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J Clin Gastroenterol. 2013 July ; 47(0): S2S6. doi:10.1097/MCG.0b013e3182872f29.

Epidemiology of HCC: Consider the Population

Sahil Mittal, MD, MS1,2 and Hashem B. El-Serag, MD, MPH1,2
1Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of
Medicine, Houston, Texas
2Section

of Health Services Research, Department of Medicine, Baylor College of Medicine and

Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas

Abstract

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Hepatocellular carcinoma (HCC) is increasing in incidence and has a very high fatality rate.
Cirrhosis due to chronic hepatitis B or hepatitis C is the leading risk factor for HCC. Global
epidemiology of HCC is determined by prevalence of dominant viral hepatitis and the age it is
acquired in the underlying population. Upcoming risk factors include obesity, diabetes and related
non-alcoholic fatty liver disease. This review discusses the latest trends of HCC globally and in
the United States. It also provides an evidence-based commentary on the risk factors and lists
some preventive measures to reduce the incidence of HCC.

Keywords
Hepatocellular carcinoma; epidemiology; chronic hepatitis B; chronic hepatitis C; prevention
Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver. It is
the fifth most common cancer in men, worldwide, and seventh among women, with over
half a million new cases diagnosed annually worldwide. It is the second leading cause of
cancer related mortality in the world.1, 2 Chronic liver disease due to hepatitis B virus
(HBV) or hepatitis C virus (HCV) accounts for the majority of HCC cases and thus, highly
amenable to preventive measures. 3

Global Epidemiology of HCC

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The distribution of HCC varies according to geographic location (Figure 1). The disease
burden is highest in areas with endemic HBV infection (where HBsAg prevalence is 8% or
more), such as in sub-Saharan Africa and Eastern Asia, with incidence rates of over 20 per
100,000 individuals. Mediterranean countries such as Italy, Spain, and Greece have
intermediate incidence rates of 10-20 per 100,000 individuals, while North and South
America have a relatively low incidence (< 5 per 100,000 individuals). The global age
distribution of HCC cases is related to dominant viral hepatitis in the underlying population
and the age at which it was acquired. In regions of high incidence the most common cause is
HBV transmitted at birth, the diagnosis of HCC is about one decade earlier as compared

Corresponding author: Hashem B. El-Serag, MD, MPH, Michael E. DeBakey VA Medical Center, 2022 Holcombe Blvd. (152),
Houston, TX 77030. Tel: 713 794 8640, Fax: 713 748 7359, hasheme@bcm.edu.
Conflict of Interest: The authors disclose no conflicts.
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with North America and Europe where the most common etiology is HCV acquired later in
life. HCC is more common in men than women as HBV, HCV, and alcohol consumption are
more prevalent and possibly more carcinogenic in males. In 80 to 90% cases, HCC occurs in
the setting of cirrhosis.4

Trends of HCC in United States

Population-based data from SEER registries showed that overall annual age-adjusted
incidence rates of HCC had doubled from 1.4 per 100,000 in 1975-77 to 4.8 per 100,000 in
2005-07.5 The greatest recent increase in incidence was seen in Hispanics and blacks among
the ages of 45-65 years (Figure 2). 6 The overall 5-year survival is less than 12%, making
HCC the fastest rising cause of cancer related death in United States. Both sexes showed a
3-fold increase in incidence of HCC from 1975-2007. Approximately half of the increase in
HCC cases was attributed to the aging cohort with chronic hepatitis C infection. A study on
veterans with chronic HCV showed that during 1996-2006 prevalence of cirrhosis and
decompensated liver disease doubled, whereas the prevalence of HCC increased 10-fold
(0.07% to 1.3%).7 HBV accounts for 10-15% of HCC cases in the US; less than 5% are
infected with both viruses and 30-35% has neither HCV nor HBV. Increasing incidence of
obesity and non-alcoholic fatty liver disease (NAFLD) is another factor responsible for the
surge in HCC cases in United States.

