With great interest, we read the meta-analysis of observational cohort studies by Mantovani et al 1 providing significant evidence for an increased long-term risk of developing certain extrahepatic malignancies (especially gastrointestinal (GI), breast and gynaecological cancers) in patients with non-alcoholic fatty liver disease (NAFLD). Given the dramatically increasing global relevance of NAFLD, which currently has a prevalence of 25%,2–4 these findings are of immense clinical importance and may lead to prevention and screening algorithms.

In a retrospective cohort study, we identified 86 777 NAFLD patients (International Classification of Diseases (Version 10) (ICD-10): K75.8, K76.0) and a matched cohort of equal size without NAFLD from the Disease Analyzer database (IQVIA) compiling diagnoses and demographic data from general practitioners in Germany (online supplemental figure 1).5 Propensity score matching included the following variables: sex, age, index year, yearly consultation frequency, diabetes (ICD-10: E10–E14), obesity (ICD-10: E00–E07), thyroid gland disorders (ICD-10: E00–E07), chronic bronchitis and chronic obstructive pulmonary disease (COPD) (ICD-10: J42–J44) diagnoses. Mean age was 57.7 years. 46.4% of patients were female (online supplemental table 1). Incidence of extrahepatic malignancies was analysed as a …