Up to 60% of liver cancer cases can be prevented by combating hepatitis, alcohol and fatty liver disease

Most cases of liver cancer could be prevented by reducing levels of viral hepatitis, alcohol consumption and metabolic-associated steatotic liver disease (MASLD - previously called non-alcoholic fatty liver disease), suggests an analysis by The Lancet Commission on Liver Cancer.

The Commission highlights several ways to reduce these risk factors, including increasing hepatitis B vaccination coverage and public health measures to combat obesity and alcohol consumption.

Previous analyses had predicted that the number of new cases of liver cancer would nearly double, from 870,000 in 2022 to 1.52 million in 2050, mainly due to population growth and ageing, with the largest increases expected in Africa. The number of deaths from liver cancer is expected to increase from 760,000 in 2022 to 1.37 million in 2050.

Liver cancer is already a leading cause of death and disability. Globally, it is the sixth most common cancer and the third leading cause of cancer death. More than 40% of all liver cancer cases worldwide occur in China, largely due to the country’s relatively high levels of hepatitis B infection.

The Chairman of the Commission, Professor Jian Zhou (Fudan University, China), says:

"Liver cancer is a growing health problem worldwide. It is one of the most difficult cancers to treat, with five-year survival rates ranging from approximately 5% to 30%. We risk seeing a nearly doubling of liver cancer cases and deaths over the next quarter century unless urgent action is taken to reverse this trend."

First author Professor Stephen Chan (The Chinese University of Hong Kong) adds:

“Because three out of five liver cancer cases are associated with preventable risk factors – mainly viral hepatitis, alcohol and obesity – countries have a huge opportunity to influence these risk factors, prevent liver cancer and save lives.”

Changes in the causes of liver cancer

In a new analysis, the Commission estimates that at least 60% of liver cancer cases could be prevented by controlling modifiable risk factors, including hepatitis B virus (HBV), hepatitis C virus (HCV), MACE and alcohol.

MAS (metabolic-associated steatohepatitis), a severe form of MASLD, is the fastest growing cause of liver cancer globally, followed by alcohol. The Commission projects that the proportion of liver cancer cases associated with MAS will increase from 8% in 2022 to 11% in 2050, and that alcohol-associated cases will increase from 19% in 2022 to 21% in 2050.

At the same time, the proportion of cases associated with HBV is expected to decrease from 39% to 37%, and the proportion of cases associated with HCV from 29% to 26% over the same period.

Growing risk factor: MASZP

It is estimated that about a third of the world's population has MASLD. However, only 20–30% of patients with MASLD develop a more severe form of the disease with inflammation and liver damage called metabolic-associated steatohepatitis (MAS).

The incidence of liver cancer associated with MASLD is expected to increase over the next decade, particularly in the United States, Europe, and Asia, due to rising obesity rates. In the United States, the prevalence of MASLD continues to rise in parallel with the obesity epidemic; by 2040, more than 55% of adults in the United States may have MASLD.

The author of the Commission, Professor Hashem B. El-Serag (Baylor College of Medicine, USA), says:

"Liver cancer was previously thought to occur primarily in patients with viral hepatitis or alcoholic liver disease. However, today, rising levels of obesity are becoming an increasingly significant risk factor for liver cancer, primarily due to the increasing incidence of fatty liver disease.

One approach to identifying patients at high risk of liver cancer may be to introduce screening for liver injury into routine medical practice for patients at high risk of LSC – such as those with obesity, diabetes, and cardiovascular disease.

Healthcare professionals should also integrate lifestyle advice into routine care to support patients in adopting healthy eating habits and regular physical activity. In addition, policymakers should promote healthy food environments through measures such as sugar taxes and clear labelling of foods high in fat, salt and/or sugar."

Global goals and recommendations

The commission estimates that if countries can reduce liver cancer incidence by 2–5% per year by 2050, it could prevent between 9 and 17 million new cases of liver cancer and save between 8 and 15 million lives.

With more patients living with liver cancer today than ever before, in addition to prevention efforts, there is a pressing need for increased research and attention to these patients to improve their quality of life.

The Commission proposes several strategies to reduce the global burden of liver cancer, including:

• governments should intensify efforts to increase HBV vaccination coverage – for example, by making vaccination mandatory in high-prevalence countries – and implement universal HBV screening for adults 18+, as well as targeted HCV screening in high-risk areas based on cost-effectiveness assessments;
• Lawmakers should introduce minimum unit prices for alcohol, warning labels and restrictions on advertising of alcoholic beverages;
• National health authorities and cancer programmes should prioritise investments in information campaigns and deployment of early detection resources;
• Professional organizations and the pharmaceutical industry should collaborate to reduce East-West differences in the clinical management of liver cancer;
• Hospitals and professional organizations should provide palliative care training to ensure that such care is integrated early in the life of patients in need.

The author of the Commission, Professor Valérie Paradis (Hospital Beaujeon, France), says:

"There is an urgent need to raise public awareness of the seriousness of the growing problem of liver cancer. Compared to other cancers, liver cancer is extremely difficult to treat, but has clearer risk factors that help identify specific prevention strategies.

Through collaborative and ongoing efforts, we believe that many cases of liver cancer can be prevented and the survival and quality of life of patients with this disease can be significantly improved.”