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Risk Factors for HCC

Hepatitis B Virus (HBV)

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HBV is the leading risk factor for HCC globally and accounts for at least 50% cases of
HCC.8 In endemic areas, HBV is mostly acquired by vertical and perinatal transmission
with > 90% of these cases becoming chronic HBV carriers. In contrast, areas of low
prevalence such as western countries, it is usually acquired in adulthood by horizontal
transmission (through sexual and parenteral routes) with >90% of acute infections resolving
spontaneously. HBV is a notorious HCC cause in the absence of cirrhosis; however, most
(70%-90%) HBV-related HCC develops in cirrhotic livers.9 Several factors have been
reported to increase HCC risk among HBV carriers, including demographic (male gender,
older age, Asian or African ancestry, family history of HCC), viral (higher levels of HBV
replication, HBV genotype, longer duration of infection, co-infection with HCV, HIV or
HDV), clinical (cirrhosis) and environmental or life-style factors (exposure to aflatoxin,
heavy alcohol drinking or tobacco smoking). In Asian studies, genotype C is associated with
more severe liver disease, cirrhosis and the development of HCC, compared with genotype
B; whereas in Western Europe and North America, genotype D is more associated with a
higher incidence of HCC than genotype A, as well as the development of HCC in young
carriers without cirrhosis.
Several meta-analysis have demonstrated that risk of HCC is 15-20 times greater among
HBV infected individuals as compared to uninfected population.10, 11 A systematic review
of the natural history of HBV in Asia summarized that incidence rate of HCC was 0.2 per
100 person-years in inactive carriers, 0.6 person-years with chronic HBV infection without
cirrhosis, and 3.7 person-years in patients with compensated cirrhosis.12 The Risk
Evaluation of Viral Load Elevation and Associated Liver Disease/ Cancer-Hepatitis B Virus
(REVEAL-HBV) study from Taiwan showed that the risk of HCC in HBV infected
participants increased in proportion to viral load (HBV DNA) independent of age, sex,
smoking, alcohol consumption, and HbeAg status.13 There is a lack of high quality studies
from Europe and North America, but reasonable estimates of HBV natural history in
western population are incidence rate of 0.02 per 100 person-years in inactive carriers, 0.3 in
chronic carriers without cirrhosis and 2.2 in subjects with compensated cirrhosis.14

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Hepatitis C Virus (HCV)

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HCV was detected in 44-66% of patients with HCC in Italy, and among 80% of HCC cases
in Japan.15-17 In the United States, chronic HCV is the leading risk factor for HCC.
Prospective studies have shown increased risk of HCC among HCV infected cohort.18 A
meta-analysis of case control studies showed that individuals positive for anti-HCV had 17
times the risk of HCC as compared to anti-HCV negative cohort.19

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HCV appears to increase the risk of HCC by inducing hepatic inflammation and importantly
fibrosis, but also promoting malignant transformation of infected cells.20 The risk is highest
among cirrhotics where HCC develops at rate of 1-4% per year, though rates up to 8% have
been reported in Japan.21 HCC has also been reported in chronic HCV patients without
cirrhosis but with intermediate to advanced hepatic fibrosis. The Hepatitis C Antiviral Long
Term Treatment Against Cirrhosis trial (HALT-C) showed that 8% patients without
cirrhosis, but with advanced fibrosis, developed HCC.22 Other risk factors that increase risk
of HCC in infected patients include male sex, co-infection with HIV, HBV, HCV genotype
1b, old age, presence of diabetes and obesity, and a high level of chronic alcohol
consumption. A meta-analysis of 21 studies presenting age-adjusted risk estimates for HCV
genotype 1b vs. other HCV genotypes reported that patients infected with HCV genotype 1b
have almost double the risk of developing HCC of those infected with other genotypes
(pooled relative risk = 1.78, 95% CI: 1.36-2.32). 23 The pooled risk estimate was lower in an
analysis limited to the 8 studies conducted in patients with liver cirrhosis (1.60; 1.07-2.39).
There is no consistent evidence that HCV viral load or quasispecies are important in
determining the risk of progression to HCC.
Non-Alcoholic Fatty Liver Disease (NAFLD)
NAFLD is now the leading cause of chronic liver disease in the United States. Features of
metabolic syndrome such as visceral obesity or insulin resistance are present in virtually all
cases of NAFLD. A population-based study using SEER-Medicare database showed a
statistically significant association between metabolic syndrome and HCC.24 Most likely,
this increased risk is thought to be due to NASH.

