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Page 2 of 15 Molinari et al. Hepatoma Res 2018;4:56 I http://dx.doi.org/10.20517/2394-5079.2018.71

(8.8%) and Asians (8.6%). Overall 30-, 60-, 90-day and 1-year mortality was 1.7%, 2.3%, 3.0% and 8.8%
respectively with no statistically significant differences among ethnicities. Log-rank comparisons however showed
that African American had the lowest 5-year survival with statistically significant differences in comparison to all
other ethnic groups (P ≤ 0.001). At multivariate Cox-regression analysis, African American ethnicity remained an
independent predictor for increased mortality (HR = 1.524; 95% CI: 1.283-1.803; P < 0.001) after adjusting for the
recipient and donor age, recipient sex, recipient history of diabetes and recipient functional status at the time of
transplantation.

Conclusion: Short-term outcomes of African Americans undergoing cadaveric LT for HCC are similar to other
ethnic groups. However, African American ethnicity is an independent predictor of lower 5-year overall survival
when compared to all other ethnic groups.

Keywords: Hepatocellular carcinoma, ethnicity, survival, Cox-regression, liver transplantation, predictor

INTRODUCTION
[1]
Hepatocellular carcinoma (HCC) is the fifth most common cancer in the world with over 1,000,000 new
[2]
patients diagnosed every year and 250,000 cancer-related deaths . The worldwide incidence of HCC is
unequally distributed with South-East Asia and Sub-Saharan Africa having the highest incidence while
[3]
the lowest is recorded in Western Europe and North America . Geographical differences of the incidence
of HCC reflect variations of the most common risk factors for HCC such as viral hepatitis B (HBV) and C
[3,4]
(HCV), aflatoxin, alcohol consumption and genetics . However, over the last decades, the incidence of
HCC has steadily increased in Western countries due to a rise in the incidence of HCV and non-alcoholic
[5]
steatohepatitis (NASH) .

Treatment modalities for HCC depend on patient age and comorbidities, tumor characteristics and degree
[6]
of liver disease and portal hypertension in addition to other factors such as local expertise and resources .
[7-9]
Liver resection and transplantation provide the best long-term survival followed by ablative therapies,
locoregional and systemic chemotherapy [7,8,10,11] . Despite the survival advantage of hepatic resection and
liver transplantation (LT), most patients are unable to undergo surgery because of their advanced tumors
or the presence of co-morbidities. Even after radical resections, cirrhosis predisposes to the development of
recurrent disease in 50%-80% of patients within 5 years [12,13] . Consequently, LT remains the best treatment
as it addresses both the tumor and cirrhosis [14,15] . Nevertheless, only 10%-12% of patients with HCC are
transplanted due to the limited number of donors [16-22] .

Previous studies have reported that in the United States, LT for HCC is performed less frequently in non-
Caucasians than in recipients of other ethnicities [23-25] . The reasons for these disparities are not completely
understood but there is some evidence suggesting that disadvantaged ethnic groups face more barriers to
access healthcare and are more frequently diagnosed with advanced diseases [23,24,26] .

To be listed for a LT in the United States and Europe, patients with HCC must fulfill not only strict
[15]
oncological criteria but also other requirements such as evidence of adequate social support, financial
stability, the absence of active mental disorders, abstinence from substance abuse and adherence to
diagnostic and therapeutic recommendations. These requirements, especially the ones linked to financial
[27]
status, might affect certain demographic or socioeconomic groups more than others , but are necessary to
optimize the outcomes of LT recipients.

Since all LT candidates have to satisfy similar inclusion criteria, we hypothesized that there should not be
differences in short and long-term outcomes among different ethnic groups, and since studies on ethnicity