VIENNA – Non-alcoholic fatty liver disease is emerging as the leading cause of liver cancer in the United States, according to a new study presented at the 50th Annual Meeting of the European Society for the Study of the Liver (EASL). In fact, from 2004 to 2009, the annual increase in liver cancer in patients with fatty liver disease was about 5 percent. Patients with fatty liver disease who have cancer have a lower survival rate than patients with hepatitis B or C who have liver cancer, said Zobair Younossi from Inova Health System in Falls Church, Va. He reported that patients with fatty liver-related cancers had advanced tumor stage at the time of diagnosis, while it was less common in liver transplant patients (advanced stage). ”Given the prevalence of NAFLD, the burden of disease-related complications is expected to rise,” Dr. Younossi said at the 2015 Liver Disease Congress. Fatty liver disease affects about 25 percent of the U.S. population. About 2 to 3 percent of the population has the progressive type of the disease – nonalcoholic steatohepatitis. ”I suspect that this is the patient with nonalcoholic steatohepatitis who is at poor prognostic risk,” Dr. Younossi told WebMD Medical News. “In 2015, the only way to confirm a diagnosis of steatohepatitis was a liver biopsy. Because of the invasive nature of the biopsy, only a small number of patients had a biopsy completed. As a result, a large number of nonalcoholic steatohepatitis has not been diagnosed,” he explained. “And it is possible that the risk of developing liver cancer in patients with advanced fibrosis has not been recognized,” he added. His advice is to “determine whether patients with steatohepatitis have steatohepatitis-associated fibrosis or cirrhosis. If so, get screened for liver cancer every 6 months.” From 2004 to 2009, Dr. Younossi and colleagues identified 5,748 patients with liver cancer and 17,244 cancer-free controls in the Surveillance, Epidemiology and End Results (SEER)-Medicare database. Liver cancer was associated with 48% of hepatitis C, 26% of fatty liver, 14% of alcoholic liver disease, 8% of hepatitis B, and 4% of cases of autoimmune hepatitis or biliary cirrhosis. The number of liver cancer cases increased each year during the study period. The annual growth rate of fatty liver-associated cancers was comparable to the annual growth rate of liver cancers associated with other etiologies. Patients with fatty liver-associated cancers were older at diagnosis than patients with hepatitis B or C-associated cancers (72 years: 66 years) and were more likely to be white, and the cancers were more often ungraded or advanced. In addition, the mean survival of patients with fatty liver-related cancer was 4 months shorter (P<0.05). Multivariate analysis showed that being male and non-white or non-black was independently associated with cancer, as was a higher Charlson comorbidity index score and the presence of hepatitis B, C, or fatty liver. Patients with fatty liver-related liver cancer died more often within one year of diagnosis compared with those with hepatitis B or C-related liver cancer (50%:62%, P<0.05). The most common cause of death was cancer or liver disease (96.3%), followed by cardiac cause of death (3.7%). For cancer patients, factors associated with 1-year mortality were older age, lower income, ungraded tumor, Medicare eligibility, end-stage renal disease, and fatty liver. protective factors for 1-year mortality were liver transplantation, and limited tumor, respectively. "This is a very important study because of the very large number of patients," said session moderator Dr. Helena Cortez-Pinto from the Medical University of Lisbon, Portugal. Detection of fatty liver-related cancer is particularly challenging because it can occur in the absence of cirrhosis. "You can't monitor all patients with fatty liver without the burden being very high," she told WebMD Medical News. But it should be kept in mind that this possibility exists, especially in obese patients. "What we have to realize is that it is possible for patients with fatty liver to develop cancer even without cirrhosis. We don't know the exact incidence, but it does exist," Dr. Cortez-Pinto explained. "If there is any doubt, patients are asked to have further tests." The fatty liver-related cancer mortality rate is quite surprising and has not been seen in all studies, Dr. Cortez-Pinto said. This finding is likely the result of less cancer surveillance in patients with fatty liver. "If tumors are found in cirrhosis surveillance, then tumors are easier to monitor," she noted. Dr. Younossi said he agreed with these observations. "Survival is shorter in fatty liver because it is advanced by the time these patients present with clinical symptoms, which may be due to their failure to screen or failure of ultrasound screening to detect small fatty liver abdominal obesity tumors." And, he added, "because of comorbidities, patients are unable to undergo liver transplantation."