Striking Racial/Ethnic Disparities in Liver Cancer Incidence Rates and Temporal Trends in California, 1988–2012

Striking Racial/Ethnic Disparities in Liver Cancer Incidence Rates and Temporal Trends in... Abstract Background Hepatocellular carcinoma (HCC) is characterized by disparate risk patterns by race/ethnicity. We examined HCC incidence patterns and temporal trends among detailed racial/ethnic populations, including disaggregated Asian-American subgroups. Methods Using data from the population-based California Cancer Registry, we identified 41 929 invasive HCC cases diagnosed during 1988–2012. Patients were grouped into mutually exclusive racial/ethnic groups of non-Hispanic (NH) white, NH black, Hispanic, and NH Asian/Pacific Islander (API), as well as Asian subgroups of Chinese, Filipino, Japanese, Korean, Vietnamese, Cambodian, Laotian, and South Asian. Age-adjusted and age-specific incidence rates by sex, race/ethnicity, and time period were calculated. The average annual percent change (AAPC) in incidence rates was estimated using joinpoint regression. All estimates were provided with the 95% confidence intervals (CIs). Results Aggregated NH API had higher HCC risk than NH whites, NH blacks, and Hispanics. When disaggregated, Southeast Asians (Vietnamese, Cambodians, and Laotians) had overall HCC incidence rates eight to nine times higher than NH whites and more than twice that of other ethnic Asians. Statistically significant rising temporal trends of HCC were found in NH whites, NH blacks, and Hispanics, especially those older than age 50 years. Overall HCC risk declined in Chinese males (AAPC = –1.3%, 95% CI = –2.0 to –0.6), but rose in Filipino (AAPC = +1.2%, 95% CI = 0.3 to 2.1) and Japanese males (AAPC = +3.0%, 95% CI = 0.4 to 5.6) and Vietnamese (AAPC = +4.5%, 95% CI = 0.7 to 8.5) and Laotian (+3.4%, 95% CI = 0.1 to 6.8) females. Conclusions Our findings provide valuable information for the identification of at-risk ethnic subgroups of Asian Americans while underscoring the importance of disaggregating ethnic populations in cancer research. Primary liver cancer is the fifth most common malignancy in men and the seventh among women worldwide, resulting in liver cancer being the third leading cause of cancer mortality in men and sixth in women (1). The predominant primary liver malignancy (85%–90% of cases) is hepatocellular carcinoma (HCC) (2). Most HCC cases are associated with chronic liver disease and cirrhosis (3). The incidence of HCC varies throughout the world, with the highest incidence in Southeast Asia and Sub-Saharan Africa, where chronic infections by hepatitis B virus (HBV) and hepatitis C virus (HCV) are more prevalent (2,4). Chronic HBV and HCV infections increase HCC risk (2,4,5) and account for nearly 78% of all HCC cases (6). Effective vaccination has resulted in dramatic reduction in the prevalence of chronic HBV infection, and thus reduction of HCC incidence worldwide (7,8). Nonetheless, HCC remains a disproportionate burden affecting Asian Americans (9). Although constituting only 5.6% of the total population in the United States (10), Asian Americans account for more than 60% of the country’s chronic HBV infections (11). Despite being a generally lower-risk group for overall cancer incidence as compared with non-Hispanic (NH) whites (9,12), Asian Americans experience statistically significantly higher liver cancer risk, with a five-year survival rate of less than 10% (2,4,12,13). Asian Americans are the fastest-growing minority group in the United States (10), comprising a heterogeneous population from more than 60 different ethnic groups speaking more than 100 different languages (14), with substantial socioeconomic diversity (15). For instance, nearly 50% of Chinese-American adults have a Bachelor’s degree or higher, while 53% of Cambodian-American adults have less than a high school degree (16). The aggregated categories of “Asian” and “Asian and Pacific Islander” conflate these diverse socioeconomic and cultural backgrounds, producing information that is not helpful for understanding disease burden or developing targeted intervention strategies for any specific group (9–17). While a few studies in recent years examined liver cancer or HCC incidence rates among selected ethnic Asian subgroups (17–19), none provided detailed temporal trend assessments. In this study, we systematically examined HCC incidence patterns and temporal trends among aggregated and disaggregated racial/ethnic groups in California, including eight Asian-American subgroups. Our aims were to provide the needed information to identify specific targets for further reducing HCC burden in high-risk Asian Americans. Methods HCC Cases Data from the population-based California Cancer Registry (CCR) were used to examine invasive primary HCC cases diagnosed in California residents from 1988 to 2012. HCC was defined by the International Classification of Diseases for Oncology, 3rd Edition (ICD-O-3), site code C22.0 and histology codes 8160, 8162, 8170–8172, 8174–8175, 8180, and 8190. A total of 41 929 cases of invasive HCC were studied. Patients were classified by sex (male, female), age group (0–39, 40–49, 50–59, 60–69, and 70+ years), aggregated race/ethnicity (NH white, NH black, Hispanic, NH Asian/Pacific Islander [NH API], and disaggregated Asian subgroups of Chinese, Filipino, Japanese, Korean, Vietnamese, Cambodian, Laotian and South Asian [including Asian Indian, Pakistani, Sri Lankan, Bangladeshi, and other South Asian groups]), birthplace (US-born, foreign-born, or unknown/missing), and socioeconomic status (SES; 1 for low to 5 for high). Patient racial/ethnic information was routinely collected by cancer registrars based on information in their medical records. Hispanic and Asian ethnic identifications were enhanced by applying NHIA and NAPIIA algorithms developed by the North American Association of Central Cancer Registries (NAACCR) (20,21). Unknown or missing birthplaces were estimated using a published method based on social security numbers (21). Patient SES was estimated using an established area-based composite of multiple socioeconomic indicators from census sources, as previously published (22–24). Tumor stage was derived from registry-collected tumor information and categorized as localized, regional, distant, or unknown, as defined by the Surveillance, Epidemiology, and End Results (SEER) Program's Summary Stage (SS) schemes. SS 1977 version was used for cases diagnosed prior to 2001, and SS 2000 was used for subsequent diagnoses (22). The study period of 1988–2012 was divided into three segments: 1988–1995, 1996–2003, and 2004–2012, in order to have sufficient case counts for even the small ethnic populations. Rate estimates based on fewer than 10 cases were withheld from the tabular presentation but included in the graphs for better visualization. Annual Population Estimates We used the annual population estimates for the state of California released by the National Center for Health Statistics with the corresponding racial/ethnic categories of NH white, NH black, Hispanic, and NH API available for 1990–2012 (23). The 1990–2000 linear growth trends by sex, age, and race/ethnicity were extrapolated to obtain 1988–1989 population estimates. The annual population estimates for the Asian subgroups were developed by the CCR using the Asian ethnic-specific population counts from the 1990 STF2 and PUMS, 2000 SF2, and 2010 SF2 census files. Due to the multiracial scheme used in the 2000 and 2010 US census (24), population counts for each Asian subgroup by age and sex were represented by the simple average between the minimum and maximum population counts for each sex-age-ethnicity-specific combination in each census year. Annual population estimates for these Asian subgroups in California from 1988–2012 were obtained by linear interpolation of sex-age-specific population counts between census years 1990–2000 and 2000–2010, and extrapolation of the linear trend in the adjacent decade for 1988–1989 and 2011–2012. Statistical Analysis The percentages of HCC cases by demographic and tumor characteristics for each of the racial/ethnic groups were calculated for the entire study period. Tumor stage distribution was further examined by race/ethnicity and time period. Age-adjusted (2000 US standard) incidence rates (AAIRs) and age-specific incidence rates (ASIRs), along with the 95% confidence intervals (CIs), were calculated by sex, race/ethnicity, and time period. Male to female (M:F) rate ratios and 95% CIs were calculated using the sex-specific AAIRs by race/ethnicity. The average annual percent changes (AAPCs) in annual AAIRs and ASIRs by race/ethnicity and