Hepatocellular carcinoma – the most common type of primary liver cancer – is the fifth most common cancer in men and the ninth most common in women worldwide. In 2012 there were approximately 782,000 new cases worldwide.
Liver cancer is the second most common cause of death from cancer worldwide, with an estimated 746,000 deaths in 2012. This is in part due to its high mortality/incidence ratio (0.95). The Global Burden of Disease study reported that in 2010 there were approximately 752,000 deaths due to liver cancer globally. While the number of liver cancer deaths increased by 62% from 1990 to 2010 (from 463,000), the age-standardised incidence rate increased by only 2%.
Around 83% of cases worldwide occur in less developed regions. Regions with high incidence include eastern and south-eastern Asia, northern and western Africa, and Melanesia and Micronesia/Polynesia (particularly in men). Rates are comparatively low in developed areas with the exception of southern Europe, where incidence in men is significantly higher than in other developed countries.
This geographical variation in the incidence of hepatocellular carcinoma is largely explained by the prevalence of the major risk factors - hepatitis C virus (HCV) and hepatitis B virus (HBV) infection - as explored in the Causes section of this chapter.
Liver cancer in Australia
Liver cancer incidence is relatively low in Australia compared with other regions of the world but is growing faster than that of any other cancer in Australia. Liver cancer is rarely detected early and as a consequence has a high mortality rate.
In Australia in 20113, 1,778 people were diagnosed with primary liver cancer. Hepatocellular carcinoma accounted for the majority of liver cancer cases, but Australian classifications of liver cancer include other tumours such as cholangiocarcinoma, hepatoblastoma and tumours without histological confirmation. Liver cancer caused 1,732 deaths (4% of cancer deaths) in Australia in 2014, elevating it to the top 10 causes of cancer deaths.
In Australia, age-standardised liver cancer incidence rates are highest in some overseas-born populations, particularly those from countries where HBV and HCV are endemic. Analysis of incidence in NSW shows liver cancer rates are higher in geographic areas that have a large overseas-born population, especially immigrants from southeastern and eastern Asia and middle and western Africa.
Compared with the non-Indigenous population, Indigenous Australians have a five to 10 times higher population-based incidence rate of hepatocellular carcinoma and are 12 times more likely to die of liver cancer. This reflects a higher burden of chronic liver disease in Australian Aboriginal populations, including high rates of chronic HBV infection.
While liver cancer is relatively uncommon in Australia, age-standardised rates have been steadily increasing over the past three decades. Incidence has increased from 1.8 cases per 100,000 people in 1982 to 6.9 cases per 100,000 in 2013.
Age-standardised liver cancer incidence – particularly hepatitis B related liver cancer – is expected to continue to rise over the next two decades. Incidence in Australia is projected to almost double by 2020, from 1,304 cases in 2008 to 2,465 in 2020. This continuing rise is attributed to a large number of asymptomatic people with chronic viral hepatitis, immigration from countries where hepatitis infection is prevalent and the slow disease progression from chronic hepatitis infection to liver cancer.
There is little data on the direct economic cost of liver cancer in Australia. Studies on the costs associated with HBV and HCV are generally not able to be compared due to different methodologies used, costs included and data sources. As such, the figures below for the economic costs associated with HBV and HCV in Australia are not comparable as study methodologies and inclusions differ.
In 2009-2010, Government spending on HBV and HCV agents through the Pharmaceutical Benefits Scheme amounted to almost $88 million. This figure represents Government spending on ten hepatitis drugs and does not include the patient co-payment portion for the included drugs.
In 2008, the direct costs of managing and treating people with HBV infection in Australia were estimated at $171.8 million. The direct costs of managing a patient with HBV includes all medical, hospital and allied health service and support service costs. Based on projections for chronic HBV infection, this evaluation estimated that the direct costs, under current practices, would increase to $308 million in 2017, representing an 80% increase. The average cost of managing each patient with chronic HBV infection and hepatocellular carcinoma was estimated at nearly $14,000 (without therapy) to about $19,000 (with therapy) .
