Both endogenous insulin bioavailability and exogenous insulin therapy are associated with an increased risk of HCC.3,4,11–13,15,18,20,43,45 The association between the duration of exogenous insulin therapy and HCC may be confounded by the control of hyperglycemia and endogenous insulin bioavailability, which are represented in part by the blood glucose control state. Here, INS is linked to hepatocellular carcinoma.