We thank the authors for their interest in our paper and the correspondence. Regarding the possibility of a few centers not being representative of the entire South American population, we could not agree more. However, our cohort of patients included six different countries in South America which, in addition to our previous study of the South American Liver Research Network (SALRN), is the most expansive in the region [1,2]. Although different epidemiological realities apply to single centers, we believe a study including multiple centers is more powerful than the experience of a single center. In this regard, it should be kept in mind that the center referred to by the authors of the letter is a national cancer center, whereas the centers in our study are hepatology referral centers. Moreover, it is plausible, and likely, that the specific population seen at a cancer center will be biased towards the treatment of non-cirrhotic hepatocellular carcinoma, thus resulting in a larger number of individuals with hepatitis B-related HCC (HBV-HCC). We do agree with the authors that HBV is still a major problem in the region and we highlight the earlier age associated with HBV-HCC, and consequently, the high mortality of these patients in our study. Ultimately, our study described the epidemiology of the centers included and the epidemiology changes, in the same centers, over time suggesting a much higher impact of non-alcoholic fatty liver disease (NAFLD)-related HCC.
We do acknowledge the impact that the COVID-19 pandemic has had, as well as the vast effect on healthcare access and utilization in South America and the world at large. Although it is possible that this would have biased the epidemiology exclusively against HBV-infected patients with difficult access to hospitals, it is actually more likely to have increased HCC-related to alcohol liver disease as an increase in alcohol consumption and alcohol liver disease is likely to have occurred in the region as it has been reported worldwide [3,4]. Despite this, our study found a more dramatic increase in NAFLD-related HCC.