sex from 1988–2012 were estimated using the Joinpoint Regression Program (version 4.1.0, National Cancer Institute) to describe changes in incidence rates over time. AAPC is a weighted average of the segmented annual percent change (APC) over multiple time intervals and offers a valid summary measure for comparing rate changes across groups over the same period of time. The statistical significance of the AAPCs was tested at 95% confidence level based on a two-sided t distribution. Results Demographic Characteristics This analysis included 16 830 NH white, 3295 NH black, 10 634 Hispanic, and 11 170 aggregated NH API HCC patients. The disaggregated Asian ethnic groups comprised 3271 Chinese, 1708 Filipino, 789 Japanese, 1332 Korean, 243 South Asian, 2409 Vietnamese, 276 Cambodian, and 231 Laotian patients (Table 1). Table 1. Demographic and tumor characteristics of invasive HCC patients by race/ethnicity, California, 1988–2012* Characteristics NH white NH black Hispanic NH API Chinese Filipino Japanese Korean South Asian Vietnamese Cambodian Laotian (n = 16 830), % (n = 3295), % (n = 10 634), % (n = 11 170), % (n = 3271), % (n = 1708), % (n = 789), % (n = 1332), % (n = 243), % (n = 2409), % (n = 276), % (n = 231), % Sex  Male 76.1 75.2 73.7 72.3 74.9 74.0 43.5 68.2 71.6 77.3 76.8 79.2  Female 23.9 24.8 26.3 27.7 25.1 26.0 56.5 31.8 28.4 22.7 23.2 20.8 Age group, y  ≤39 1.7 2.2 2.1 4.1 4.6 3.9 0.3 2.6 2.1 4.6 5.8 12.6  40–49 7.2 9.6 11.2 10.2 9.8 9.4 3.7 12.0 4.1 9.8 20.3 13.4  50–59 26.6 33.6 29.1 22.2 19.2 20.5 15.6 24.8 23.9 25.2 33.0 26.0  60–69 27.8 32.4 28.2 27.9 27.3 23.4 33.1 30.9 34.2 29.1 25.7 28.1  70+ 36.7 22.2 29.4 35.5 39.1 42.8 47.4 29.7 35.8 31.3 15.2 19.9 Socioeconomic status  1 (low) 12.5 34.6 35.5 16.1 13.8 14.1 9.9 16.8 10.7 15.5 48.6 46.8  2 19.8 25.0 26.0 19.8 15.1 18.8 17.9 18.8 18.9 26.3 18.8 30.7  3 23.1 18.5 19.2 20.3 18.2 25.3 21.9 16.6 17.7 23.4 13.0 11.7  4 22.9 14.5 12.2 22.8 24.3 26.3 25.5 22.8 31.3 19.2 10.1 9.5  5 (high) 21.7 7.3 7.1 21.1 28.6 15.5 24.8 24.9 21.4 15.6 9.4 1.3 Immigrant status  US-born 85.1 88.5 53.9 9.3 8.7 7.4 35.1 2.5 7.0 2.4 1.4 2.2  Foreign-born 14.2 10.5 44.7 89.9 90.8 91.5 63.4 96.8 90.9 97.3 98.6 97.8  Unknown 0.7 1.0 1.4 0.7 0.6 1.1 1.5 0.7 2.1 0.3 0.0 0.0 Tumor stage  Localized 40.8 37.0 43.0 41.6 41.0 39.0 42.2 39.3 41.2 45.8 38.4 30.3  Regional 21.9 24.0 22.5 22.0 20.6 24.8 20.8 21.9 24.3 22.5 24.3 17.7  Distant 21.7 24.9 19.6 21.7 22.0 24.0 21.5 20.0 22.6 19.3 23.9 32.0  Unknown 15.7 14.1 14.9 14.7 16.4 12.2 15.5 18.7 11.9 12.5 13.4 19.9 Characteristics NH white NH black Hispanic NH API Chinese Filipino Japanese Korean South Asian Vietnamese Cambodian Laotian (n = 16 830), % (n = 3295), % (n = 10 634), % (n = 11 170), % (n = 3271), % (n = 1708), % (n = 789), % (n = 1332), % (n = 243), % (n = 2409), % (n = 276), % (n = 231), % Sex  Male 76.1 75.2 73.7 72.3 74.9 74.0 43.5 68.2 71.6 77.3 76.8 79.2  Female 23.9 24.8 26.3 27.7 25.1 26.0 56.5 31.8 28.4 22.7 23.2 20.8 Age group, y  ≤39 1.7 2.2 2.1 4.1 4.6 3.9 0.3 2.6 2.1 4.6 5.8 12.6  40–49 7.2 9.6 11.2 10.2 9.8 9.4 3.7 12.0 4.1 9.8 20.3 13.4  50–59 26.6 33.6 29.1 22.2 19.2 20.5 15.6 24.8 23.9 25.2 33.0 26.0  60–69 27.8 32.4 28.2 27.9 27.3 23.4 33.1 30.9 34.2 29.1 25.7 28.1  70+ 36.7 22.2 29.4 35.5 39.1 42.8 47.4 29.7 35.8 31.3 15.2 19.9 Socioeconomic status  1 (low) 12.5 34.6 35.5 16.1 13.8 14.1 9.9 16.8 10.7 15.5 48.6 46.8  2 19.8 25.0 26.0 19.8 15.1 18.8 17.9 18.8 18.9 26.3 18.8 30.7  3 23.1 18.5 19.2 20.3 18.2 25.3 21.9 16.6 17.7 23.4 13.0 11.7  4 22.9 14.5 12.2 22.8 24.3 26.3 25.5 22.8 31.3 19.2 10.1 9.5  5 (high) 21.7 7.3 7.1 21.1 28.6 15.5 24.8 24.9 21.4 15.6 9.4 1.3 Immigrant status  US-born 85.1 88.5 53.9 9.3 8.7 7.4 35.1 2.5 7.0 2.4 1.4 2.2  Foreign-born 14.2 10.5 44.7 89.9 90.8 91.5 63.4 96.8 90.9 97.3 98.6 97.8  Unknown 0.7 1.0 1.4 0.7 0.6 1.1 1.5 0.7 2.1 0.3 0.0 0.0 Tumor stage  Localized 40.8 37.0 43.0 41.6 41.0 39.0 42.2 39.3 41.2 45.8 38.4 30.3  Regional 21.9 24.0 22.5 22.0 20.6 24.8 20.8 21.9 24.3 22.5 24.3 17.7  Distant 21.7 24.9 19.6 21.7 22.0 24.0 21.5 20.0 22.6 19.3 23.9 32.0  Unknown 15.7 14.1 14.9 14.7 16.4 12.2 15.5 18.7 11.9 12.5 13.4 19.9 * API = Asian and Pacific Islander; HCC = hepatocellular carcinoma; NH = non-Hispanic. Table 1. Demographic and tumor characteristics of invasive HCC patients by race/ethnicity, California, 1988–2012* Characteristics NH white NH black Hispanic NH API Chinese Filipino Japanese Korean South Asian Vietnamese Cambodian Laotian (n = 16 830), % (n = 3295), % (n = 10 634), % (n = 11 170), % (n = 3271), % (n = 1708), % (n = 789), % (n = 1332), % (n = 243), % (n = 2409), % (n = 276), % (n = 231), % Sex  Male 76.1 75.2 73.7 72.3 74.9 74.0 43.5 68.2 71.6 77.3 76.8 79.2  Female 23.9 24.8 26.3 27.7 25.1 26.0 56.5 31.8 28.4 22.7 23.2 20.8 Age group, y  ≤39 1.7 2.2 2.1 4.1 4.6 3.9 0.3 2.6 2.1 4.6 5.8 12.6  40–49 7.2 9.6 11.2 10.2 9.8 9.4 3.7 12.0 4.1 9.8 20.3 13.4  50–59 26.6 33.6 29.1 22.2 19.2 20.5 15.6 24.8 23.9 25.2 33.0 26.0  60–69 27.8 32.4 28.2 27.9 27.3 23.4 33.1 30.9 34.2 29.1 25.7 28.1  70+ 36.7 22.2 29.4 35.5 39.1 42.8 47.4 29.7 35.8 31.3 15.2 19.9 Socioeconomic status  1 (low) 12.5 34.6 35.5 16.1 13.8 14.1 9.9 16.8 10.7 15.5 48.6 46.8  2 19.8 25.0 26.0 19.8 15.1 18.8 17.9 18.8 18.9 26.3 18.8 30.7  3 23.1 18.5 19.2 20.3 18.2 25.3 21.9 16.6 17.7 23.4 13.0 11.7  4 22.9 14.5 12.2 22.8 24.3 26.3 25.5 22.8 31.3 19.2 10.1 9.5  5 (high) 21.7 7.3 7.1 21.1 28.6 15.5 24.8 24.9 21.4 15.6 9.4 1.3 Immigrant status  US-born 85.1 88.5 53.9 9.3 8.7 7.4 35.1 2.5 7.0 2.4 1.4 2.2  Foreign-born 14.2 10.5 44.7 89.9 90.8 91.5 63.4 96.8 90.9 97.3 98.6 97.8  Unknown 0.7 1.0 1.4 0.7 0.6 1.1 1.5 0.7 2.1 0.3 0.0 0.0 Tumor stage  Localized 40.8 37.0 43.0 41.6 41.0 39.0 42.2 39.3 41.2 45.8 38.4 30.3  Regional 21.9 24.0 22.5 22.0 20.6 24.8 20.8 21.9 24.3 22.5 24.3 17.7  Distant 21.7 24.9 19.6 21.7 22.0 24.0 21.5 20.0 22.6 19.3 23.9 32.0  Unknown 15.7 14.1 14.9 14.7 16.4 12.2 15.5 18.7 11.9 12.5 13.4 19.9 Characteristics NH white NH black Hispanic NH API Chinese Filipino Japanese Korean South Asian Vietnamese Cambodian Laotian (n = 16 830), % (n = 3295), % (n = 10 634), % (n = 11 170), % (n = 3271), % (n = 1708), % (n = 789), % (n = 1332), % (n = 243), % (n = 2409), % (n = 276), % (n = 231), % Sex  Male 76.1 75.2 73.7 72.3 74.9 74.0 43.5 68.2 71.6 77.3 76.8 79.2  Female 23.9 24.8 26.3 27.7 25.1 26.0 56.5 31.8 28.4 22.7 23.2 20.8 Age group, y  ≤39 1.7 2.2 2.1 4.1 4.6 3.9 0.3 2.6 2.1 4.6 5.8 12.6  40–49 7.2 9.6 11.2 10.2 9.8 9.4 3.7 12.0 4.1 9.8 20.3 13.4  50–59 26.6 33.6 29.1 22.2 19.2 20.5 15.6 24.8 23.9 25.2 33.0 26.0  60–69 27.8 32.4 28.2 27.9 27.3 23.4 33.1 30.9 34.2 29.1 25.7 28.1  70+ 36.7 22.2 29.4 35.5 39.1 42.8 47.4 29.7 35.8 31.3 15.2 19.9 Socioeconomic status  1 (low) 12.5 34.6 35.5 16.1 13.8 14.1 9.9 16.8 10.7 15.5 48.6 46.8  2 19.8 25.0 26.0 19.8 15.1 18.8 17.9 18.8 18.9 26.3 18.8 30.7  3 23.1 18.5 19.2 20.3 18.2 25.3 21.9 16.6 17.7 23.4 13.0 11.7  4 22.9 14.5 12.2 22.8 24.3 26.3 25.5 22.8 31.3 19.2 10.1 9.5  5 (high) 21.7 7.3 7.1 21.1 28.6 15.5 24.8 24.9 21.4 15.6 9.4 1.3 Immigrant status  US-born 85.1 88.5 53.9 9.3 8.7 7.4 35.1 2.5 7.0 2.4 1.4 2.2  Foreign-born 14.2 10.5 44.7 89.9 90.8 91.5 63.4 96.8 90.9 97.3 98.6 97.8  Unknown 0.7 1.0 1.4 0.7 0.6 1.1 1.5 0.7 2.1 0.3 0.0 0.0 Tumor stage  Localized 40.8 37.0 43.0 41.6 41.0 39.0 42.2 39.3 41.2 45.8 38.4 30.3  Regional 21.9 24.0 22.5 22.0 20.6 24.8 20.8 21.9 24.3 22.5 24.3 17.7  Distant 21.7 24.9 19.6 21.7 22.0 24.0 21.5 20.0 22.6 19.3 23.9 32.0  Unknown 15.7 14.1 14.9 14.7 16.4 12.2 15.5 18.7 11.9 12.5 13.4 19.9 * API = Asian and Pacific Islander; HCC = hepatocellular carcinoma; NH = non-Hispanic. The demographic characteristics of HCC patients varied by race/ethnicity (Table 1). There were striking differences in the proportion of foreign-born patients among the various ethnic groups: 89.9% among NH APIs, 44.7% Hispanics, 10.5% NH blacks, and 14.2% NH whites. Among the Asian groups, only the Japanese had a proportion of foreign-born individuals below 90% (63.4%). The Japanese group also had the highest proportion of patients age 70 years and older (47.4%), which likely caused the higher percentage of female HCC patients (56.5%) among the Japanese due to the higher proportion of older females. Although the aggregated NH API group had a similar SES distribution to that of NH whites (who were more affluent than the Hispanic and NH black groups), there were substantial SES disparities among the Asian subgroups: 48.6% of Cambodians and 46.8% of Laotians were in the lowest SES category, compared with only 9.9% of Japanese and 10.7% of South Asians. Tumor Stage The distribution of disease stage at diagnosis by time period showed encouraging temporal trends, with substantial increases in