Which Races And Ethnic Groups Have The Highest Rates Of Liver Cancer?

Liver cancer is the sixth leading cancer cause of death in the United States.¹ However, it doesn’t affect everyone equally. There are racial differences in the incidence and mortality rates of liver cancer, of which socioeconomic disparities and structural racism may play a significant role.

How common is liver cancer?

There are clear trends in liver cancer incidence and mortality, which have changed over time but still show stark differences based on race.

Recent rates and dynamics

In 2023, it’s estimated that around 41,200 new cases and 29,380 deaths will occur from liver cancer in the United States.²

Liver cancer is rare compared to other cancers, making up only around 2% of all cancers in the United States. However, it accounts for about 4.8% of all cancer deaths in the country.³ The most common type of liver cancer is hepatocellular carcinoma (HCC).⁴

During the past few decades, the incidence and mortality of liver cancer has rapidly increased in the US. However, since 2017, the incidence rate has been declining and the death rate has stabilized. That being said, liver cancer is still considered to have one of the worst survival rates,⁵ with an average five-year survival rate of 21.6%.

Rates of liver cancer in minority racial and ethnic groups

The Surveillance, Epidemiology, and End Results Program (SEER), run by the National Cancer Institute, provides information on cancer incidence and mortality in different demographics.  

Recent SEER data shows that per 100,000 people, the rates of liver cancer are highest inAmerican Indian/Alaskan Natives (17.8%), followed by Hispanics (14%), Asian/Pacific Islanders (10.6%), and Black people (9.5%).⁶ The rates of liver cancer are lowest in non-Hispanic White people (7.3%). Minority racial groups also have significantly higher mortality rates from liver cancer.⁷

Introduction to liver cancer and its stages

The stage of cancer describes how much it has grown and spread around the body. 

The most common way to stage cancer is using the American Joint Committee on Cancer (AJCC) TNM system. It classifies tumors based on the following characteristics:⁸

T: The size of the tumor

• T0: There is no evidence of a primary tumor

• Tis: The cancer is in situ (in the single layer of cells where they started) 

• T1: A single tumor less than 2cm that has not invaded blood vessels

• T2: A single tumor, either greater than 2cm with growth into blood vessels or multiple tumors but none larger than 5cm

• T3: Multiple tumors, with at least one larger than 5cm

• T4: Multiple tumors, with growth into one of the liver’s large blood vessels 

N: Whether it has spread to nearby lymph nodes 

• N0: There is no spread to nearby lymph nodes

• N1: Cancer has spread to nearby lymph nodes 

M: Whether it has spread (metastasized) to distant lymph nodes or organs 

• M0: The cancer has not metastasized to distant lymph nodes or organs

• M1: The cancer has metastasized to distant lymph nodes or organs 

SEER uses the TNM system to estimate relative survival rates. Relative survival rates describe the percentage of people likely to survive the effects of their cancer after a given time, usually five years, when compared to those living without the disease. The overall five-year survival rate for liver cancer is 21.6%, but it also depends on the following stages:⁹

• Localized: 42%

• Regional: 26%

• Distant: 19% 

The information can also be used to stage a person’s cancer from I-IV. 

Stage I

• IA: T1a, N0, M0

• IB: T1b, N0, M0 

Stage II

• T2, N0, M0

Stage III

• IIIA: T3, N0, M0

• IIIB: T4, N0, M0

Stage IV

• IVA: T1-4, N1, M0

• IVB: T1-4, N0-1, M1 

Risk factors for liver cancer

Around 70% of liver cancer cases in the United States can be prevented by removing risk factors.¹⁰ Some of these factors can’t be changed, such as gender or genetic predisposition, but most risk factors involved with this type of cancer can be mitigated.

Below are some of the factors that can make someone more likely to develop liver cancer. However, it’s important to remember that liver cancer can develop even in individuals with no known risk factors:

Gender: Hepatocellular carcinoma is far more common in men than in women.¹¹

Race/Ethnicity: In the United States, non-White populations, such as Asian Americans, Pacific Islanders, American Indians, Alaska Natives, Hispanics, and African Americans, have a much higher risk of liver cancer than White populations.¹²

Hereditary and rare diseases: Certain diseases can increase the risk of liver cancer, including hemochromatosis, alpha1-antitrypsin deficiency, porphyria cutanea tarda, glycogen storage diseases, and Wilson disease.¹³

Chronic viral hepatitis B or C: Viral hepatitis is the largest liver cancer risk factor.¹⁴ It causes cirrhosis (scarring/fibrosis) of the liver. Hepatitis B virus (HBV) can spread through body fluids such as blood or semen — it can spread by blood transfusions, unprotected sex, childbirth, and sharing contaminated needles. Hepatitis C virus (HCV) mainly spreads through blood, for example, via blood transfusion or contaminated needles, and is less likely through sex.

