Nonalcoholic Steatohepatitis and Hepatocellular Carcinoma: Crying Wolf or Promoting Healthy Living?

Abstract

The title “Nonalcoholic Steatohepatitis (NASH) Is the Fastest Growing Cause of Hepatocellular Carcinoma (HCC) in Liver Transplant Candidates (in the US)” differs with wise warnings in the discussion section, for example, “we were unable to study temporal trends extensively in populations of patients with more than 1 cause of chronic liver disease and, most importantly, with NASH being superimposed on another etiology.”1Younossi Z. et al.Clin Gastroenterol Hepatol. 2019; 17: 748-755.e3Abstract Full Text Full Text PDF PubMed Scopus (232) Google Scholar This deserved deeper insights. First, nutritional and hepatic histologic findings in a series 50 nonselected subjects with morbid obesity showed that severe liver damage (16%) was constantly associated with alcohol intake.2Braillon A. et al.Gut. 1985; 26: 133-139Crossref PubMed Scopus (117) Google Scholar There is no evidence yet that fatty liver, a most frequent symptom in rich countries, can be responsible per se for severe lesions despite decades of research. In addition, overweight and diabetes are associated with 11 types of cancer, the case of hepatocellular carcinoma is not specific.3López-Suárez A. Metabolism. 2019; 92: 136-146Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar Second, why bypass the search for causes of a disease? Alcohol is a most potent toxin, but 58% of US patients are labeled by hepatologists as nonalcoholic fatty liver disease despite self-report of “moderate” alcohol use.4Braillon A. Gastroenterology. 2018; 154: 1549-1550Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar How is it possible to overlook that self-report has poor reliability and most frequently underestimates use? Could use be moderate when the substance is a drug and also a human carcinogen at a dose as low as 1 glass of wine a day? In France and in the United Kingdom, the drinking at low risk level for those who choose to drink is less than 100 g/wk vs 300 g/wk in the United States.4Braillon A. Gastroenterology. 2018; 154: 1549-1550Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Tobacco smoking causes a dose-related increase in hepatocellular carcinoma, and is the main cause in rich countries. In Europe, the population-attributable factor (the proportional reduction in population disease that would occur if exposure to a risk factor were reduced to an alternative ideal exposure) for tobacco use in hepatocellular carcinoma is 48%, more than twice the second most attributed risk factor of hepatitis C. Nevertheless, this cause is almost always overlooked.5Dubois G. et al.Int J Epidemiol. 2010; 39: 1399Crossref PubMed Scopus (8) Google Scholar Air pollution has deleterious effects on the liver and evidence of this is accumulating.6Hsieh S. et al.Pediatr Obes. 2018; 13: 342-347Crossref PubMed Scopus (6) Google Scholar Although these risks may be low (eg, 1.5 for tobacco), the burden is a major one because prevalence is high and combination effects (cocktail effect) have a greater effect than individual substances added together. Third, how to overlook the present “public health crisis”?7Grant B.F. et al.JAMA Psychiatry. 2017; 74: 911-923Crossref PubMed Scopus (514) Google Scholar In the United States, alcohol use, high-risk drinking, and alcohol use disorders are increasing.7Grant B.F. et al.JAMA Psychiatry. 2017; 74: 911-923Crossref PubMed Scopus (514) Google Scholar Marketing on social media has a free ride and, worse, some public policies promote use of alcohol, as in Washington state. In 2008, Washington State axed funding for the Basic Liquor Law Enforcement Academy (Washington State Criminal Justice Training Center), ending the program. In 2011, it ended the state monopoly on liquor sales despite warnings it will increase alcohol use. In 2017, it decreased liquor taxes and fees from $35 to $31 per gallon.8Braillon A. Alcohol Alcohol. 2019; 54: 119-121Crossref PubMed Scopus (2) Google Scholar Nonalcoholic Steatohepatitis Is the Fastest Growing Cause of Hepatocellular Carcinoma in Liver Transplant CandidatesClinical Gastroenterology and HepatologyVol. 17Issue 4PreviewAlthough hepatitis B and C have been the main drivers of hepatocellular carcinoma (HCC), nonalcoholic steatohepatitis (NASH) has recently become an important cause of HCC. The aim of this study was to assess the causes of HCC among liver transplant (LT) candidates in the United States. Full-Text PDF ReplyClinical Gastroenterology and HepatologyVol. 17Issue 11PreviewWe are grateful to Dr Braillon for a comment on our work that suggested that nonalcoholic steatohepatitis (NASH) is the most rapidly growing etiology of hepatocellular carcinoma in liver transplant candidates in the United States.1,2 The author raised a number of important points that indeed deserve additional consideration in the context of our study. One point being made is the impact of “mild” or “moderate” alcohol use, which may, in fact, contribute to the hepatocellular carcinoma (HCC) risk even in patients technically falling into the nonalcoholic category. Full-Text PDF