the proportion of localized disease concomitant with decreases in distant disease across all racial/ethnic groups (Table 2). The percentage of localized stage was more than doubled from 1988–1995 to 2004–2012 for most of the groups examined. The percentage of unknown stage also decreased dramatically by more than 60% across groups. However, stage disparities still existed in the most recent period, with a low proportion of localized and a high proportion of distant stage disease found in Laotians (41.7% localized and 21.9% distant), Cambodians (42.6% vs 16.9%), South Asians (43.8% vs 19.4%), and NH blacks (44.0 vs 17.8%). Table 2. Tumor stage distribution by race/ethnicity and time period, invasive HCC, California, 1988–2012 Time period, % Temporal Race/ethnicity Stage 1988–1995 1996–2003 2004–2012 change* NH white Localized 25.3 37.6 47.4 87.6 Regional 11.6 16.9 27.7 138.3 Distant 32.7 27.0 15.3 −53.2 Unknown 30.3 18.5 9.5 −68.6 NH black Localized 21.8 30.8 44.0 101.9 Regional 9.8 20.5 29.6 201.4 Distant 38.7 31.7 17.8 −54.0 Unknown 29.7 17.0 8.6 −71.1 Hispanic Localized 24.0 38.1 48.6 102.7 Regional 10.8 17.4 26.7 147.3 Distant 30.9 25.4 15.1 −51.2 Unknown 34.4 19.0 9.6 −72.0 NH API Localized 24.9 37.7 49.7 99.9 Regional 12.6 17.9 27.6 118.8 Distant 32.7 28.3 13.9 −57.5 Unknown 29.8 16.1 8.8 −70.6 Chinese Localized 23.8 38.9 50.0 110.4 Regional 12.4 17.6 26.3 112.1 Distant 34.7 27.7 12.5 −63.9 Unknown 29.2 15.8 11.2 −61.6 Filipino Localized 25.7 36.0 45.5 76.8 Regional 14.3 20.0 31.4 119.8 Distant 33.3 30.1 17.1 −48.6 Unknown 26.7 13.9 6.0 −77.5 Japanese Localized 25.6 36.1 54.9 114.3 Regional 15.2 17.3 26.1 71.5 Distant 34.1 28.5 10.1 −70.5 Unknown 25.0 18.1 8.9 −64.4 Korean Localized 26.2 37.8 46.2 76.4 Regional 9.4 17.4 30.8 228.9 Distant 25.0 24.8 14.2 −43.3 Unknown 39.5 20.0 8.8 −77.6 South Asian Localized 20.7 44.4 43.8 111.5 Regional 17.2 13.0 29.4 70.4 Distant 20.7 33.3 19.4 −6.4 Unknown 41.4 9.3 7.5 −81.9 Vietnamese Localized 25.6 39.3 54.0 111.2 Regional 13.8 18.9 26.4 91.8 Distant 32.5 27.4 11.8 −63.7 Unknown 28.2 14.4 7.8 −72.4 Cambodian Localized 29.2 36.3 42.6 45.9 Regional 12.5 13.8 33.8 170.3 Distant 35.4 30.0 16.9 −52.3 Unknown 22.9 20.0 6.8 −70.5 Laotian Localized 17.0 25.6 41.7 145.4 Regional 7.5 15.9 25.0 231.3 Distant 34.0 42.7 21.9 −35.6 Unknown 41.5 15.9 11.5 −72.4 Time period, % Temporal Race/ethnicity Stage 1988–1995 1996–2003 2004–2012 change* NH white Localized 25.3 37.6 47.4 87.6 Regional 11.6 16.9 27.7 138.3 Distant 32.7 27.0 15.3 −53.2 Unknown 30.3 18.5 9.5 −68.6 NH black Localized 21.8 30.8 44.0 101.9 Regional 9.8 20.5 29.6 201.4 Distant 38.7 31.7 17.8 −54.0 Unknown 29.7 17.0 8.6 −71.1 Hispanic Localized 24.0 38.1 48.6 102.7 Regional 10.8 17.4 26.7 147.3 Distant 30.9 25.4 15.1 −51.2 Unknown 34.4 19.0 9.6 −72.0 NH API Localized 24.9 37.7 49.7 99.9 Regional 12.6 17.9 27.6 118.8 Distant 32.7 28.3 13.9 −57.5 Unknown 29.8 16.1 8.8 −70.6 Chinese Localized 23.8 38.9 50.0 110.4 Regional 12.4 17.6 26.3 112.1 Distant 34.7 27.7 12.5 −63.9 Unknown 29.2 15.8 11.2 −61.6 Filipino Localized 25.7 36.0 45.5 76.8 Regional 14.3 20.0 31.4 119.8 Distant 33.3 30.1 17.1 −48.6 Unknown 26.7 13.9 6.0 −77.5 Japanese Localized 25.6 36.1 54.9 114.3 Regional 15.2 17.3 26.1 71.5 Distant 34.1 28.5 10.1 −70.5 Unknown 25.0 18.1 8.9 −64.4 Korean Localized 26.2 37.8 46.2 76.4 Regional 9.4 17.4 30.8 228.9 Distant 25.0 24.8 14.2 −43.3 Unknown 39.5 20.0 8.8 −77.6 South Asian Localized 20.7 44.4 43.8 111.5 Regional 17.2 13.0 29.4 70.4 Distant 20.7 33.3 19.4 −6.4 Unknown 41.4 9.3 7.5 −81.9 Vietnamese Localized 25.6 39.3 54.0 111.2 Regional 13.8 18.9 26.4 91.8 Distant 32.5 27.4 11.8 −63.7 Unknown 28.2 14.4 7.8 −72.4 Cambodian Localized 29.2 36.3 42.6 45.9 Regional 12.5 13.8 33.8 170.3 Distant 35.4 30.0 16.9 −52.3 Unknown 22.9 20.0 6.8 −70.5 Laotian Localized 17.0 25.6 41.7 145.4 Regional 7.5 15.9 25.0 231.3 Distant 34.0 42.7 21.9 −35.6 Unknown 41.5 15.9 11.5 −72.4 * From 1988–1995 to 2004–2012. API = Asian and Pacific Islander; HCC = hepatocellular carcinoma; NH = non-Hispanic. Table 2. Tumor stage distribution by race/ethnicity and time period, invasive HCC, California, 1988–2012 Time period, % Temporal Race/ethnicity Stage 1988–1995 1996–2003 2004–2012 change* NH white Localized 25.3 37.6 47.4 87.6 Regional 11.6 16.9 27.7 138.3 Distant 32.7 27.0 15.3 −53.2 Unknown 30.3 18.5 9.5 −68.6 NH black Localized 21.8 30.8 44.0 101.9 Regional 9.8 20.5 29.6 201.4 Distant 38.7 31.7 17.8 −54.0 Unknown 29.7 17.0 8.6 −71.1 Hispanic Localized 24.0 38.1 48.6 102.7 Regional 10.8 17.4 26.7 147.3 Distant 30.9 25.4 15.1 −51.2 Unknown 34.4 19.0 9.6 −72.0 NH API Localized 24.9 37.7 49.7 99.9 Regional 12.6 17.9 27.6 118.8 Distant 32.7 28.3 13.9 −57.5 Unknown 29.8 16.1 8.8 −70.6 Chinese Localized 23.8 38.9 50.0 110.4 Regional 12.4 17.6 26.3 112.1 Distant 34.7 27.7 12.5 −63.9 Unknown 29.2 15.8 11.2 −61.6 Filipino Localized 25.7 36.0 45.5 76.8 Regional 14.3 20.0 31.4 119.8 Distant 33.3 30.1 17.1 −48.6 Unknown 26.7 13.9 6.0 −77.5 Japanese Localized 25.6 36.1 54.9 114.3 Regional 15.2 17.3 26.1 71.5 Distant 34.1 28.5 10.1 −70.5 Unknown 25.0 18.1 8.9 −64.4 Korean Localized 26.2 37.8 46.2 76.4 Regional 9.4 17.4 30.8 228.9 Distant 25.0 24.8 14.2 −43.3 Unknown 39.5 20.0 8.8 −77.6 South Asian Localized 20.7 44.4 43.8 111.5 Regional 17.2 13.0 29.4 70.4 Distant 20.7 33.3 19.4 −6.4 Unknown 41.4 9.3 7.5 −81.9 Vietnamese Localized 25.6 39.3 54.0 111.2 Regional 13.8 18.9 26.4 91.8 Distant 32.5 27.4 11.8 −63.7 Unknown 28.2 14.4 7.8 −72.4 Cambodian Localized 29.2 36.3 42.6 45.9 Regional 12.5 13.8 33.8 170.3 Distant 35.4 30.0 16.9 −52.3 Unknown 22.9 20.0 6.8 −70.5 Laotian Localized 17.0 25.6 41.7 145.4 Regional 7.5 15.9 25.0 231.3 Distant 34.0 42.7 21.9 −35.6 Unknown 41.5 15.9 11.5 −72.4 Time period, % Temporal Race/ethnicity Stage 1988–1995 1996–2003 2004–2012 change* NH white Localized 25.3 37.6 47.4 87.6 Regional 11.6 16.9 27.7 138.3 Distant 32.7 27.0 15.3 −53.2 Unknown 30.3 18.5 9.5 −68.6 NH black Localized 21.8 30.8 44.0 101.9 Regional 9.8 20.5 29.6 201.4 Distant 38.7 31.7 17.8 −54.0 Unknown 29.7 17.0 8.6 −71.1 Hispanic Localized 24.0 38.1 48.6 102.7 Regional 10.8 17.4 26.7 147.3 Distant 30.9 25.4 15.1 −51.2 Unknown 34.4 19.0 9.6 −72.0 NH API Localized 24.9 37.7 49.7 99.9 Regional 12.6 17.9 27.6 118.8 Distant 32.7 28.3 13.9 −57.5 Unknown 29.8 16.1 8.8 −70.6 Chinese Localized 23.8 38.9 50.0 110.4 Regional 12.4 17.6 26.3 112.1 Distant 34.7 27.7 12.5 −63.9 Unknown 29.2 15.8 11.2 −61.6 Filipino Localized 25.7 36.0 45.5 76.8 Regional 14.3 20.0 31.4 119.8 Distant 33.3 30.1 17.1 −48.6 Unknown 26.7 13.9 6.0 −77.5 Japanese Localized 25.6 36.1 54.9 114.3 Regional 15.2 17.3 26.1 71.5 Distant 34.1 28.5 10.1 −70.5 Unknown 25.0 18.1 8.9 −64.4 Korean Localized 26.2 37.8 46.2 76.4 Regional 9.4 17.4 30.8 228.9 Distant 25.0 24.8 14.2 −43.3 Unknown 39.5 20.0 8.8 −77.6 South Asian Localized 20.7 44.4 43.8 111.5 Regional 17.2 13.0 29.4 70.4 Distant 20.7 33.3 19.4 −6.4 Unknown 41.4 9.3 7.5 −81.9 Vietnamese Localized 25.6 39.3 54.0 111.2 Regional 13.8 18.9 26.4 91.8 Distant 32.5 27.4 11.8 −63.7 Unknown 28.2 14.4 7.8 −72.4 Cambodian Localized 29.2 36.3 42.6 45.9 Regional 12.5 13.8 33.8 170.3 Distant 35.4 30.0 16.9 −52.3 Unknown 22.9 20.0 6.8 −70.5 Laotian Localized 17.0 25.6 41.7 145.4 Regional 7.5 15.9 25.0 231.3 Distant 34.0 42.7 21.9 −35.6 Unknown 41.5 15.9 11.5 −72.4 * From 1988–1995 to 2004–2012. API = Asian and Pacific Islander; HCC = hepatocellular carcinoma; NH = non-Hispanic. Age-Adjusted Incidence Rates The AAIR per 100 000 was highest among aggregated NH APIs in both males (20.6, 95% CI = 20.1 to 21.1) and females (6.7, 95% CI = 6.5 to 6.9), followed by Hispanics (12.9, 95% CI = 12.6 to 13.2, in males; 4.2, 95% CI = 4.0 to 4.4, in females), NH blacks (11.9, 95% CI = 11.4 to 12.4, in males; 3.3, 95% CI = 3.1 to 3.6, in females), and NH whites (5.7, 95% CI = 5.6 to 5.8, in males; 1.5, 95% CI = 1.5 to 1.5, in females) (Table 3, Figure 1). However, AAIRs among the Asian subgroups were far more disparate, with the highest in Vietnamese (47.3, 95% CI = 45.0 to 49.6, in males; 14.4, 95% CI = 13.2 to 15.7, in females), Laotians (45.6, 95% CI = 38.4 to 52.7, in males; 12.3, 95% CI = 8.6 to 16.0, in females), and Cambodians (42.8, 95% CI = 36.3 to 49.3, in males; 11.7, 95% CI = 8.6 to 14.8, in females); the lowest in South Asians (6.7, 95% CI = 5.6 to 7.9, in males; 2.8, 95% CI = 2.1 to 3.5, in females) and Japanese (8.1, 95% CI = 7.2 to 8.9, in males; 6.8, 95% CI = 6.2 to 7.4, in females). When disaggregated, Southeast Asians (Vietnamese, Laotian, Cambodian) had an HCC risk eight to nine times higher than that of NH whites and more than twice that of other ethnic Asians. The M:F ratios of AAIRs indicated that for most of the racial/ethnic