Mortality due to cirrhosis and liver cancer in the United States, 1999-2016: observational studyBMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k2817 (Published 18 July 2018) Cite this as: BMJ 2018;362:k2817
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Re: Mortality due to cirrhosis and liver cancer in the United States, 1999-2016: observational study
The paper by Tapper and Parikh  reports an inversion in the trend for liver cirrhosis mortality in the US, with increasing rates observed starting from 2009, mainly due to alcohol-related liver disease; by contrast, mortality due to hepatocellular carcinoma increased through the whole study period (1999-2016).
Findings on alcohol-related liver disease are consistent with analyses on any alcohol-induced cause of death, with increasing age-standardized mortality rates observed since 2009 in the 15-64-year age class, mainly due to alcoholic liver disease . A recent report from the National Institute on Alcohol Abuse and Alcoholism confirms a rise by 15.7% from 2000 to 2015 in the age-adjusted rate from all liver cirrhosis, especially in the 24-34 (+81.8%) and the 55-64 (+41.8%) age classes .
Findings on trends in mortality from hepatocellular carcinoma should be interpreted in view of the history of hepatitis C virus (HCV) infection in the US: notably, mortality rates largely decreased among subjects aged 45-54 years, and increased among those aged 55-64 years . This observation is consistent with a clear birth cohort effect: analyses on multiple causes of death demonstrated an increase in HCV-related mortality from 2003 to 2013, wholly accounted by the 1945-1965 birth cohort . Meanwhile, the peak in HCV-related mortality shifted from the 45-49 to the 55-64 age class . Furthermore, among persons for whom both HCV and liver cancer were listed as cause of death, those born between 1945 and 1965 had the largest increase in mortality from 1999 to 2013 .
The authors cite the paper from Asrani and colleagues , who reported that between 1979 and 2008 mortality from liver disease remained roughly unchanged. In their paper, Asrani et al. grouped mortality from chronic liver disease, liver cancer, and viral hepatitis to obtain a more complete picture of the burden of liver disease. This latter straightforward approach should be coupled with the analysis of multiple causes of death, to obtain data (although incomplete) on the alcoholic/viral etiology of the disease. Such methodology would allow not only monitoring of the recent increase in alcohol-related mortality, but also assessment of whether the long-term rising trend in HCV-related mortality will be halted by the availability of new anti-HCV drugs.
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Competing interests: No competing interests