Smoking: Current and ex-smokers are at greater risk of liver cancer.¹⁵

Excessive alcohol consumption: Excessive alcohol consumption is one of the leading risk factors associated with liver cancer, as it causes alcoholic fatty liver, leading to inflammation and cirrhosis, which greatly increases the risk of liver cancer.¹⁶

NAFLD, then NASH: Non-alcoholic fatty liver disease (NAFLD) is a condition where excess fat accumulates in the liver. It can occur in people with obesity, type 2 diabetes, and high lipid levels. Non-alcoholic steatohepatitis (NASH) is what happens when NAFLD gets worse. NASH involves inflammation and damage of the liver cells, which eventually can cause cirrhosis, leading to an increased risk of liver cancer.¹⁷

Cirrhosis: Cirrhosis is when liver cells are replaced by scar tissue after being damaged. Various causes can lead to cirrhosis, including excessive alcohol intake, hepatitis infections, obesity, and diabetes. Cirrhosis is present in 80–90% of people with liver disease and is one of the main risk factors for liver cancer.¹⁸

Obesity or excessive weight: Excess fat tissue in obesity causes inflammation, leading to cirrhosis, NAFLD and NASH, and, subsequently, an increased risk of liver cancer.¹⁹

Type 2 diabetes: People living with type 2 diabetes are more likely to develop liver cancer.²⁰ In many cases, this may be due to co-existing health concerns, such as obesity, which can lead to inflammation, NAFLD and NASH, and insulin resistance. 

Exposure to aflatoxins: Aflatoxins are toxins produced by fungi. They’re found on crops such as corn, peanuts, cottonseed, and tree nuts, particularly if stored in hot climates.²¹ Aflatoxins increase the risk of liver cancer.²² Exposure can occur by eating products contaminated with aflatoxins or by inhaling them when working on farms. 

Anabolic steroids: Some research suggests that using anabolic steroids for an extended period of time is linked to HCC.²³

Age: Liver cancer is more common in older people, with the median age at diagnosis being 66.²⁴

Risk factors associated with racial/ethnicity disparities

Many of the risk factors linked to liver cancer are socioeconomic or environmental in nature. It’s not known how much exactly of an impact genetic and biological differences have on liver cancer disparities. 

While the same risk factors are associated with developing liver cancer in all racial groups, some studies suggest that the strength and association between each of these risk factors and developing HCC may vary by race, implying a potentially higher genetic susceptibility in some races than others.²⁵

Despite this, data from various studies suggest that social determinants of health (which are socioeconomic factors that generate disparities in quality of living, access to healthcare, and health outcomes) are highly implicated in the disparities in liver cancer incidence and mortality rates among different racial and ethnic populations in the US.²⁶

Some of the factors associated with racial/ethnic disparities that affect liver cancer incidence, prognosis, and survival rates, are:

Lower socioeconomic levels

Those living in lower socioeconomic areas have a higher incidence and mortality rate of liver cancer than those living in neighbourhoods with higher socioeconomic levels. This is apparent even within the same racial group. However, in the US, generally, racial and ethnic minorities tend to have lower socioeconomic levels than their white counterparts. This spans from historical racism, lack of opportunities, and systemic discrimination in  everyday life. 

Living in a lower socioeconomic community increases the risk of contracting infections such as hepatitis, which is a significant risk factor for liver cancer.²⁷ A lower socioeconomic level is also associated with high rates of smoking, high alcohol use, obesity, and diabetes. This is because people with a lower socioeconomic level may have worse living and work conditions and less health education, health insurance, and access to healthier food. They subsequently experience much higher rates of liver disease and cancer.²⁸

Not only does socioeconomic level affect the incidence of developing liver cancer, but it also significantly impacts prognosis and mortality rates. For example, Black males with low socioeconomic levels were found to have the lowest five years survival rate compared to all the other racial/ethnic populations in the US.