populations examined, men had more than 3 times the risk of developing HCC as women (Figure 2). Some Asian ethnic groups exhibited lower M:F rate ratios, including Japanese (2.2, 95% CI = 1.8 to 2.7), South Asians (2.4, 95% CI = 1.8 to 3.3), and Koreans (2.6, 95% CI = 2.3 to 3.0). Table 3. Average annual age-specific incidence rate and age-adjusted incidence rate per 100 000 population by sex, race/ethnicity with average annual percent change in rates, invasive HCC, California, 1988–2012 Race/ethnicity Age ≤ 39 y Age 40–49 y Age 50–59 y Age 60–69 y Age 70+ y All ages ASIR Cases ASIR Cases ASIR Cases ASIR Cases ASIR Cases AAIR Cases Males  NH white 0.2 (0.1 to 0.2) 177 3.1 (2.9 to 3.2) 981 14.6 (14.1 to 15.0) 3776 20.1 (19.5 to 20.8) 3702 22.3 (21.6 to 22.9) 4171 5.7 (5.6 to 5.8) 12 807 AAPC 1.4 (−0.4 to 3.3) 5.1 (2.6 to 7.6)* 9.8 (8.8 to 10.9)* 5.3 (4.5 to 6.1)* 3.0 (2.7 to 3.4)* 5.3 (4.9 to 5.6)*  NH black 0.3 (0.2 to 0.3) 48 6.4 (5.6 to 7.2) 250 32.5 (30.4 to 34.7) 886 50.1 (46.6 to 53.5) 816 39.4 (35.9 to 42.9) 479 11.9 (11.4 to 12.4) 2479 AAPC 0.4 (−3.5 to 4.5) 0.8 (−1.5 to 3.1) 7.4 (5.7 to 9.1)* 5.4 (3.9 to 6.9)* 2.8 (0.6 to 5.0)* 4.6 (3.8 to 5.5)*  Hispanic 0.1 (0.1 to 0.2) 144 6.5 (6.1 to 6.9) 1037 28.6 (27.5 to 29.7) 2579 45.9 (44.0 to 47.8) 2173 56.9 (54.3 to 59.4) 1907 12.9 (12.6 to 13.2) 7840 AAPC −1.3 (−3.2 to 0.8) 5.5 (3.4 to 7.6)* 6.7 (6.0 to 7.3)* 4.3 (3.4 to 5.2)* 4.0 (3.2 to 4.8)* 4.7 (4.1 to 5.2)*  NH API 1.2 (1.1 to 1.4) 375 13.6 (12.7 to 14.4) 958 40.3 (38.5 to 42.0) 2060 69.6 (66.7 to 72.5) 2226 89.9 (86.4 to 93.5) 2453 20.6 (20.1 to 21.1) 8072 AAPC −2.0 (−3.4 to –0.6)* −0.3 (−1.7 to 1.1) 0.6 (−0.2 to 1.5) 0.4 (−0.6 to 1.4) 1.3 (0.6 to 2.0)* 0.5 (0.0 to 1.1)*  Chinese 1.8 (1.5 to 2.1) 128 13.9 (12.2 to 15.6) 263 36.4 (33.3 to 39.5) 528 70.4 (65.1 to 75.7) 678 93.5 (87.2 to 99.8) 854 20.8 (20.0 to 21.6) 2451 AAPC −2.3 (−4.6 to 0.1) −1.7 (−3.4 to 0.1) −0.9 (−2.4 to 0.6) −1.7 (−3.0 to – 0.4)* −0.6 (−1.5 to 0.4) −1.3 (−2.0 to –0.6)*  Filipino 0.7 (0.5 to 0.9) 54 8.0 (6.6 to 9.4) 134 23.5 (20.8 to 26.1) 298 37.6 (33.4 to 41.8) 303 69.9 (63.6 to 76.2) 475 13.5 (12.8 to 14.3) 1264 AAPC −4.4 (−7.3 to –1.5)* −0.5 (−3.7 to 2.9) 3.0 (0.1 to 5.9)* 0.3 (−1.4 to 2.2) 1.9 (0.5 to 3.4)* 1.2 (0.3 to 2.1)*  Japanese — — 3.9 (2.3 to 5.4) 23 17.2 (13.4 to 21.0) 79 28.4 (22.8 to 34.0) 98 37.7 (31.5 to 43.9) 142 8.1 (7.2 to 8.9) 343 AAPC — — 0.1 (−3.4 to 3.7) 3.5 (0.0 to 7.0)* 2.3 (−0.6 to 5.3) 3.0 (0.4 to 5.6)*  Korean 0.8 (0.4 to 1.1) 20 20.2 (16.7 to 23.7) 127 55.7 (49.0 to 62.4) 264 98.2 (86.8 to 109.5) 288 98.7 (85.3 to 112.1) 209 26.1 (24.3 to 27.9) 908 AAPC −2.7 (−5.9 to 0.6) −1.8 (−4.6 to 1.2) −1 (−2.8 to 0.8) −1.8 (−4.0 to 0.5) 0.5 (−2.1 to 3.2) −0.5 (−1.8 to 0.7)  South Asian — — — — 8.8 (6.1 to 11.5) 41 22.9 (17.2 to 28.6) 61 37.2 (27.7 to 46.7) 59 6.7 (5.6 to 7.9) 174 AAPC — — — — — 1.8 (−1.6 to 5.2)  Vietnamese 2.6 (2.1 to 3.1) 96 26.6 (23.1 to 30.1) 218 93.6 (85.6 to 101.6) 524 160.8 (147.1 to 174.5) 531 215.9 (196.9 to 234.9 494 47.3 (45.0 to 49.6) 1863 AAPC −1.0 (−4.0 to 2.2) −1.1 (−3.5 to 1.4) 1.9 (0.1 to 3.8)* 1.1 (−0.8 to 3.1) 0.8 (−1.2 to 2.8) 0.3 (−0.8 to 1.4)  Cambodian 2.0 (1.0 to 3.1) 14 45.6 (32.5 to 58.8) 46 106.5 (82.2 to 130.8) 74 138.8 (101.1 to 176.5) 52 114.4 (70.4 to 158.3) 26 42.8 (36.3 to 49.3) 212 AAPC — — −0.7 (−3.4 to 1.9) — — 2.4 (−0.8 to 5.7)  Laotian 4.2 (2.5 to 5.9) 23 29.8 (17.9 to 41.7) 24 101.8 (74.9 to 128.7) 55 159.5 (113.9 to 205.1) 47 174.4 (115.8 to 233.1) 34 45.6 (38.4 to 52.7) 183 AAPC — — −1.6 (−4.6 to 1.5) — — −0.4 (−2.7 to 1.9) Females  NH white 0.1 (0.1 to 0.1) 104 0.8 (0.7 to 0.9) 236 2.7 (2.5 to 2.9) 693 4.9 (4.6 to 5.2) 980 7.4 (7.1 to 7.7) 2010 1.5 (1.5 to 1.5) 4023 AAPC −0.1 (−2.7 to 2.6) 2.2 (0.4 to 3.9)* 6.0 (4.3 to 7.8)* 3.9 (2.6 to 5.2)* 3.5 (2.8 to 4.3)* 3.8 (3.3 to 4.3)*  NH black 0.1 (0.1 to 0.2) 26 1.6 (1.2 to 2.0) 65 7.5 (6.5 to 8.5) 221 13.0 (11.4 to 14.6) 252 13.2 (11.5 to 14.8) 252 3.3 (3.1 to 3.6) 816 AAPC −1.7 (−4.5 to 1.1) 0.4 (−3.0 to 3.8) 7.3 (4.7 to 10.0)* 5.3 (2.8 to 7.9)* 1.6 (−0.2 to 3.4) 3.5 (2.6 to 4.4)*  Hispanic 0.1 (0.1 to 0.1) 84 1.0 (0.8 to 1.1) 149 5.4 (4.9 to 5.9) 515 14.8 (13.8 to 15.8) 831 24.8 (23.4 to 26.2) 1215 4.2 (4.0 to 4.4) 2794 AAPC 0.9 (−1.9 to 3.8) 1.4 (−1.8 to 4.7) 5.8 (3.9 to 7.7)* 4.7 (3.0 to 6.5)* 3.7 (2.3 to 5.2)* 4.0 (3.1 to 4.8)*  NH API 0.3 (0.2 to 0.3) 80 2.3 (1.9 to 2.6) 183 7.1 (6.4 to 7.8) 423 22.5 (21.0 to 23.9) 895 40.9 (38.9 to 43.0) 1517 6.7 (6.5 to 6.9) 3098 AAPC 0.5 (−2.1 to 3.2) 0.0 (−2.5 to 2.6) −1.8 (−3.3 to –0.3)* 0.3 (−1.5 to 2.1) 2.3 (1.1 to 3.6)* 0.8 (0.1 to 1.5)*  Chinese 0.3 (0.2 to 0.4) 21 2.7 (2.0 to 3.3) 59 6.0 (4.8 to 7.2) 99 19.4 (16.8 to 22.0) 215 37.4 (33.9 to 41.0) 426 6.2 (5.7 to 6.6) 820 AAPC — −3.0 (−6.2 to 0.3) −1.3 (−4.6 to 2.1) 0.0 (−2.2 to 2.3) 1.4 (−0.5 to 3.3) 0.8 (−0.4 to 1.9)  Filipino 0.2 (0.1 to 0.2) 12 1.3 (0.8 to 1.7) 27 3.1 (2.2 to 3.9) 52 8.4 (6.8 to 10.1) 97 26.3 (23.1 to 29.5) 256 3.7 (3.3 to 4.0) 444 AAPC — — −3.4 (−6.1 to –0.6)* −1.7 (−5.4 to 2.2) 2.3 (−0.4 to 5) 1.1 (−1.1 to 3.3)  Japanese — — — — 7.5 (5.3 to 9.7) 44 31.5 (26.7 to 36.4) 163 38.2 (33.3 to 43.2) 232 6.8 (6.2 to 7.4) 446 AAPC — — — −6.5 (−10.1 to –2.8)* 6.5 (3.9 to 9.1)* 1.0 (−0.7 to 2.8)  Korean 0.5 (0.3 to 0.8) 15 4.2 (2.7 to 5.6) 33 11.4 (8.6 to 14.1) 66 33.2 (27.3 to 39.0) 124 58.4 (50.0 to 66.7) 186 10.0 (9.0 to 11.0) 424 AAPC — — −4.4 (−7.4 to –1.3)* −2.6 (−5.9 to 0.9) 0.3 (−2.2 to 3.0) −0.9 (−2.8 to 1.1)  South Asian — — — — 4.3 (2.3 to 6.4) 17 8.8 (5.1 to 12.5) 22 16.6 (10.5 to 22.7) 28 2.8 (2.1 to 3.5) 69 AAPC — — — — — 0.6 (−2.9 to 4.1)  Vietnamese 0.4 (0.2 to 0.6) 14 2.3 (1.2 to 3.3) 19 13.7 (10.7 to 16.7) 82 48.3 (41.1 to 55.6) 170 95.5 (83.9 to 107.1) 261 14.4 (13.2 to 15.7) 546 AAPC — — −3.6 (−6.4 to –0.7)* 1.3 (−1.9 to 4.6) 2.6 (0.1 to 5.2)* 4.5 (0.7 to 8.5)*  Cambodian — — 8.5 (3.2 to 13.8) 10 20.8 (10.9 to 30.7) 17 43.4 (23.9 to 62.9) 19 47.7 (24.3 to 71.1) 16 11.7 (8.6 to 14.8) 64 AAPC — — — — — 0.2 (−3.0 to 3.6)  Laotian — — — — — — 62.3 (33.5 to 91.1) 18 49.2 (21.4 to 77.0) 12 12.3 (8.6 to 16.0) 48 AAPC — — — — — 3.4 (0.1 to 6.8)* Race/ethnicity Age ≤ 39 y Age 40–49 y Age 50–59 y Age 60–69 y Age 70+ y All ages ASIR Cases ASIR Cases ASIR Cases ASIR Cases ASIR Cases AAIR Cases Males  NH white 0.2 (0.1 to 0.2) 177 3.1 (2.9 to 3.2) 981 14.6 (14.1 to 15.0) 3776 20.1 (19.5 to 20.8) 3702 22.3 (21.6 to 22.9) 4171 5.7 (5.6 to 5.8) 12 807 AAPC 1.4 (−0.4 to 3.3) 5.1 (2.6 to 7.6)* 9.8 (8.8 to 10.9)* 5.3 (4.5 to 6.1)* 3.0 (2.7 to 3.4)* 5.3 (4.9 to 5.6)*  NH black 0.3 (0.2 to 0.3) 48 6.4 (5.6 to 7.2) 250 32.5 (30.4 to 34.7) 886 50.1 (46.6 to 53.5) 816 39.4 (35.9 to 42.9) 479 11.9 (11.4 to 12.4) 2479 AAPC 0.4 (−3.5 to 4.5) 0.8 (−1.5 to 3.1) 7.4 (5.7 to 9.1)* 5.4 (3.9 to 6.9)* 2.8 (0.6 to 5.0)* 4.6 (3.8 to 5.5)*  Hispanic 0.1 (0.1 to 0.2) 144 6.5 (6.1 to 6.9) 1037 28.6 (27.5 to 29.7) 2579 45.9 (44.0 to 47.8) 2173 56.9 (54.3 to 59.4) 1907 12.9 (12.6 to 13.2) 7840 AAPC −1.3 (−3.2 to 0.8) 5.5 (3.4 to 7.6)* 6.7 (6.0 to 7.3)* 4.3 (3.4 to 5.2)* 4.0 (3.2 to 4.8)* 4.7 (4.1 to 5.2)*  NH API 1.2 (1.1 to 1.4) 375 13.6 (12.7 to 14.4) 958 40.3 (38.5 to 42.0) 2060 69.6 (66.7 to 72.5) 2226 89.9 (86.4 to 93.5) 2453 20.6 (20.1 to 21.1) 8072 AAPC −2.0 (−3.4 to –0.6)* −0.3 (−1.7 to 1.1) 0.6 (−0.2 to 1.5) 0.4 (−0.6 to 1.4) 1.3 (0.6 to 2.0)* 0.5 (0.0 to 1.1)*  Chinese 1.8 (1.5 to 2.1) 128 13.9 (12.2 to 15.6) 263 36.4 (33.3 to 39.5) 528 70.4 (65.1 to 75.7) 678 93.5 (87.2 to 99.8) 854 20.8 (20.0 to 21.6) 2451 AAPC −2.3 (−4.6 to 0.1) −1.7 (−3.4 to 0.1) −0.9 (−2.4 to 0.6) −1.7 (−3.0 to – 0.4)* −0.6 (−1.5 to 0.4) −1.3 (−2.0 to –0.6)*  Filipino 0.7 (0.5 to 0.9) 54 8.0 (6.6 to 9.4) 134 23.5 (20.8 to 26.1) 298 37.6 (33.4 to 41.8) 303 69.9 (63.6 to 76.2) 475 13.5 (12.8 to 14.3) 1264 AAPC −4.4 (−7.3 to –1.5)* −0.5 (−3.7 to 2.9) 3.0 (0.1 to 5.9)* 0.3 (−1.4 to 2.2) 1.9 (0.5 to 3.4)* 1.2 (0.3 to 2.1)*  Japanese — — 3.9 (2.3 to 5.4) 23 17.2 (13.4 to 21.0) 79 28.4 (22.8 to 34.0) 98 37.7 (31.5 to 43.9) 142 8.1 (7.2 to 8.9) 343 AAPC — — 0.1 (−3.4 to 3.7) 3.5 (0.0 to 7.0)* 2.3 (−0.6 to 5.3) 3.0 (0.4 to 5.6)*  Korean 0.8 (0.4 to 1.1) 20 20.2 (16.7 to 23.7) 127 55.7 (49.0 to 62.4) 264 98.2 (86.8 to 109.5) 288 98.7 (85.3 to 112.1) 209 26.1 (24.3 to 27.9) 908 AAPC −2.7 (−5.9 to 0.6) −1.8 (−4.6 to 1.2) −1 (−2.8 to 0.8) −1.8 (−4.0 to 0.5) 0.5 (−2.1 to 3.2) −0.5 (−1.8 to 0.7)  South Asian — — — — 8.8 (6.1 to 11.5) 41 22.9 (17.2 to 28.6) 61 37.2 (27.7 to 46.7) 59 6.7 (5.6 to 7.9) 174 AAPC — — — — — 1.8 (−1.6 to 5.2)  Vietnamese 2.6 (2.1 to 3.1) 96 26.6 (23.1 to 30.1) 218 93.6 (85.6 to 101.6) 524 160.8 (147.1 to 174.5) 531 215.9 (196.9 to 234.9 494 47.3 (45.0 to 49.6) 1863 AAPC −1.0 (−4.0 to 2.2) −1.1 (−3.5 to 1.4) 1.9 (0.1 to 3.8)* 1.1 (−0.8 to 3.1) 0.8 (−1.2 to 2.8) 0.3 (−0.8 to 1.4)  Cambodian 