Primary liver cancer: Worldwide incidence and trends

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Estimates from the year 2000 indicate that liver cancer remains the fifth most common malignancy in men and the eighth in women worldwide. The number of new cases is estimated to be 564,000 per year, including 398,000 in men and 166,000 in women. In high-risk countries, liver cancer can arise before the age of 20 years, whereas, in countries at low risk, liver cancer is rare before the age of 50 years. Rates of liver cancer in men are typically 2 to 4 times higher than in women. The incidence of primary liver cancer is increasing in several developed countries, including the United States, and the increase will likely continue for some decades. The trend is a result of a cohort effect related to infection with hepatitis B and C viruses, the incidence of which peaked in the 1950s to 1980s. In selected areas of some developing countries, the incidence of primary liver cancer has decreased, possibly as a result of the introduction of hepatitis B virus vaccine. The geographic variability in incidence of primary liver cancer is largely explained by the distribution and the natural history of the hepatitis B and C viruses. The attributable risk estimates for the combined effects of these infections account for well over 80% of liver cancer cases worldwide. Primary liver cancer is the first human cancer largely amenable to prevention using hepatitis B virus vaccines and screening of blood and blood products for hepatitis B and C viruses.

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Mortality from liver cancer

Coding recommendations for primary liver cancer and liver metastasis changed slightly from the eighth to the ninth revisions of the International Classification of Diseases (ICD) implemented after 1965 and 1975 respectively.6, 7 The tenth revision was introduced as from 1992.8 The impact of coding practices in mortality statistics is relevant in liver cancer, although its impact has probably been over estimated in relation to the impact of improving diagnostic technology such as ultrasound and

Liver cancer incidence in different ethnic groups and immigrant populations

The incidence of liver cancer in populations by ethnic origin in the United States is shown in Figure 6.12 The lowest incidence rates are consistently found among whites (3.8 in men and 1.4 in women). Gradually increasing rates are found in the Japanese (5.5 in men and 4.3 in women), African American (7.1 in men and 2.1 in women), Hispanic white (9.8 in men and 3.5 in women), Filipino (10.9 in men and 2.4 in women), Chinese (16.2 in men and 5.0 in women), and Korean American (20.7 in men and

Age-specific incidence rates

In most high-risk areas, such as Southeast Asia (Qidong in China) or the West Coast of Africa (Bamako in Mali), rates of liver cancer increase after 20 years of age and peak or stabilize at the age of 50 years and above (Figure 7). In these countries, liver cancer is not a rare event at ages 20 to 35 years. Still, the incidence in Qidong is substantially higher at each age group than the corresponding incidence in Mali, a high-risk country in Africa, and the age of occurrence is significantly

Trends in liver cancer incidence and mortality

International variation in the availability of diagnostic testing as well as in the coding and registration practices for liver cancer (HCC, intrahepatic cholangiocarcinoma, metastases, and liver tumors of uncertain nature as if primary or secondary) makes the interpretation of long-term time trends difficult. Of particular concern in some countries is the likely impact of immigration from high-risk countries. These populations are often visible in the health system at the time of diagnosis but

Risk factors for primary liver cancer

The etiology of primary liver cancer has been largely established, and Table 2 shows current estimates of the attributable fractions for the main risk factors by 3 geographic areas. The broad traits of the epidemiology of primary liver cancer can be interpreted by the natural history of the hepatotropic viral infections and by the patterns of exposure to the key risk factors in each population.

Opportunities for prevention

By the year 2000, HBV vaccination programs had been implemented in 135 countries, including the lesser developed areas in Africa and Asia. A major input from donor agencies has made it possible to provide HBV vaccine to all newborns in the last decade, and such efforts should be encouraged and supported. HBV vaccination trials initiated in the 1980s have already shown the ability of HBV vaccines to prevent the chronic carriage of HBsAg68, 69 and the development of primary liver cancer when

Conclusions

Primary liver cancer remains a major health problem with great geographic variability. Men are consistently more affected than women, and survival is poor worldwide. Increasing trends in incidence in some developed countries, including the United States, suggest an underlying cohort effect linked to HCV and HBV exposures. Reduction of primary liver cancer burden in most developing countries should give priority to HBV vaccination campaigns and to prevention of nosocomial spread of HBV and HCV.

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    Supported by a personal research grant from the “Pla Oncologic de Catalunya” (to R.C.), by a research grant from the “Fondo de Investigaciones Sanitarias de la Seguridad Social” of the Spanish Government (Reference: 01/1569), and from the Instituto de Salud Carlos III of the Spanish Government (grants RTICCC C03/09 and RTICESP C03/10).

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