenterology and Hepatology, Houston, Texas.
authors.forename: Peter A
authors.initials: PA
authors.lastname: Richardson
authors.affiliation: Center of Innovation, Effectiveness and Quality, Sections of Health Services Research, Section of Gastroenterology and Hepatology, Houston, Texas.
authors.forename: Jessica A
authors.initials: JA
authors.lastname: Davila
mesh_terms: D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000453:epidemiology*; D015331:Cohort Studies; D005260:Female; D006801:Humans; D008113:Liver Neoplasms / Q000453:epidemiology*; D008297:Male; D008875:Middle Aged; D065626:Non-alcoholic Fatty Liver Disease / Q000150:complications*; D015995:Prevalence; D014481:United States; D014728:Veterans
keywords: Incidence; Liver Cancer; NASH; Time