2.0 (1.0 to 3.1) 14 45.6 (32.5 to 58.8) 46 106.5 (82.2 to 130.8) 74 138.8 (101.1 to 176.5) 52 114.4 (70.4 to 158.3) 26 42.8 (36.3 to 49.3) 212 AAPC — — −0.7 (−3.4 to 1.9) — — 2.4 (−0.8 to 5.7)  Laotian 4.2 (2.5 to 5.9) 23 29.8 (17.9 to 41.7) 24 101.8 (74.9 to 128.7) 55 159.5 (113.9 to 205.1) 47 174.4 (115.8 to 233.1) 34 45.6 (38.4 to 52.7) 183 AAPC — — −1.6 (−4.6 to 1.5) — — −0.4 (−2.7 to 1.9) Females  NH white 0.1 (0.1 to 0.1) 104 0.8 (0.7 to 0.9) 236 2.7 (2.5 to 2.9) 693 4.9 (4.6 to 5.2) 980 7.4 (7.1 to 7.7) 2010 1.5 (1.5 to 1.5) 4023 AAPC −0.1 (−2.7 to 2.6) 2.2 (0.4 to 3.9)* 6.0 (4.3 to 7.8)* 3.9 (2.6 to 5.2)* 3.5 (2.8 to 4.3)* 3.8 (3.3 to 4.3)*  NH black 0.1 (0.1 to 0.2) 26 1.6 (1.2 to 2.0) 65 7.5 (6.5 to 8.5) 221 13.0 (11.4 to 14.6) 252 13.2 (11.5 to 14.8) 252 3.3 (3.1 to 3.6) 816 AAPC −1.7 (−4.5 to 1.1) 0.4 (−3.0 to 3.8) 7.3 (4.7 to 10.0)* 5.3 (2.8 to 7.9)* 1.6 (−0.2 to 3.4) 3.5 (2.6 to 4.4)*  Hispanic 0.1 (0.1 to 0.1) 84 1.0 (0.8 to 1.1) 149 5.4 (4.9 to 5.9) 515 14.8 (13.8 to 15.8) 831 24.8 (23.4 to 26.2) 1215 4.2 (4.0 to 4.4) 2794 AAPC 0.9 (−1.9 to 3.8) 1.4 (−1.8 to 4.7) 5.8 (3.9 to 7.7)* 4.7 (3.0 to 6.5)* 3.7 (2.3 to 5.2)* 4.0 (3.1 to 4.8)*  NH API 0.3 (0.2 to 0.3) 80 2.3 (1.9 to 2.6) 183 7.1 (6.4 to 7.8) 423 22.5 (21.0 to 23.9) 895 40.9 (38.9 to 43.0) 1517 6.7 (6.5 to 6.9) 3098 AAPC 0.5 (−2.1 to 3.2) 0.0 (−2.5 to 2.6) −1.8 (−3.3 to –0.3)* 0.3 (−1.5 to 2.1) 2.3 (1.1 to 3.6)* 0.8 (0.1 to 1.5)*  Chinese 0.3 (0.2 to 0.4) 21 2.7 (2.0 to 3.3) 59 6.0 (4.8 to 7.2) 99 19.4 (16.8 to 22.0) 215 37.4 (33.9 to 41.0) 426 6.2 (5.7 to 6.6) 820 AAPC — −3.0 (−6.2 to 0.3) −1.3 (−4.6 to 2.1) 0.0 (−2.2 to 2.3) 1.4 (−0.5 to 3.3) 0.8 (−0.4 to 1.9)  Filipino 0.2 (0.1 to 0.2) 12 1.3 (0.8 to 1.7) 27 3.1 (2.2 to 3.9) 52 8.4 (6.8 to 10.1) 97 26.3 (23.1 to 29.5) 256 3.7 (3.3 to 4.0) 444 AAPC — — −3.4 (−6.1 to –0.6)* −1.7 (−5.4 to 2.2) 2.3 (−0.4 to 5) 1.1 (−1.1 to 3.3)  Japanese — — — — 7.5 (5.3 to 9.7) 44 31.5 (26.7 to 36.4) 163 38.2 (33.3 to 43.2) 232 6.8 (6.2 to 7.4) 446 AAPC — — — −6.5 (−10.1 to –2.8)* 6.5 (3.9 to 9.1)* 1.0 (−0.7 to 2.8)  Korean 0.5 (0.3 to 0.8) 15 4.2 (2.7 to 5.6) 33 11.4 (8.6 to 14.1) 66 33.2 (27.3 to 39.0) 124 58.4 (50.0 to 66.7) 186 10.0 (9.0 to 11.0) 424 AAPC — — −4.4 (−7.4 to –1.3)* −2.6 (−5.9 to 0.9) 0.3 (−2.2 to 3.0) −0.9 (−2.8 to 1.1)  South Asian — — — — 4.3 (2.3 to 6.4) 17 8.8 (5.1 to 12.5) 22 16.6 (10.5 to 22.7) 28 2.8 (2.1 to 3.5) 69 AAPC — — — — — 0.6 (−2.9 to 4.1)  Vietnamese 0.4 (0.2 to 0.6) 14 2.3 (1.2 to 3.3) 19 13.7 (10.7 to 16.7) 82 48.3 (41.1 to 55.6) 170 95.5 (83.9 to 107.1) 261 14.4 (13.2 to 15.7) 546 AAPC — — −3.6 (−6.4 to –0.7)* 1.3 (−1.9 to 4.6) 2.6 (0.1 to 5.2)* 4.5 (0.7 to 8.5)*  Cambodian — — 8.5 (3.2 to 13.8) 10 20.8 (10.9 to 30.7) 17 43.4 (23.9 to 62.9) 19 47.7 (24.3 to 71.1) 16 11.7 (8.6 to 14.8) 64 AAPC — — — — — 0.2 (−3.0 to 3.6)  Laotian — — — — — — 62.3 (33.5 to 91.1) 18 49.2 (21.4 to 77.0) 12 12.3 (8.6 to 16.0) 48 AAPC — — — — — 3.4 (0.1 to 6.8)* * Indicates statistical significance at 95% confidence level. — = data withheld if based on less than 10 cases; AAIR = age-adjusted incidence rate; AAPC = average annual percent change; API = Asian and Pacific Islander; ASIR = age-specific incidence rate; HCC = hepatocellular carcinoma; NH = non-Hispanic. Table 3. Average annual age-specific incidence rate and age-adjusted incidence rate per 100 000 population by sex, race/ethnicity with average annual percent change in rates, invasive HCC, California, 1988–2012 Race/ethnicity Age ≤ 39 y Age 40–49 y Age 50–59 y Age 60–69 y Age 70+ y All ages ASIR Cases ASIR Cases ASIR Cases ASIR Cases ASIR Cases AAIR Cases Males  NH white 0.2 (0.1 to 0.2) 177 3.1 (2.9 to 3.2) 981 14.6 (14.1 to 15.0) 3776 20.1 (19.5 to 20.8) 3702 22.3 (21.6 to 22.9) 4171 5.7 (5.6 to 5.8) 12 807 AAPC 1.4 (−0.4 to 3.3) 5.1 (2.6 to 7.6)* 9.8 (8.8 to 10.9)* 5.3 (4.5 to 6.1)* 3.0 (2.7 to 3.4)* 5.3 (4.9 to 5.6)*  NH black 0.3 (0.2 to 0.3) 48 6.4 (5.6 to 7.2) 250 32.5 (30.4 to 34.7) 886 50.1 (46.6 to 53.5) 816 39.4 (35.9 to 42.9) 479 11.9 (11.4 to 12.4) 2479 AAPC 0.4 (−3.5 to 4.5) 0.8 (−1.5 to 3.1) 7.4 (5.7 to 9.1)* 5.4 (3.9 to 6.9)* 2.8 (0.6 to 5.0)* 4.6 (3.8 to 5.5)*  Hispanic 0.1 (0.1 to 0.2) 144 6.5 (6.1 to 6.9) 1037 28.6 (27.5 to 29.7) 2579 45.9 (44.0 to 47.8) 2173 56.9 (54.3 to 59.4) 1907 12.9 (12.6 to 13.2) 7840 AAPC −1.3 (−3.2 to 0.8) 5.5 (3.4 to 7.6)* 6.7 (6.0 to 7.3)* 4.3 (3.4 to 5.2)* 4.0 (3.2 to 4.8)* 4.7 (4.1 to 5.2)*  NH API 1.2 (1.1 to 1.4) 375 13.6 (12.7 to 14.4) 958 40.3 (38.5 to 42.0) 2060 69.6 (66.7 to 72.5) 2226 89.9 (86.4 to 93.5) 2453 20.6 (20.1 to 21.1) 8072 AAPC −2.0 (−3.4 to –0.6)* −0.3 (−1.7 to 1.1) 0.6 (−0.2 to 1.5) 0.4 (−0.6 to 1.4) 1.3 (0.6 to 2.0)* 0.5 (0.0 to 1.1)*  Chinese 1.8 (1.5 to 2.1) 128 13.9 (12.2 to 15.6) 263 36.4 (33.3 to 39.5) 528 70.4 (65.1 to 75.7) 678 93.5 (87.2 to 99.8) 854 20.8 (20.0 to 21.6) 2451 AAPC −2.3 (−4.6 to 0.1) −1.7 (−3.4 to 0.1) −0.9 (−2.4 to 0.6) −1.7 (−3.0 to – 0.4)* −0.6 (−1.5 to 0.4) −1.3 (−2.0 to –0.6)*  Filipino 0.7 (0.5 to 0.9) 54 8.0 (6.6 to 9.4) 134 23.5 (20.8 to 26.1) 298 37.6 (33.4 to 41.8) 303 69.9 (63.6 to 76.2) 475 13.5 (12.8 to 14.3) 1264 AAPC −4.4 (−7.3 to –1.5)* −0.5 (−3.7 to 2.9) 3.0 (0.1 to 5.9)* 0.3 (−1.4 to 2.2) 1.9 (0.5 to 3.4)* 1.2 (0.3 to 2.1)*  Japanese — — 3.9 (2.3 to 5.4) 23 17.2 (13.4 to 21.0) 79 28.4 (22.8 to 34.0) 98 37.7 (31.5 to 43.9) 142 8.1 (7.2 to 8.9) 343 AAPC — — 0.1 (−3.4 to 3.7) 3.5 (0.0 to 7.0)* 2.3 (−0.6 to 5.3) 3.0 (0.4 to 5.6)*  Korean 0.8 (0.4 to 1.1) 20 20.2 (16.7 to 23.7) 127 55.7 (49.0 to 62.4) 264 98.2 (86.8 to 109.5) 288 98.7 (85.3 to 112.1) 209 26.1 (24.3 to 27.9) 908 AAPC −2.7 (−5.9 to 0.6) −1.8 (−4.6 to 1.2) −1 (−2.8 to 0.8) −1.8 (−4.0 to 0.5) 0.5 (−2.1 to 3.2) −0.5 (−1.8 to 0.7)  South Asian — — — — 8.8 (6.1 to 11.5) 41 22.9 (17.2 to 28.6) 61 37.2 (27.7 to 46.7) 59 6.7 (5.6 to 7.9) 174 AAPC — — — — — 1.8 (−1.6 to 5.2)  Vietnamese 2.6 (2.1 to 3.1) 96 26.6 (23.1 to 30.1) 218 93.6 (85.6 to 101.6) 524 160.8 (147.1 to 174.5) 531 215.9 (196.9 to 234.9 494 47.3 (45.0 to 49.6) 1863 AAPC −1.0 (−4.0 to 2.2) −1.1 (−3.5 to 1.4) 1.9 (0.1 to 3.8)* 1.1 (−0.8 to 3.1) 0.8 (−1.2 to 2.8) 0.3 (−0.8 to 1.4)  Cambodian 2.0 (1.0 to 3.1) 14 45.6 (32.5 to 58.8) 46 106.5 (82.2 to 130.8) 74 138.8 (101.1 to 176.5) 52 114.4 (70.4 to 158.3) 26 42.8 (36.3 to 49.3) 212 AAPC — — −0.7 (−3.4 to 1.9) — — 2.4 (−0.8 to 5.7)  Laotian 4.2 (2.5 to 5.9) 23 29.8 (17.9 to 41.7) 24 101.8 (74.9 to 128.7) 55 159.5 (113.9 to 205.1) 47 174.4 (115.8 to 233.1) 34 45.6 (38.4 to 52.7) 183 AAPC — — −1.6 (−4.6 to 1.5) — — −0.4 (−2.7 to 1.9) Females  NH white 0.1 (0.1 to 0.1) 104 0.8 (0.7 to 0.9) 236 2.7 (2.5 to 2.9) 693 4.9 (4.6 to 5.2) 980 7.4 (7.1 to 7.7) 2010 1.5 (1.5 to 1.5) 4023 AAPC −0.1 (−2.7 to 2.6) 2.2 (0.4 to 3.9)* 6.0 (4.3 to 7.8)* 3.9 (2.6 to 5.2)* 3.5 (2.8 to 4.3)* 3.8 (3.3 to 4.3)*  NH black 0.1 (0.1 to 0.2) 26 1.6 (1.2 to 2.0) 65 7.5 (6.5 to 8.5) 221 13.0 (11.4 to 14.6) 252 13.2 (11.5 to 14.8) 252 3.3 (3.1 to 3.6) 816 AAPC −1.7 (−4.5 to 1.1) 0.4 (−3.0 to 3.8) 7.3 (4.7 to 10.0)* 5.3 (2.8 to 7.9)* 1.6 (−0.2 to 3.4) 3.5 (2.6 to 4.4)*  Hispanic 0.1 (0.1 to 0.1) 84 1.0 (0.8 to 1.1) 149 5.4 (4.9 to 5.9) 515 14.8 (13.8 to 15.8) 831 24.8 (23.4 to 26.2) 1215 4.2 (4.0 to 4.4) 2794 AAPC 0.9 (−1.9 to 3.8) 1.4 (−1.8 to 4.7) 5.8 (3.9 to 7.7)* 4.7 (3.0 to 6.5)* 3.7 (2.3 to 5.2)* 4.0 (3.1 to 4.8)*  NH API 0.3 (0.2 to 0.3) 80 2.3 (1.9 to 2.6) 183 7.1 (6.4 to 7.8) 423 22.5 (21.0 to 23.9) 895 40.9 (38.9 to 43.0) 1517 6.7 (6.5 to 6.9) 3098 AAPC 0.5 (−2.1 to 3.2) 0.0 (−2.5 to 2.6) −1.8 (−3.3 to –0.3)* 0.3 (−1.5 to 2.1) 2.3 (1.1 to 3.6)* 0.8 (0.1 to 1.5)*  Chinese 0.3 (0.2 to 0.4) 21 2.7 (2.0 to 3.3) 59 6.0 (4.8 to 7.2) 99 19.4 (16.8 to 22.0) 215 37.4 (33.9 to 41.0) 426 6.2 (5.7 to 6.6) 820 AAPC — −3.0 (−6.2 to 0.3) −1.3 (−4.6 to 2.1) 0.0 (−2.2 to 2.3) 1.4 (−0.5 to 3.3) 0.8 (−0.4 to 1.9)  Filipino 0.2 (0.1 to 0.2) 12 1.3 (0.8 to 1.7) 27 3.1 (2.2 to 3.9) 52 8.4 (6.8 to 10.1) 97 26.3 (23.1 to 29.5) 256 3.7 (3.3 to 4.0) 444 AAPC — — −3.4 (−6.1 to –0.6)* −1.7 (−5.4 to 2.2) 2.3 (−0.4 to 5) 1.1 (−1.1 to 3.3)  Japanese — — — — 7.5 (5.3 to 9.7) 44 31.5 (26.7 to 36.4) 163 38.2 (33.3 to 43.2) 232 6.8 (6.2 to 7.4) 446 AAPC — — — −6.5 (−10.1 to –2.8)* 6.5 (3.9 to 9.1)* 1.0 (−0.7 to 2.8)  Korean 0.5 (0.3 to 0.8) 15 4.2 (2.7 to 5.6) 33 11.4 (8.6 to 14.1) 66 33.2 (27.3 to 39.0) 124 58.4 (50.0 to 66.7) 186 10.0 (9.0 to 11.0) 424 AAPC — — −4.4 (−7.4 to –1.3)* −2.6 (−5.9 to 0.9) 0.3 (−2.2 to 3.0) −0.9 (−2.8 to 1.1)  South Asian — — — — 4.3 (2.3 to 6.4) 17 8.8 (5.1 to 12.5) 22 16.6 (10.5 to 22.7) 28 2.8 (2.1 to 3.5) 69 AAPC — — — — — 0.6 (−2.9 to 4.1)  Vietnamese 0.4 (0.2 to 0.6) 14 2.3 (1.2 to 3.3) 19 13.7 (10.7 to 16.7) 82 48.3 (41.1 to 55.6) 170 95.5 (83.9 to 107.1) 261 14.4 (13.2 to 15.7) 546 AAPC — — −3.6 (−6.4 to –0.7)* 1.3 (−1.9 to 4.6) 2.6 (0.1 to 