In 2004-05 the estimated costs associated with HCV, including research, prevention, care and treatment, was $156 million. The cost of diagnosing and treating people with chronic HCV in 2004-05 was estimated at approximately $78.9 million, including all medical, hospital, laboratory and pharmaceutical costs. The average cost of treatment of each person with hepatitis C related hepatocellular carcinoma was estimated at $118,146.
- International Agency for Research on Cancer. GLOBOCAN 2012: estimated cancer incidence, mortality and prevalence worldwide in 2012. Lyon, France: IARC; 2013 Dec Available from: http://globocan.iarc.fr/.
- Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012 Dec 15;380(9859):2095-128 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23245604.
- Australian Institute of Health and Welfare. Cancer incidence projections: Australia, 2011 to 2020. Cancer Series no. 66. Cat. No. CAN 62. Canberra: AIHW; 2012.
- Australian Institute of Health and Welfare. Australian Cancer Incidence and Mortality (ACIM) books. [homepage on the internet] Canberra: AIHW; 2017 Feb 3 Available from: http://www.aihw.gov.au/acim-books/.
- Law MG, Roberts SK, Dore GJ, Kaldor JM. Primary hepatocellular carcinoma in Australia, 1978-1997: increasing incidence and mortality. Med J Aust 2000 Oct 16;173(8):403-5 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/11090031.
- Alam N, Chen W, Baker D, Bishop JF. Liver cancer in New South Wales. Sydney: Cancer Institute NSW; 2009 Feb Available from: http://www.cancerinstitute.org.au/media/24473/2009-02_liver_cancer_in_nsw.pdf.
- Wan X, Mathews JD. Primary hepatocellular carcinoma in aboriginal Australians. Aust J Public Health 1994 Sep;18(3):286-90 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/7841258.
- Cunningham J, Paradies Y. Mortality of Aboriginal and Torres Strait Islander Australians 1997. Canberra: Australian Bureau of Statistics; 1998. Report No.: ABS Occasional Paper 3315.0. Available from: http://www.abs.gov.au/ausstats/abs@.nsf/mediareleasesbytitle/83089DF98E4E6EE3CA2568C40004A466?OpenDocument.
- Fisher DA, Huffam SE. Management of chronic hepatitis B virus infection in remote-dwelling Aboriginals and Torres Strait Islanders: an update for primary healthcare providers. Med J Aust 2003 Jan 20;178(2):82-5 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/12526729.
- Nguyen VT, Razali K, Amin J, Law MG, Dore GJ. Estimates and projections of hepatitis B-related hepatocellular carcinoma in Australia among people born in Asia-Pacific countries. J Gastroenterol Hepatol 2008 Jun;23(6):922-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17608637.
- Infection in Endoscopy Study Group, Tawk HM, Vickery K, Bisset L, Lo SK, Selby W, et al. The current pattern of hepatitis B virus infection in Australia. J Viral Hepat 2006 Mar;13(3):206-15 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16475997.
- Dore G, Wallace J, Locarnini S, Desmond P, Gane E, Crawford D. Hepatitis B in Australia: responding to a diverse epidemic. Sydney: Australian Society for HIV Medicine; 2007 Available from: http://vhba.org.au/sites/default/files/Hep%20B%20in%20Australia%20-%20responding%20to%20a%20diverse%20epidemic.pdf.
- Pharmaceutical Benefits Pricing Authority. Pharmaceutical benefits pricing authority annual report for the year ended 30 June 2010. Canberra: Commonwealth of Australia; 2010 Available from: http://www.pbs.gov.au/industry/pricing/pbs-items/historical/pbpa-pdf/pbpa-annual-report-2010.pdf.
- Butler JRG, Korda RJ, Watson KJR, Watson DAR. The impact of chronic hepatitis B in Australia: projecting mortality, morbidity and economic impact. Canberra: Australian Centre for Economic Research on Health; 2009 Sep Available from: http://www.acerh.edu.au/publications/ACERH_RR7.pdf.
- Gadiel D, Powell M. Economic evaluation of hepatitis C in Australia. A report prepared for the Australian Government Department of Health and Ageing. Sydney: Applied Economics Pty Ltd; 2005 Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/B24AB78E97822CACCA2571CA0000E270/$File/hepc-econeval.pdf.