To the Editor The multicenter study by Xu et al1 concluding that recurrence after hepatocellular carcinoma (HCC) resection is associated with sex deserves robust comment. The sophisticated multivariate Cox regression analyses failed to account for smoking status (dose and duration and also cessation after resection) despite smoking being an independent and a dose-related contributing factor for HCC all over the world,2 including Asia.3 The mean relative risk was 1.5 but exposure was high, specifically in China, where the prevalence of smoking was almost 50% in men, 22-fold that of women. In a large European cohort,4 the population attributable fraction for tobacco use in HCC was 48%, more than twice the population attributable fraction of the second most attributed risk factor (hepatitis C, 21%). Last, smoking cessation is an important factor in cancer outcomes (eg, cancer treatment effectiveness, overall survival, recurrence, risk of second primary malignancies, and quality of life).5
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Braillon A, Regimbeau J. Care After Liver Resection for Hepatocellular Carcinoma. JAMA Surg. Published online March 20, 2019154(6):567–568. doi:10.1001/jamasurg.2019.0148
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