5.2)* 4.5 (0.7 to 8.5)*  Cambodian — — 8.5 (3.2 to 13.8) 10 20.8 (10.9 to 30.7) 17 43.4 (23.9 to 62.9) 19 47.7 (24.3 to 71.1) 16 11.7 (8.6 to 14.8) 64 AAPC — — — — — 0.2 (−3.0 to 3.6)  Laotian — — — — — — 62.3 (33.5 to 91.1) 18 49.2 (21.4 to 77.0) 12 12.3 (8.6 to 16.0) 48 AAPC — — — — — 3.4 (0.1 to 6.8)* Race/ethnicity Age ≤ 39 y Age 40–49 y Age 50–59 y Age 60–69 y Age 70+ y All ages ASIR Cases ASIR Cases ASIR Cases ASIR Cases ASIR Cases AAIR Cases Males  NH white 0.2 (0.1 to 0.2) 177 3.1 (2.9 to 3.2) 981 14.6 (14.1 to 15.0) 3776 20.1 (19.5 to 20.8) 3702 22.3 (21.6 to 22.9) 4171 5.7 (5.6 to 5.8) 12 807 AAPC 1.4 (−0.4 to 3.3) 5.1 (2.6 to 7.6)* 9.8 (8.8 to 10.9)* 5.3 (4.5 to 6.1)* 3.0 (2.7 to 3.4)* 5.3 (4.9 to 5.6)*  NH black 0.3 (0.2 to 0.3) 48 6.4 (5.6 to 7.2) 250 32.5 (30.4 to 34.7) 886 50.1 (46.6 to 53.5) 816 39.4 (35.9 to 42.9) 479 11.9 (11.4 to 12.4) 2479 AAPC 0.4 (−3.5 to 4.5) 0.8 (−1.5 to 3.1) 7.4 (5.7 to 9.1)* 5.4 (3.9 to 6.9)* 2.8 (0.6 to 5.0)* 4.6 (3.8 to 5.5)*  Hispanic 0.1 (0.1 to 0.2) 144 6.5 (6.1 to 6.9) 1037 28.6 (27.5 to 29.7) 2579 45.9 (44.0 to 47.8) 2173 56.9 (54.3 to 59.4) 1907 12.9 (12.6 to 13.2) 7840 AAPC −1.3 (−3.2 to 0.8) 5.5 (3.4 to 7.6)* 6.7 (6.0 to 7.3)* 4.3 (3.4 to 5.2)* 4.0 (3.2 to 4.8)* 4.7 (4.1 to 5.2)*  NH API 1.2 (1.1 to 1.4) 375 13.6 (12.7 to 14.4) 958 40.3 (38.5 to 42.0) 2060 69.6 (66.7 to 72.5) 2226 89.9 (86.4 to 93.5) 2453 20.6 (20.1 to 21.1) 8072 AAPC −2.0 (−3.4 to –0.6)* −0.3 (−1.7 to 1.1) 0.6 (−0.2 to 1.5) 0.4 (−0.6 to 1.4) 1.3 (0.6 to 2.0)* 0.5 (0.0 to 1.1)*  Chinese 1.8 (1.5 to 2.1) 128 13.9 (12.2 to 15.6) 263 36.4 (33.3 to 39.5) 528 70.4 (65.1 to 75.7) 678 93.5 (87.2 to 99.8) 854 20.8 (20.0 to 21.6) 2451 AAPC −2.3 (−4.6 to 0.1) −1.7 (−3.4 to 0.1) −0.9 (−2.4 to 0.6) −1.7 (−3.0 to – 0.4)* −0.6 (−1.5 to 0.4) −1.3 (−2.0 to –0.6)*  Filipino 0.7 (0.5 to 0.9) 54 8.0 (6.6 to 9.4) 134 23.5 (20.8 to 26.1) 298 37.6 (33.4 to 41.8) 303 69.9 (63.6 to 76.2) 475 13.5 (12.8 to 14.3) 1264 AAPC −4.4 (−7.3 to –1.5)* −0.5 (−3.7 to 2.9) 3.0 (0.1 to 5.9)* 0.3 (−1.4 to 2.2) 1.9 (0.5 to 3.4)* 1.2 (0.3 to 2.1)*  Japanese — — 3.9 (2.3 to 5.4) 23 17.2 (13.4 to 21.0) 79 28.4 (22.8 to 34.0) 98 37.7 (31.5 to 43.9) 142 8.1 (7.2 to 8.9) 343 AAPC — — 0.1 (−3.4 to 3.7) 3.5 (0.0 to 7.0)* 2.3 (−0.6 to 5.3) 3.0 (0.4 to 5.6)*  Korean 0.8 (0.4 to 1.1) 20 20.2 (16.7 to 23.7) 127 55.7 (49.0 to 62.4) 264 98.2 (86.8 to 109.5) 288 98.7 (85.3 to 112.1) 209 26.1 (24.3 to 27.9) 908 AAPC −2.7 (−5.9 to 0.6) −1.8 (−4.6 to 1.2) −1 (−2.8 to 0.8) −1.8 (−4.0 to 0.5) 0.5 (−2.1 to 3.2) −0.5 (−1.8 to 0.7)  South Asian — — — — 8.8 (6.1 to 11.5) 41 22.9 (17.2 to 28.6) 61 37.2 (27.7 to 46.7) 59 6.7 (5.6 to 7.9) 174 AAPC — — — — — 1.8 (−1.6 to 5.2)  Vietnamese 2.6 (2.1 to 3.1) 96 26.6 (23.1 to 30.1) 218 93.6 (85.6 to 101.6) 524 160.8 (147.1 to 174.5) 531 215.9 (196.9 to 234.9 494 47.3 (45.0 to 49.6) 1863 AAPC −1.0 (−4.0 to 2.2) −1.1 (−3.5 to 1.4) 1.9 (0.1 to 3.8)* 1.1 (−0.8 to 3.1) 0.8 (−1.2 to 2.8) 0.3 (−0.8 to 1.4)  Cambodian 2.0 (1.0 to 3.1) 14 45.6 (32.5 to 58.8) 46 106.5 (82.2 to 130.8) 74 138.8 (101.1 to 176.5) 52 114.4 (70.4 to 158.3) 26 42.8 (36.3 to 49.3) 212 AAPC — — −0.7 (−3.4 to 1.9) — — 2.4 (−0.8 to 5.7)  Laotian 4.2 (2.5 to 5.9) 23 29.8 (17.9 to 41.7) 24 101.8 (74.9 to 128.7) 55 159.5 (113.9 to 205.1) 47 174.4 (115.8 to 233.1) 34 45.6 (38.4 to 52.7) 183 AAPC — — −1.6 (−4.6 to 1.5) — — −0.4 (−2.7 to 1.9) Females  NH white 0.1 (0.1 to 0.1) 104 0.8 (0.7 to 0.9) 236 2.7 (2.5 to 2.9) 693 4.9 (4.6 to 5.2) 980 7.4 (7.1 to 7.7) 2010 1.5 (1.5 to 1.5) 4023 AAPC −0.1 (−2.7 to 2.6) 2.2 (0.4 to 3.9)* 6.0 (4.3 to 7.8)* 3.9 (2.6 to 5.2)* 3.5 (2.8 to 4.3)* 3.8 (3.3 to 4.3)*  NH black 0.1 (0.1 to 0.2) 26 1.6 (1.2 to 2.0) 65 7.5 (6.5 to 8.5) 221 13.0 (11.4 to 14.6) 252 13.2 (11.5 to 14.8) 252 3.3 (3.1 to 3.6) 816 AAPC −1.7 (−4.5 to 1.1) 0.4 (−3.0 to 3.8) 7.3 (4.7 to 10.0)* 5.3 (2.8 to 7.9)* 1.6 (−0.2 to 3.4) 3.5 (2.6 to 4.4)*  Hispanic 0.1 (0.1 to 0.1) 84 1.0 (0.8 to 1.1) 149 5.4 (4.9 to 5.9) 515 14.8 (13.8 to 15.8) 831 24.8 (23.4 to 26.2) 1215 4.2 (4.0 to 4.4) 2794 AAPC 0.9 (−1.9 to 3.8) 1.4 (−1.8 to 4.7) 5.8 (3.9 to 7.7)* 4.7 (3.0 to 6.5)* 3.7 (2.3 to 5.2)* 4.0 (3.1 to 4.8)*  NH API 0.3 (0.2 to 0.3) 80 2.3 (1.9 to 2.6) 183 7.1 (6.4 to 7.8) 423 22.5 (21.0 to 23.9) 895 40.9 (38.9 to 43.0) 1517 6.7 (6.5 to 6.9) 3098 AAPC 0.5 (−2.1 to 3.2) 0.0 (−2.5 to 2.6) −1.8 (−3.3 to –0.3)* 0.3 (−1.5 to 2.1) 2.3 (1.1 to 3.6)* 0.8 (0.1 to 1.5)*  Chinese 0.3 (0.2 to 0.4) 21 2.7 (2.0 to 3.3) 59 6.0 (4.8 to 7.2) 99 19.4 (16.8 to 22.0) 215 37.4 (33.9 to 41.0) 426 6.2 (5.7 to 6.6) 820 AAPC — −3.0 (−6.2 to 0.3) −1.3 (−4.6 to 2.1) 0.0 (−2.2 to 2.3) 1.4 (−0.5 to 3.3) 0.8 (−0.4 to 1.9)  Filipino 0.2 (0.1 to 0.2) 12 1.3 (0.8 to 1.7) 27 3.1 (2.2 to 3.9) 52 8.4 (6.8 to 10.1) 97 26.3 (23.1 to 29.5) 256 3.7 (3.3 to 4.0) 444 AAPC — — −3.4 (−6.1 to –0.6)* −1.7 (−5.4 to 2.2) 2.3 (−0.4 to 5) 1.1 (−1.1 to 3.3)  Japanese — — — — 7.5 (5.3 to 9.7) 44 31.5 (26.7 to 36.4) 163 38.2 (33.3 to 43.2) 232 6.8 (6.2 to 7.4) 446 AAPC — — — −6.5 (−10.1 to –2.8)* 6.5 (3.9 to 9.1)* 1.0 (−0.7 to 2.8)  Korean 0.5 (0.3 to 0.8) 15 4.2 (2.7 to 5.6) 33 11.4 (8.6 to 14.1) 66 33.2 (27.3 to 39.0) 124 58.4 (50.0 to 66.7) 186 10.0 (9.0 to 11.0) 424 AAPC — — −4.4 (−7.4 to –1.3)* −2.6 (−5.9 to 0.9) 0.3 (−2.2 to 3.0) −0.9 (−2.8 to 1.1)  South Asian — — — — 4.3 (2.3 to 6.4) 17 8.8 (5.1 to 12.5) 22 16.6 (10.5 to 22.7) 28 2.8 (2.1 to 3.5) 69 AAPC — — — — — 0.6 (−2.9 to 4.1)  Vietnamese 0.4 (0.2 to 0.6) 14 2.3 (1.2 to 3.3) 19 13.7 (10.7 to 16.7) 82 48.3 (41.1 to 55.6) 170 95.5 (83.9 to 107.1) 261 14.4 (13.2 to 15.7) 546 AAPC — — −3.6 (−6.4 to –0.7)* 1.3 (−1.9 to 4.6) 2.6 (0.1 to 5.2)* 4.5 (0.7 to 8.5)*  Cambodian — — 8.5 (3.2 to 13.8) 10 20.8 (10.9 to 30.7) 17 43.4 (23.9 to 62.9) 19 47.7 (24.3 to 71.1) 16 11.7 (8.6 to 14.8) 64 AAPC — — — — — 0.2 (−3.0 to 3.6)  Laotian — — — — — — 62.3 (33.5 to 91.1) 18 49.2 (21.4 to 77.0) 12 12.3 (8.6 to 16.0) 48 AAPC — — — — — 3.4 (0.1 to 6.8)* * Indicates statistical significance at 95% confidence level. — = data withheld if based on less than 10 cases; AAIR = age-adjusted incidence rate; AAPC = average annual percent change; API = Asian and Pacific Islander; ASIR = age-specific incidence rate; HCC = hepatocellular carcinoma; NH = non-Hispanic. Figure 1. View largeDownload slide Age-adjusted (2000 US standard) incidence rates by sex and race/ethnicity, invasive hepatocellular carcinoma, California, 1988–2012. The error bars represent 95% confidence intervals. API = Asian and Pacific Islander; NH = non-Hispanic. Figure 1. View largeDownload slide Age-adjusted (2000 US standard) incidence rates by sex and race/ethnicity, invasive hepatocellular carcinoma, California, 1988–2012. The error bars represent 95% confidence intervals. API = Asian and Pacific Islander; NH = non-Hispanic. Figure 2. View largeDownload slide Male-to-female (M:F) ratios of age-adjusted incidence rates by race/ethnicity, invasive hepatocellular carcinoma, California, 1988–2012. The error bars represent 95% confidence intervals. API = Asian and Pacific Islander; F = female; M = male; NH = non-Hispanic. Figure 2. View largeDownload slide Male-to-female (M:F) ratios of age-adjusted incidence rates by race/ethnicity, invasive hepatocellular carcinoma, California, 1988–2012. The error bars represent 95% confidence intervals. API = Asian and Pacific Islander; F = female; M = male; NH = non-Hispanic. Trend tests of the AAPCs from 1988–2012 showed a statistically significant (P < .05) rise in HCC incidence for all of the aggregated racial/ethnic populations and some of the Asian subgroups in both males and females, as indicated by the AAPCs (NH whites: +5.3%, 95% CI = 4.9 to 5.6, for males; +3.8%, 95% CI = 3.3 to 4.3, for females; NH blacks: +4.6%, 95% CI = 3.8 to 5.5, for males; +3.5%, 95% CI = 2.6 to 4.4, for females; Hispanics: +4.7%, 95% CI = 4.1 to 5.2, for males; +4.0%, 95% CI = 3.1 to 4.8, for females; NH API: +0.5%, 95% CI = 0.0 to 1.1, for males; +0.8%, 95% CI = 0.1 to 1.5, for females) (Table 3). Among the Asian subgroups, statistically significantly rising AAPCs over the study period were also found in Filipino males (+1.2%, 95% CI = 0.3 to 2.1), Japanese males (+3.0%, 95% CI = 0.4 to 5.6), Vietnamese females (+4.5%, 95% CI = 0.7 to 8.5), and Laotian females (+3.4%, 95% CI = 0.1 to 6.8) (Table 3), despite the downward trends in AAIRs in some ethnic groups in recent years (Table 3, Figure 3, A and B). Chinese males were the only group to experience consistent decline in AAIR, with a statistically significant AAPC of −1.3% (95% CI = −2.0 to −0.6) (Table 3, Figure 3A). Figure 3. View largeDownload slide Age-adjusted incidence rates by sex, race/ethnicity, and time period, invasive hepatocellular carcinoma, California, 1988–2012. Results are shown separately for (A) males and (B) females. API = Asian and Pacific Islander; NH = non-Hispanic. Figure 3. View largeDownload slide Age-adjusted incidence rates by sex, race/ethnicity, and time period, invasive hepatocellular carcinoma, California, 1988–2012. Results are shown separately for (A) males and (B) females. API = Asian and Pacific Islander; NH = non-Hispanic. Age-Specific Incidence Rates Similar to the racial/ethnic risk patterns in the AAIRs, NH whites and South Asians had the lowest ASIRs across all age groups (Table 3, Figure 4, A and B). Furthermore, the ASIRs revealed that the HCC risk increased with age in most racial/ethnic groups and the risk disparities between groups also grew markedly with age. Although based on small numbers, Cambodians and Laotians younger than age 60 years appeared to have higher HCC risk than Vietnamese (Figure 4, A and B). Figure 4. View largeDownload slide Age-specific incidence rates by sex and race/ethnicity, invasive hepatocellular carcinoma, California, 1988–2012. Results are shown separately for (A) males and (B) females. API = Asian and Pacific Islander; NH = non-Hispanic. Figure 4. View largeDownload slide Age-specific incidence rates by sex and race/ethnicity, invasive hepatocellular carcinoma, California, 1988–2012. Results are shown separately for (A) males and (B) females. API = Asian and Pacific Islander; NH = non-Hispanic. The trend analysis in ASIR among NH whites, NH blacks, and Hispanics underscored the statistically significant increasing temporal trends in most age groups, with the largest AAPCs found in the age group 50–59 years (Table 3). However, while decreasing trends in ASIRs were observed in some of the Asian ethnic groups, especially in males (Chinese, Filipino, Korean), rising temporal trends were noted in some older females (Chinese, Filipina) and males as well (Japanese, Vietnamese). ASIRs based on fewer than 10 cases and associated AAPCs were not shown in Table 3 for groups including South Asians, Cambodians, and Laotians. Discussion Using population-based CCR data, we conducted a systematic and focused evaluation of HCC incidence rates and temporal trends in four aggregated racial/ethnic groups and eight disaggregated Asian ethnic groups during a 25-year span of 1988–2012. As a whole, APIs had statistically significantly higher HCC risk than NH whites, NH blacks, and Hispanics, regardless of sex. When disaggregated, Southeast Asians (Vietnamese, Cambodian, and Laotian) had exceedingly high overall HCC incidence rates, eight to nine times higher than those of NH whites and more than twice as high as other ethnic Asians. Japanese and South Asians had the lowest HCC risk among ethnic Asians, and both groups also had lower M:F rate ratios. Statistically significant rising temporal trends of HCC were found in NH whites, NH blacks, and Hispanics overall, especially those age 50–59 years. Although overall HCC risk declined statistically significantly in Chinese males, it rose statistically significantly in Filipino and Japanese males and Vietnamese and Laotian females. There are few population-based reports on liver cancer or HCC incidence rates and trends for disaggregated Asian-American subgroups (17–19,25–28). One major study examined incidence rates in disaggregated Asians in the California Bay Area, but it was not age specific, had fewer subgroups than the present study, and did not include Southern California, home to one of the largest Asian-American populations in the United States (28). Another study disaggregated Asian data but was not age specific (27). Others have conducted similarly diverse disaggregated studies that examined survival and treatment differences (29,30). To our knowledge, the present study provides the most comprehensive examination of HCC incidence temporal trends and characteristics in the United States, including subgroups of Asian Americans. Our findings confirmed the rising AAIR trends in NH whites, NH blacks, and Hispanics reported by others (9). The HCC risk in these groups statistically significantly increased at nearly all ages during the past 25 years, likely due to rises in alcoholic liver disease, nonalcoholic steatohepatitis, and chronic HCV infection. Obesity and diabetes have also been linked to HCC (2,31,32). Recent studies have suggested that HCC incidence rates in APIs were decreasing or stable (9,33), but the wide variation in incidence rates and temporal trends among Asian subgroups found in our study further highlights the importance of disaggregating APIs in order to reveal the group’s heterogeneity and more precisely identify the people in highest need of targeted interventions. The differences in HCC risk among Asian subgroups correlate with prevalence of HBV among these groups. Among foreign-born Asians in the United States, HBV prevalence rates range from 0.6% among Japanese to 12.5% in Vietnamese and 13.6% in Laotians (11). The high HCC risk among Southeast Asians is directly attributable to their high proportion (more than 97%) of foreign-born individuals from one of the highest-risk regions in the world. In contrast to Southeast Asians, we found that the proportion of foreign-born individuals was lowest in Japanese HCC patients (63.4%), which is consistent with previous findings (27,34). The most commonly implicated cause of HCC among native Japanese is HCV (35), which is also likely the leading cause in foreign-born Japanese in the United States (35–38). The HCC incidence rate has been rising statistically significantly in Japanese males overall and in older Japanese females age 70 years and older. The higher percentage of female HCC patients (56.5%) among Japanese maybe due to the higher proportion of females in older age groups. While the androgen-driven nature of HCC (39) can partially explain the male predominance in HCC incidence, the varying M:F rate ratios by race/ethnicity are of great interest but poorly understood at this point. The lower M:F ratios in Japanese and South Asians may be related to their lowest HCC risk among nonwhites and lower prevalence of HBV as compared with other Asian ethnic groups. Sex differences in cancer susceptibility are understudied but important, as they may hold important clues regarding the etiology of cancer (40). Similar to previous reports (13,41), we also saw marked increases of early-stage HCC diagnosis with a concomitant decrease in late- and unknown-stage diseases across all racial/ethnic groups, especially in the high-risk Vietnamese. These observations likely indicate the successes of outreach efforts promoting HBV testing and vaccination and improved staging of HCC, as well as heightened surveillance imaging in patients with underlying chronic liver disease. However, such progress was not as pronounced in Laotians, whose percentage of distant diagnoses was the highest in 2004–2012. Laotians had the second-highest concentration of patients with low SES, and one of the highest HCC risks for those younger than age 60 years. While the Laotian staging and age disparities may be artifacts of low case counts, they may also reflect the large proportion of low-SES Laotians who lack access to health care. Nevertheless, this highlights the need for targeted interventions in this ethnic group. HCC outreach efforts need to target individual ethnic Asian immigrant communities considering their specific needs, for which disaggregated research can provide much needed information. However, the importance of disaggregated analysis as shown in our study is not limited to Asian Americans. Every major racial/ethnic population, whether it is white, black, or Hispanic, includes heterogeneous subgroups of different backgrounds and disease profiles. This issue is particularly relevant to Hispanics, as recent research has revealed cancer incidence and mortality disparities among disaggregated Hispanic subgroups (42,43). The limitations of our study are inherent to using cancer registry data, the accuracy of which largely depends on the quality of information reported from medical facilities. Nonetheless, the CCR has been consistently recognized by NAACCR as having the highest quality of data. There were relatively fewer cases in specific Asian subgroups, but these remain the most robust published data to date. The change from SS 1977 to SS 2000 has been found to cause a stage distribution shift for liver cancer resulting in an increase in regional disease and decrease in distant disease (44), which may trigger concern for bias in our findings of stage improvement. However, the substantial increases in the proportion of localized disease observed in our analysis across racial/ethnic groups should be independent of the known “stage