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There are several case-reports and series of well-documented patients with NAFLD/NASH
who developed HCC. However, two population based cohort studies in patients with
NAFLD/ NASH showed no increased incidence and 0.3% risk of HCC, respectively, over 6
years of follow up.25, 26 Studies of NAFLD or NASH cohorts, with few or no cirrhosis
cases, demonstrated a minimal HCC risk (cumulative HCC mortality between 0% and 3%
for study periods up to two decades). 27, 28 Similarly, a study published from Denmark that
included biopsy proven NAFLD/NASH cases, but without significant fibrosis, found no
increased risk of HCC when followed up for almost 21 years.29 Conversely, consistently
increased risk was observed in NASH-cirrhosis cohorts. 30-35 They also showed that risk of
HCC was lower in NAFLD-related cirrhosis as compared to its incidence in cirrhosis due to
viral hepatitis. Natural history cohort studies that lacked control groups reported cumulative
incidence of HCC mortality between 0.25% and 2.3%. 36-40 The determinants of elevated
risk among NASH-C cohorts are unclear, as most studies were underpowered to perform
multivariate analysis.
In summary, modest epidemiological evidence supports the association between NAFLD /
NASH and increased risk of HCC that seems to be limited to patients with cirrhosis; and this
risk is lower as compared to cirrhosis from other etiologies.

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Aflatoxin

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Aflatoxins are carcinogens produced by Aspergillus species (A flavus and A parasiticus) and
infest grains, corn, cassava, peanuts, and fermented soybeans, particularly when stored in
high moisture conditions. There is a high incidence of HCC in regions where aflatoxin
contaminated food ingestion is common, such as in parts of sub-Saharan Africa and eastern
Asia; however, these regions have high HBV prevalence as well. Majority of HCC in these
regions were found to have mutation of tumor suppressor gene p53 that is most likely caused
by aflatoxins.41 There is no evidence of aflatoxin related HCC cases in the US. A study from
China demonstrated about 60 fold increased risk of HCC in patients with chronic HBV and
aflatoxin exposure.42
Alcohol

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Although heavy alcohol intake increases the risk of HCC through the development of
cirrhosis, there is no definite evidence to show carcinogenic potential of alcohol. Alcohol
acts in synergism with HCV and HBV infection, presumably accelerating the process of
fibrosis and progression to cirrhosis. A meta-analysis showed that in chronic HCV patients,
odds of developing cirrhosis were 2.3 higher in heavy alcohol drinkers as compared to none
or low quantity drinkers.43 Another study showed that risk of HCC increased in a linear
fashion with heavy alcohol intake (>60g/ day), and this risk doubled in those infected with
HCV. Similarly, a study on patients with HBV related cirrhosis; HCC risk was increased
three times by heavy alcohol intake.44 The effect of low or moderate amount of alcohol
intake on risk of HCC is unclear.
Coffee
Several epidemiological studies have elucidated the link between heavy coffee consumption
and low liver enzymes, reduced risk of cirrhosis and reduced risk of HCC. Chronic HCV
patients who consumed high levels of coffee were found to have lower fibrosis score.45 A
meta-analysis of studies on risk of HCC among coffee drinkers in European and Japanese
studies showed a reduced risk of HCC. They concluded that relative risk of HCC among low
or moderate coffee drinkers (defined as 1-2 cups / day) was 0.70 (95% CI 0.57-0.85), and
that for high drinkers (defined as 3 cups / day) was 0.45 (95% CI 0.38-0.53) as compared
to non-drinkers.46 Although the mechanism of this possible protective effect is unclear,
coffee consumption lowers insulin levels and reduces the risk of diabetes, a known risk
factors for HCC.47 Animal studies also suggest that coffee contains compounds with anticarcinogenic properties.
Host Genetic Factors

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HCC develops only in small percentage of those infected with HCV or HBV. Host genetic
makeup may be an important factor that influences progression to HCC. Two meta-analysis
indentified variants of tumor necrosis factor (TNF) associated with higher risk of HCC.48, 49
They showed that TNF-308 AA and AG variants (vs. GG) were associated with a
significantly increased risk of HCC. A recent meta-analysis concluded that null genotypes of
glutathione S-transferase (GST) genes (GSTM1 or GSTT1) were associated with an
increased risk of HCC.50

