Trends in burden of liver cancer and underlying etiologies in China, 1990−2021

<h2>Abstract</h2><h3>Background</h3> Liver cancer remains a challenging global health issue. In 2020, China accounted for 45.3% of new liver cancer cases worldwide. The high incidence and mortality rates of liver cancer highlight its profound impact, reflected in a mere 12.1% 5-year survival rate in China, posing significant challenges in managing and treating this disease. <h3>Methods</h3> Data on the number of cases, age-specific rates and age-standardized rates (ASRs) of prevalence, incidence, death, and disability-adjusted life year (DALY) attributed to liver cancer (International Classification of Diseases, 10th revision [ICD-10]: C22.0-22.8 and a proportion of C22.9) and its six etiologies (liver cancer due to hepatitis B, hepatitis C, alcohol use, other causes, NASH and hepatoblastoma) in China between 1990 and 2021 were extracted from the Global Burden of Disease Study 2021. Five-year relative survival rates were estimated using the formula (1–mortality/ incidence) ×100. Temporal trends in liver cancer burden were determined by percent changes and average annual percent change (AAPC). Decomposition analysis was conducted to understand the contributions of population aging, population growth, and epidemiological change to the observed trends. <h3>Findings</h3> In 2021, the number of liver cancer burden in terms of prevalence, incidence, deaths, and DALYs are 265,539, 196,637, 172,068, and 4,890,023, respectively. The corresponding age-standardized rates were 13.29 (95% UI: 10.75–16.41), 9.52 (95% UI: 7.72–11.78), 8.35 (95% UI: 6.80–10.29), 239.91 (95% UI: 191.98–299.37) per 100,000. The number of prevalence, incidence, deaths and DALYs attributed to liver cancer showed an increasing trend, primarily driven by population aging, then population growth. Meanwhile, decreasing trends were observed in age-standardized death and DALY rates, with AAPCs of –0.32% (95% CI: –0.35% to –0.27%) and –0.79% (95% CI: –0.86% to –0.71%), respectively. Stratified by six etiologies, liver cancer due to hepatitis B, hepatitis C, alcohol use, NASH, and other causes generally showed increasing trends in incidence, prevalence, death and DALYs. Conversely, the burden of hepatoblastoma showed a decreasing trend. The liver cancer burden in 2021 was mainly caused due to hepatitis B, hepatitis C, and alcohol use. Differences in age patterns of liver cancer burden were observed, and the 5-year relative survival rates decreased by age with an overall rate of 12.27%, not far from the goal of 15% by 2030. <h3>Interpretation</h3> This study provides a comprehensive overview of the liver cancer burden in China across both sexes and underlying etiologies from 1990 to 2021. The incidence, prevalence, death and DALY attributed to liver cancer have shown an increasing trend, primarily driven by population aging, followed by population growth. In 2021, the burden of liver cancer was mainly caused due to hepatitis B, hepatitis C, alcohol use. The study also identified a dual pattern of liver cancer burden: a childhood peak with hepatoblastoma and an adulthood peak among the elderly. These insights into variations by sex, etiology and age enhance the national understanding of epidemiological changes in liver cancer burden. These findings could inform the development of more targeted strategies to address liver cancer in China.