Age-sex-specific burden of liver cancer attributable to risk factors in China and its provincial regions, 1990–2021, and forecasts with scenarios simulation: a systematic analysis for the Global Burden of Disease Study 2021

Abstract

Background

Liver cancer (LC) is a major global health issue, with China accounting for nearly half of global cases. Key contributors include chronic hepatitis B virus (HBV) infection, aflatoxin exposure, and modifiable lifestyle risk factors. With significant global implications, China's high LC incidence and mortality underscore the need for focused research.

Methods

This study analyses age- and sex-specific LC trends and risk factors across China's 34 provincial-level administrative regions using GBD 2021 data. LC metrics examined include incidence, prevalence, mortality, disability-adjusted life years (DALYs), years lived with disability (YLDs), and years of life lost(YLLs). We also examined the relationship between these metrics and gross-domestic-product-per-capita (GDPPC). An attentive deep-learning pipeline was developed to provide long-term scenario forecasts with scenarios simulation.

Findings

Between 1990 and 2021, LC incidence and prevalence in China escalated (except in Fujian, Shanghai, and Zhejiang), reaching 196,637 new cases and 265,539 total cases in 2021, predominantly affecting individuals aged 45+ years. In 2021, LC attributed to HBV recorded the highest age-standardised incidence rate (ASIR), whereas increases in ASIR were most pronounced for cases due to alcohol use and non-alcoholic steatohepatitis (NASH) from 1990-to-2021. The national age-standardised death rate (ASDR) declined from 10.8 to 8.4 per 100,000 from 1990 to 2021. Notably, hepatoblastoma showed the most significant drop in ASDR, plummeting by 79.7%, with subsequent declines in LC due to HBV, HCV, and alcohol use. Conversely, LC due to NASH saw a marginal increase of 0.8%. Trends in age-standardised DALYs, YLDs, and YLLs moderately mirrored those of the ASDR. Men, particularly those over 20 years old, faced higher LC burdens across all provincial regions compared to women. Provincially, the lowest LC burdens were observed in high-GDPPC regions, such as Beijing and Shanghai. In 2021, smoking emerged as the leading risk factor for LC-related mortality and disability in men, especially in HBV-associated cases. Men under 20 years displayed distinct patterns, with high alcohol use being the predominant fatal risk factor. For women, inappropriate drug use was the foremost risk factor for LC-related mortality and disability, especially in HCV-related cases. Without targeted interventions, forecasts from 2021 to 2040 predict declines in age-standardized LC rates: incidence by 9.5%, mortality by 4.7%, DALYs by 6.5%, YLLs by 4.3%, and YLDs by 13%. However, the incidence of LC due to alcohol use is expected to significantly increase among those under 20 years old in all provinces except Tibet, indicating a worrying trend towards younger onset. Targeted interventions, including tobacco control, appropriate medication use, alcohol use restriction, and regular physical activity, are projected to significantly reduce LC-attributed health losses in both sexes. Notably, reductions in mortality, DALYs, YLDs, and YLLs rates for LC in men are primarily expected through tobacco control; while in women, appropriate medication use will play the most critical role.

Interpretation

Our findings indicate a rapidly increasing LC burden, particularly for cases attributable to HBV, in China. The scenario-based forecasting model provides compelling evidence that can encourage national and provincial stakeholders to develop effective interventions tailored to their specific populations.