Geographic locations and chemical exposure

The rates of liver cancer are higher in southwestern and southeastern areas of the United States, which are also areas with the highest populations of Black and Hispanic people.²⁹ ³⁰

Black and Hispanic people are also more likely to live in areas with high levels of water and air pollution, as many industrial activities tend to move to lower socioeconomic neighbourhoods. This, in turn, increases racial and ethnic minorities’ exposure to toxic chemicals and elevates their risk of liver cancer. For example, Blacks and Hispanics were found to live in areas with the highest cadmium exposure. Cadmium is a likely carcinogenic chemical.³¹

Higher prevalence of metabolic conditions

Metabolic conditions, such as obesity and type 2 diabetes, are more common in minority racial populations, including Black, Hispanic, and Native Americans.³²

This may be due to socioeconomic, lifestyle, or environmental factors, or genetic predispositions. For example, there are certain genetic variants that increase your likelihood of metabolic conditions, such as COBLL1, which increases the risk of obesity, or TCF7L2, which increases the risk of type 2 diabetes.³³

Food insecurity

Food insecurity means consistently not having enough safe and nutritious food to fulfil the dietary requirements necessary to live a healthy life. It’s more common among minority races such as Hispanic and Black populations.³⁴ Food insecurity may be linked to the development of NAFLD, which is one of the risk factors for liver cancer.³⁵

Research has found an association between specific dietary components and the risk of cancer.³⁶ A diet rich in red meat, fish, and added sugars may increase the risk of liver cancer. On the other hand, fruits, vegetables, eggs, yogurt, milk, and cereals may be protective against liver cancer. 

Lack of insurance

Research shows that patients with late-stage cancer are much less likely to receive any cancer-directed therapy, as therapy in late stages rarely provides a cure. However, it was also reported that 11% and 24% of patients with potentially curable stage A and B cancer, respectively, didn’t receive any cancer-directed therapy due to a lack of healthcare insurance and their old age.³⁷

Racial/ethnic minority populations are less likely to have adequate insurance coverage for treatment, and they may not be able to access the healthcare services they need for early diagnosis and appropriate treatment.³⁸

Worse healthcare

High-poverty neighborhoods are more likely to be medically underserved.³⁹ In these neighborhoods, access to quality healthcare could be difficult due to fewer equipped facilities or lack of transportation. There may also be less availability for important surgical procedures for liver cancer, such as liver transplants and hepatic resection. 

Late diagnosis

Black people have the highest proportion of advanced distant-stage cancer in both low and high socioeconomic groups of all races and ethnicities, despite having a lower incidence of HCC than all other ethnic groups apart from White populations. 

Black people are less likely to have timely referrals and experience the appropriate management and care as cancer patients, leading to these higher rates of distant-stage cancer.⁴¹

This may be because of discrimination and racist practices in healthcare. Additionally, healthcare providers may be less likely to suspect liver cancer due to the historically low incidence of HCC in Black populations, and, therefore, they may not screen their patients for the disease. 

Black people have the lowest liver cancer survival rates.⁴² Available data doesn’t suggest the presence of variations in the biology of the tumor by race or ethnicity, implying that this significant disparity in survival rate that black people experience is likely due to healthcare-related factors, such as provider implicit bias, patient barriers to timely and high-quality medical care, and issues of medical mistrust. 

Treatment for liver cancer

The recommended treatment for liver cancer can depend on the patient’s stage, other health concerns, and the goal of treatment. Some options include:⁴³

• Surgery: resection of part of the liver, or transplantation

• Ablation: destroying the tumors without removing them 

• Embolization therapy: injecting substances into an artery that goes into the liver, to block or reduce blood flow to the tumor 

• Radiation therapy: destroying cancer cells using high-energy radiation beams 

• Targeted drug therapy: taking drugs that target specific proteins involved in cancer growth and spread 

• Immunotherapy: an IV treatment that helps the immune system fight cancer 

• Chemotherapy: a drug treatment that destroys cancer cells⁴⁴

The lowdown

Anyone can develop liver cancer, but the incidence and mortality rates are much higher in minority races. Many of the risk factors in these populations are preventable and stem from living in lower socioeconomic conditions. The existence of systemic disparities in healthcare also has an impact on these rates. 

Therefore, research into liver cancer prevention and treatment needs to focus on minority racial and ethnic groups so that we can understand how to overcome disparities and improve liver cancer outcomes.

FAQs

Can a healthy person get liver cancer?

Anyone can develop liver cancer. The cause may be unknown in people who are otherwise healthy and don’t present with any known risk factors.

Is stage 1 liver cancer curable?

Stage I liver cancer has the highest survival rate for liver cancer. In some people, stage I liver cancer can be cured with a partial hepatectomy, which removes a portion of the liver.⁴⁵

Can liver cancer be genetic?

People with a family history of liver cancer are more likely to develop it themselves. This may be due to shared environmental risk factors, but genetics may also be involved.⁴⁶