Hepatocellular carcinoma (HCC) is the sixth most common cancer worldwide and the fourth on our continent. Africa includes six of the 15 countries with the highest HCC incidence globally.
HCC develops at a younger age in Africa than in other parts of the world, with a usually poor prognosis and death. The median overall survival of HCC in sub-Saharan Africa (SSA) is only three months.

The main risk factors for HCC are chronic infection with hepatitis B virus (HBV) or hepatitis C virus (HCV), aflatoxin-contaminated foods, heavy alcohol consumption, obesity, type-2 diabetes, and smoking. Its prevalence and etiology show some differences between North and SSA. HCC incidence in a part of North Africa is twice as high as in SSA due to the unusually high prevalence in Egypt of HCV infection, which remains the primary risk factor in this country, compared with 0.2% in Algeria. In the other parts of North Africa excluding Egypt (Maghreb), the incidence of HCC is lower than in SSA, due to lower levels of viral hepatitis, as well as low consumption of alcohol and aflatoxin exposure.

To date, establishing African guidelines including prevention, surveillance, diagnosis, and treatment for HCC is too ambitious. Barcelona liver cancer classification (BCLC) is the most popular staging system adopted by our colleagues and experts from our regions. According to survey studies, implementation of screening programs is sub-optimal. The utilization of combinations of serum alpha-protein and liver ultrasonography is encountered in only 50% of African countries . The access of diagnosis is also lacking due to a 56% rate of use for computed tomography scans and deployment of magnetic resonance imaging in only 5.2% cases.

Most patients are diagnosed at advanced stages (BCLC B, C, and D) due to the absence of or inefficient screening, ensuring that access to therapy will be limited. In our context, liver transplantation is available for only 28% of northern and southern (NS) patients and 3% eastern and western patients. Availability of local therapy ranged from 94% in NS to 62% in Central Africa. Sorafenib is the most commonly used systemic therapy (66%). Only 12.9% reported access to other medications, including immune checkpoint inhibitors.

From what we reported previously, HCC management programs must be focused on prevention.
All adult patients with chronic liver disease including cirrhosis, chronic HBV, and HCV infections, and NASH/NAFLD with advanced fibrosis (fibrosis stages 3 and 4) are considered at high risk for developing HCC and should be enrolled in a screening and surveillance program. As mentioned in a previous newsletter by  Dr. Nanelin Alice Guingané, the burden of chronic hepatitis B is largely attributed to MTCT. To prevent MTCT, WHO recommends administering a birth-dose vaccine, screening pregnant women, and providing antiviral treatment with tenofovir disoproxyl fumarate (TDF) for women with a high viral load (≥200,000 IU/ml) or a positive HBV(e) antigen (HBeAg) test. Vaccination remains the cornerstone of the fight against MTCT of hepatitis B.

The HCV elimination program, particulary in Egypt and Rwanda is driven by political commitment with the decreasing cost of direct-acting antivirals in Egypt from $1,650 for 12 weeks of sofosbuvir plus daclatasvir in early 2015 to $85 for local generics in 2018. The management is simplified, supported by primary care physicians. Aflatoxin has been shown to be an important risk factor in the initiation of HCC, particulary in synergism with HBV and HCV infection. The introduction of Alfasafe to check the toxin producing Aflavus will hopefully lead to a substantive decrease in alfatoxin-induced HCC.

Another challenge to take on is the epidemic rising of non-communicable diseases in SSA which includes cardiovascular disease, cancer, and metabolic diseases such as diabetes and obesity. Thus the contribution of MASH as a risk factor for HCC is expected to rise. We also have an excessive amount of alcohol consumption in most African countries, so its role in developing HCC in our regions is probably underestimated. Therefore, efforts to reduce the incidence of HCC should be holistic, based on primary prevention and targeting HBV and HCV infections, toxin exposure, and metabolic risk factors.

To conclude, therapeutic management of HCC depends on allocated financial resources and the level of development of medicine in general. For the moment, a pragmatic approach adapted and specific to each country based on prevention of risk factor is the most direct route to prevention.