Prevention of HCC
HBV vaccination
Development of HBV vaccine has been a major success in reducing the incidence of HBV
infection and subsequent development of HCC. The vaccine is safe and effective against all
HBV genotypes and serotypes. HBV vaccine is recommended for all newborns, pregnant

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women at their first pre-natal visit, and high-risk individuals. Neonates born to HBV
infected mothers should get a dose of hepatitis B immune globulin in addition to
vaccination. Countries like Taiwan that have implemented universal hepatitis B vaccination
program have demonstrated its success. Twenty years after adopting the program, HBV
carrier rate among children in Taiwan has decreased to 1.2% and incidence of HCC among
the vaccinated children has dropped by 70%. 51
Antiviral treatment
A metanalysis of non-randomized trials and observational studies demonstrated reduced risk
of HCC after anti-viral treatment for HBV infection. A multicenter randomized controlled
study on patients with chronic HBV and advanced hepatic fibrosis showed that 3.9%
developed HCC on lamivudine therapy as compared to 7.4% in placebo arm when treated up
to 5 years. 52
Randomized and non-randomized studies have shown that achieving sustained viral
response in chronic HCV patients, both with and without cirrhosis, leads to a substantial
reduction in risk of HCC. 53, 54 Although viremia of any level is a risk factor for HCC, viral
load is not associated with HCC. HCV+ patients with advanced fibrosis who clear viremia
with anti-viral treatment have a reduced, but not eliminated risk, of HCC and should
undergo surveillance for HCC.

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HCC Surveillance
Only one randomized trial from China showed that HCC related mortality was reduced by
37% in the surveillance arm that consisted of AFP and ultrasound every 6 months compared
with a no surveillance control arm.55 Observational cohort and case control studies, with
their inevitable limitations, have demonstrated similar benefits for surveillance.56, 57 This
expected benefit and the fact that patients diagnosed early are eligible for liver
transplantation, prompted some but not all professional societies such as American
Association for the study of Liver diseases to recommend surveillance for patients at high
risk of HCC.

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Alpha-fetoprotein (AFP) surveillance with cutoff as 20 ng/ml has a sensitivity of only 60%
and is inadequate as sole means of surveillance. Ultrasonography has sensitivity between
65-80% and specificity of over 95% as a surveillance modality. 58 Although AASLD
guidelines recommend 6 monthly screening with ultrasound, we feel that using combination
of alpha-fetoprotein and ultrasonography can increase the yield of screening. Adherence to
guidelines is a problem as highlighted in a study conducted on Veterans Administration
(VA) practice setting, where most patients who were eligible for surveillance did not receive
regular imaged based surveillance.59 Computed tomography (CT) and magnetic resonance
imaging (MRI) are better at imaging the liver as compared to ultrasonography, but they have
not been examined as surveillance tools, and therefore should be used for diagnosis and
staging HCC rather than surveillance.
HBV and HCV will continue to be the leading cause of HCC. Antiviral treatment for
chronic hepatitis B and C while very efficacious, their effectiveness in community practice
is low due to the barriers in access, diagnosis, cost of medications, and presence of comorbidities and contraindications. Large proportions of infected population live
undiagnosed with HBV or HCV for decades and only get detected when they seek medical
care for advanced liver disease or HCC. In a new initiative, U.S. Centers for Disease Control
and Prevention now recommends routine screening for HCV in all baby boomers born
between the years 1945-1965. Measures to increase awareness among general population,

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primary care providers and improving access to specialist care are some other steps that can
help in reducing the incidence of HCC.

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Acknowledgments
Funding: Authors report no funding for this article.

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Figure 1.

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Age-standardized incidence rates of hepatocellular carcinoma per 100,000 populations at

risk, in different regions of world (Source: GLOBOCAN 2002).

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Figure 2.

Age-adjusted incidence rate of hepatocellular carcinoma by race based on SEER registry

data from 1975-2007.

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NIH-PA Author Manuscript
J Clin Gastroenterol. Author manuscript; available in PMC 2014 July 01.