Preventing the preventable: Adolescent hepatocellular carcinoma and implications for hepatitis B virus prevention policy in South Africa

Abstract

Background: Hepatocellular carcinoma (HCC) is a fatal disease of the young in sub-Saharan Africa (SSA) and chronic hepatitis B virus (HBV) infection remains the predominant aetiology. There is paucity of data regarding HCC in the adolescent population globally.

Methods: Adolescents, defined as individuals aged 10 to 19 years according to the World Health Organization (WHO), with HCC treated at Groote Schuur Hospital (GSH) in South Africa from 1 January 2012 and 31 December 2024 were studied.

Results: Five (0.5%) of the 726 HCC patients managed at GSH during the study period were adolescents. The median age was 18 (13-19) years and three were female. All five had chronic HBV infection and most presented with pain (60%) and/or an abdominal mass (40%). All had advanced disease, with four (80%) having Barcelona Clinic Liver Cancer (BCLC) stage C and one (20%) with BCLC stage D. Two (40%) had extrahepatic metastases and three (60%) had portal vein tumour thrombosis. Treatment included liver resection (1), sorafenib (1), lenvatinib (1), and best supportive care (2). At the time of the study, only one patient was alive. The median survival was 137 (25–425) days.

Conclusions: Despite national HBV vaccination programmes in South Africa, in our experience adolescent HCC was HBV-related in all five patients. Extrahepatic metastases and macrovascular invasion were frequently reported and restricted patient access to curative- intended therapies (ablation, liver resection, transplantation). These findings highlight the urgent need for improved early detection and prevention strategies against perinatal HBV transmission in South Africa, including the rollout of the WHO-recommended universal hepatitis B birth-dose vaccination rather than the current targeted prevention approach.