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Letter to the editor
Response to “On the risk of further excluding outcast patient populations in South America”
Jose D. Debesa,
Corresponding author
debes003@umn.edu

Corresponding author.
, Chimaobi Anugwoma, Marina Farahb, Javier Diaz-Ferrerc
a University of Minnesota, Minneapolis, USA
b University of Balamand, Beirut, Lebanon
c Universidad San Martin de Porres, Lima Peru
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="para0002" class="elsevierStylePara elsevierViewall">We thank the authors for their interest in our paper and the correspondence&#46; Regarding the possibility of a few centers not being representative of the entire South American population&#44; we could not agree more&#46; However&#44; our cohort of patients included six different countries in South America which&#44; in addition to our previous study of the South American Liver Research Network &#40;SALRN&#41;&#44; is the most expansive in the region &#91;<a class="elsevierStyleCrossRef" href="#bib0001">1</a>&#44;<a class="elsevierStyleCrossRef" href="#bib0002">2</a>&#93;&#46; Although different epidemiological realities apply to single centers&#44; we believe a study including multiple centers is more powerful than the experience of a single center&#46; In this regard&#44; it should be kept in mind that the center referred to by the authors of the letter is a national cancer center&#44; whereas the centers in our study are hepatology referral centers&#46; Moreover&#44; it is plausible&#44; and likely&#44; that the specific population seen at a cancer center will be biased towards the treatment of non-cirrhotic hepatocellular carcinoma&#44; thus resulting in a larger number of individuals with hepatitis B-related HCC &#40;HBV-HCC&#41;&#46; 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&#44; and consequently&#44; the high mortality of these patients in our study&#46; Ultimately&#44; our study described the epidemiology of the centers included and the epidemiology changes&#44; in the same centers&#44; over time suggesting a much higher impact of non-alcoholic fatty liver disease &#40;NAFLD&#41;-related HCC&#46;</p><p id="para0003" class="elsevierStylePara elsevierViewall">We do acknowledge the impact that the COVID-19 pandemic has had&#44; as well as the vast effect on healthcare access and utilization in South America and the world at large&#46; Although it is possible that this would have biased the epidemiology exclusively against HBV-infected patients with difficult access to hospitals&#44; 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 &#91;<a class="elsevierStyleCrossRef" href="#bib0003">3</a>&#44;<a class="elsevierStyleCrossRef" href="#bib0004">4</a>&#93;&#46; Despite this&#44; our study found a more dramatic increase in NAFLD-related HCC&#46;</p></span>"
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Article information
ISSN: 16652681
Original language: English
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