Chapter 9: Primary Liver Cancer

The Burden of Digestive Diseases in the United States

James E. Everhart, M.D., M.P.H.

The major malignant neoplasm of the liver is liver cell cancer (hepatocellular carcinoma). Also included in this category in this report are the rare malignancies of hepatoblastoma and angiosarcoma as well as other primary specified and unspecified liver carcinomas. Intrahepatic bile duct carcinoma is included among bile duct cancers (see Appendix 1 for ICD codes).

In 2004, primary liver cancer occurred at an earlier age than any other digestive system cancer, with 50 percent of cases being diagnosed under the age of 65 years (Table 1). Hepatoblastoma, although the most common liver neoplasm among children, had minimal influence on this association because of its rarity. Incidence was lowest among non-Hispanic whites, intermediate among non-Hispanic blacks and Hispanics, and highest among Asians and American Indians. Males had more than 3 times the age-adjusted incidence of females.

The incidence of primary liver cancer rose modestly between 1979 and 1988 (14.5 percent) and more rapidly subsequently (90 percent over the period 1988–2004) (Figure 1). Liver cancer was one of the most lethal digestive system cancers, although 5-year survival did increase nearly fourfold during this period, albeit to only 8 percent.

Medical care visits and hospitalizations for liver cancer were too infrequent in 2004 to make firm statements about them. Hospitalization discharge rates (Table 2) had a demographic pattern similar to incidence rates (Table 1), with the highest rates among patients age 65 years and older, blacks, and males. Hospitalization rates more than doubled from 1984 to 2004 (Figure 2), also in keeping with the increase in incidence.

Death rates increased with age, but not as markedly as in other digestive system cancers (Table 3). Age-adjusted death rates were higher among blacks and males. Because of its increasing incidence and poor survival, primary liver cancer has contributed an increasing number and proportion of deaths, although it accounted for only 4.7 percent of all deaths from digestive system cancers in 2004. Because of the relatively early age of onset, it accounted for a higher proportion of YPLL due to digestive system cancers (7.7 percent). As with incidence, mortality rate increased, although not as quickly. The mortality rate increased 75 percent between 1979 and 2004 (Figure 3).

Table 1. Primary Liver Cancer: Number of Cases and Incidence Rate by Age, Race/Ethnicity, and Sex, 2004

Source: Surveillance, Epidemiology, and End Results (SEER) Program

Demographic Characteristics Number of Cases Incidence per 100,000 Unadjusted Incidence per 100,000 Age-Adjusted
AGE (Years)
Under 15
165 0.3
AGE (Years)
15–44
856 0.7
AGE (Years)
45–64
7,863 11.2
AGE (Years)
65+
8,093 23.7
RACE/ETHNICITY
Non-Hispanic White
9,507 4.9 4.2
RACE/ETHNICITY
Non-Hispanic Black
2,244 6.6 8.3
RACE/ETHNICITY
Hispanic
1,894 4.7 9.0
RACE/ETHNICITY
Asian/Pacific Islander
1,414 11.5 12.9
RACE/ETHNICITY
American Indian/Alaska Native
151 8.2 10.0
Sex
Female
4,350 3.0 2.8
Sex
Male
11,827 8.5 9.4
Total 16,260 5.7

Figure 1. Primary Liver Cancer: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004

Incidence per 100,000 rose modestly from 2.56 in 1979 to 2.93 in 1988 and then more rapidly to 5.56 in 2004. Five-year survival increased from 2.38 percent in 1979 to 8.12 percent in 1999, the last year for which it could be calculated.
Source: Surveillance, Epidemiology, and End Results (SEER) Program

Table 2. Primary Liver Cancer: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Demographic Characteristics Ambulatory Care Visits First-Listed Diagnosis Number in Thousands Ambulatory Care Visits First-Listed Diagnosis Rate per 100,000 Ambulatory Care Visits All-Listed Diagnosis Number in Thousands Ambulatory Care Visits All-Listed Diagnosis Rate per 100,000 Hospital Discharges First-Listed Diagnosis Number in Thousands Hospital Discharges First-Listed Diagnosis Rate per 100,000 Hospital Discharges All-Listed Diagnosis Number in Thousands Hospital Discharges All-Listed Diagnosis Rate per 100,000
AGE (Years)
Under 15
0 1 2 3
AGE (Years)
15–44
1 1 2 2
AGE (Years)
45–64
6 9 15 21
AGE (Years)
65+
6 17 14 39
Race
White
10 4 25 10
Race
Black
2 7 5 14
Sex
Female
4 3 9 6
Sex
Male
10 7 23 17
Total 63 21 14 5 33 11

Figure 2. Primary Liver Cancer: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The number of ambulatory care visits during the period was too small to provide estimates, except for 2003-2005 when the rate was 21.0 per 100,000. Hospitalizations per 100,000 increased from 3.02 in 1979 to 9.58 in 2004.
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

Table 3. Primary Liver Cancer: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Source: Vital Statistics of the United States

Demographic Characteristics Underlying Cause Number of Deaths Underlying Cause Rate per 100,000 Underlying Cause Years of Potential Life Lost in Thousands Underlying or Other Cause Number of Deaths Underlying or Other Cause Rate per 100,000
AGE (Years)
Under 15
33 0.1 2.3 34 0.1
AGE (Years)
15–44
243 0.2 9.1 250 0.2
AGE (Years)
45–64
2,781 3.9 53.9 3,069 4.3
AGE (Years)
65+
3,266 9.0 7.2 3,567 9.8
Race
White
4,742 1.8 49.8 5,204 2.0
Race
Black
944 3.1 14.7 1,021 3.4
Sex
Female
1,522 0.9 12.0 1,666 1.0
Sex
Male
4,801 3.5 60.4 5,254 3.9
Total 6,323 2.2 72.4 6,920 2.4

Figure 3. Primary Liver Cancer: Age-Adjusted Rates of Death in the United States, 1979–2004

The mortality rate increased between 1979 and 2004. Underlying-cause mortality per 100,000 rose from 1.19 in 1979 to 2.08 in 2004. All-cause mortality per 100,000 rose from 1.33 in 1979 to 2.27 in 2004.
Source: Vital Statistics of the United States
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