Editorial: Steatotic Liver Diseases Emerge as Rapidly Growing Drivers of Primary Liver Cancer in the United States—Author's Reply

We extend our sincere gratitude for the recent editorial highlighting our manuscript [1]. In our study titled ‘Alcohol-Related Liver Disease, Followed by Metabolic Dysfunction-Associated Steatotic Liver Disease, Emerges as the Fastest-Growing Aetiologies for Primary Liver Cancer in the United States’, we analysed the prevalence, incidence and mortality trends of primary liver cancer (PLC) in the United States using data from the Global Burden of Disease (GBD) 2021 database [2]. Our findings emphasise the increasing contribution of steatotic liver disease–related PLC to the overall burden of PLC in the United States, although chronic hepatitis C virus (HCV) infection remains the leading contributor of PLC. We also acknowledge the limitations raised by Torosian et al. [1], particularly the inability of the GBD database to evaluate trends based on race, ethnicity, histological subtypes or distinctions between metabolic dysfunction–associated and alcohol-associated liver disease (MetALD) [3]. Future iterations of the GBD should strive to incorporate these subgroups to provide a more nuanced understanding.

Despite recent advancements in PLC management, progress in identifying at-risk individuals and achieving early detection of HCC in these populations has not kept pace with treatment innovations, particularly for PLC associated with steatotic liver disease (SLD) [4, 5]. For instance, prior meta-analyses demonstrated that SLD-associated hepatocellular carcinoma is significantly less likely to be detected by screening and is often diagnosed at a more advanced stage compared to other etiologies [6, 7]. Beyond improving screening, policy measures such as alcohol taxation, pricing strategies and reducing alcohol availability could play a pivotal role in alleviating the burden of alcohol-associated PLC [8].

For metabolic dysfunction-associated steatohepatitis (MASH), it is essential to implement strategies that include screening, intensive lifestyle interventions, and pharmacological treatments to slow or prevent the progression of liver fibrosis [9]. Supporting patients with MASH requires a multidisciplinary approach, including expanded involvement of nutritionists, social prescribing initiatives and acknowledgement of the critical role of social nutrition. These steps are essential for addressing the public health challenges posed by MASLD, MASH and MASH-associated PLC [10]. The elimination of HCV requires sustained momentum as it continues to contribute significantly to the global disease burden. However, elimination is attainable due to HCV's distinct characteristics, reliable diagnostic tests and the availability of cost-effective or cost-saving interventions. Key measures include screening blood donors for HCV, promoting safe injection practices, enforcing robust infection-control programmes to minimise HCV transmission and providing effective antiviral treatments for those infected.

In summary, our findings highlight the need for early, targeted interventions to mitigate the burden of steatotic liver disease and sustain progress in eliminating HCV. Such efforts are essential to reduce the burden of PLC in the United States synergistically.