migration” between the two versions of the summary staging systems, indicating real progress in early detection of HCC. Misclassification of race/ethnicity may occur in cancer registry data, which would likely result in underestimated risk for minority groups, particularly Vietnamese (45), and actually underestimate their already disproportionate HCC risk. Given the general agreement between our findings and those reported by others on the same population groups, we feel confident in our results. In summary, our findings demonstrate the striking HCC risk disparities and temporal trends among the diverse racial/ethnic populations in California, especially the heterogeneous Asian subgroups. The statistically significant rises in overall HCC incidence across all major aggregated racial/ethnic groups highlight the urgency for continued HCC prevention and surveillance efforts. The importance of disaggregated examinations in health research by population subgroup has implications for all other aggregated groups, particularly Hispanics. Funding The collection of cancer incidence data used in this study was supported by the California Department of Public Health pursuant to California Health and Safety Code Section 103885; the Centers for Disease Control and Prevention’s National Program of Cancer Registries, under cooperative agreement 5NU58DP003862-04/DP003862; and the National Cancer Institute’s Surveillance, Epidemiology, and End Results Program under contract HHSN261201000140C, awarded to the Cancer Prevention Institute of California; contract HHSN261201000035C, awarded to the University of Southern California; and contract HHSN261201000034C, awarded to the Public Health Institute. Notes Affiliations of authors: The Doctor of Medicine Program (CP), Division of Gastrointestinal and Liver Diseases, Department of Medicine (TLF), Los Angeles Cancer Surveillance Program, Department of Preventive Medicine (JZ, LL), Keck School of Medicine, University of Southern California, Los Angeles, CA. 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Striking Racial/Ethnic Disparities in Liver Cancer Incidence Rates and Temporal Trends in California, 1988–2012

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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com
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0027-8874
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1460-2105
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10.1093/jnci/djy051
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Abstract

Abstract Background Hepatocellular carcinoma (HCC) is characterized by disparate risk patterns by race/ethnicity. We examined HCC incidence patterns and temporal trends among detailed racial/ethnic populations, including disaggregated Asian-American subgroups. Methods Using data from the population-based California Cancer Registry, we identified 41 929 invasive HCC cases diagnosed during 1988–2012. Patients were grouped into mutually exclusive racial/ethnic groups of non-Hispanic (NH) white, NH black, Hispanic, and NH Asian/Pacific Islander (API), as well as Asian subgroups of Chinese, Filipino, Japanese, Korean, Vietnamese, Cambodian, Laotian, and South Asian. Age-adjusted and age-specific incidence rates by sex, race/ethnicity, and time period were calculated. The average annual percent change (AAPC) in incidence rates was estimated using joinpoint regression. All estimates were provided with the 95% confidence intervals (CIs). Results Aggregated NH API had higher HCC risk than NH whites, NH blacks, and Hispanics. When disaggregated, Southeast Asians (Vietnamese, Cambodians, and Laotians) had overall HCC incidence rates eight to nine times higher than NH whites and more than twice that of other ethnic Asians. Statistically significant rising temporal trends of HCC were found in NH whites, NH blacks, and Hispanics, especially those older than age 50 years. Overall HCC risk declined in Chinese males (AAPC = –1.3%, 95% CI = –2.0 to –0.6), but rose in Filipino (AAPC = +1.2%, 95% CI = 0.3 to 2.1) and Japanese males (AAPC = +3.0%, 95% CI = 0.4 to 5.6) and Vietnamese (AAPC = +4.5%, 95% CI = 0.7 to 8.5) and Laotian (+3.4%, 95% CI = 0.1 to 6.8) females. Conclusions Our findings provide valuable information for the identification of at-risk ethnic subgroups of Asian Americans while underscoring the importance of disaggregating ethnic populations in cancer research. Primary liver cancer is the fifth most common malignancy in men and the seventh among women worldwide, resulting in liver cancer being the third leading cause of cancer mortality in men and sixth in women (1). The predominant primary liver malignancy (85%–90% of cases) is hepatocellular carcinoma (HCC) (2). Most HCC cases are associated with chronic liver disease and cirrhosis (3). The incidence of HCC varies throughout the world, with the highest incidence in Southeast Asia and Sub-Saharan Africa, where chronic infections by hepatitis B virus (HBV) and hepatitis C virus (HCV) are more prevalent (2,4). Chronic HBV and HCV infections increase HCC risk (2,4,5) and account for nearly 78% of all HCC cases (6). Effective vaccination has resulted in dramatic reduction in the prevalence of chronic HBV infection, and thus reduction of HCC incidence worldwide (7,8). Nonetheless, HCC remains a disproportionate burden affecting Asian Americans (9). Although constituting only 5.6% of the total population in the United States (10), Asian Americans account for more than 60% of the country’s chronic HBV infections (11). Despite being a generally lower-risk group for overall cancer incidence as compared with non-Hispanic (NH) whites (9,12), Asian Americans experience statistically significantly higher liver cancer risk, with a five-year survival rate of less than 10% (2,4,12,13). Asian Americans are the fastest-growing minority group in the United States (10), comprising a heterogeneous population from more than 60 different ethnic groups speaking more than 100 different languages (14), with substantial socioeconomic diversity (15). For instance, nearly 50% of Chinese-American adults have a Bachelor’s degree or higher, while 53% of Cambodian-American adults have less than a high school degree (16). The aggregated categories of “Asian” and “Asian and Pacific Islander” conflate these diverse socioeconomic and cultural backgrounds, producing information that is not helpful for understanding disease burden or developing targeted intervention strategies for any specific group (9–17). While a few studies in recent years examined liver cancer or HCC incidence rates among selected ethnic Asian subgroups (17–19), none provided detailed temporal trend assessments. In this study, we systematically examined HCC incidence patterns and temporal trends among aggregated and disaggregated racial/ethnic groups in California, including eight Asian-American subgroups. Our aims were to provide the needed information to identify specific targets for further reducing HCC burden in high-risk Asian Americans. Methods HCC Cases Data from the population-based California Cancer Registry (CCR) were used to examine invasive primary HCC cases diagnosed in California residents from 1988 to 2012. HCC was defined by the International Classification of Diseases for Oncology, 3rd Edition (ICD-O-3), site code C22.0 and histology codes 8160, 8162, 8170–8172, 8174–8175, 8180, and 8190. A total of 41 929 cases of invasive HCC were studied. Patients were classified by sex (male, female), age group (0–39, 40–49, 50–59, 60–69, and 70+ years), aggregated race/ethnicity (NH white, NH black, Hispanic, NH Asian/Pacific Islander [NH API], and disaggregated Asian subgroups of Chinese, Filipino, Japanese, Korean, Vietnamese, Cambodian, Laotian and South Asian [including Asian Indian, Pakistani, Sri Lankan, Bangladeshi, and other South Asian groups]), birthplace (US-born, foreign-born, or unknown/missing), and socioeconomic status (SES; 1 for low to 5 for high). Patient racial/ethnic information was routinely collected by cancer registrars based on information in their medical records. Hispanic and Asian ethnic identifications were enhanced by applying NHIA and NAPIIA algorithms developed by the North American Association of Central Cancer Registries (NAACCR) (20,21). Unknown or missing birthplaces were estimated using a published method based on social security numbers (21). Patient SES was estimated using an established area-based composite of multiple socioeconomic indicators from census sources, as previously published (22–24). Tumor stage was derived from registry-collected tumor information and categorized as localized, regional, distant, or unknown, as defined by the Surveillance, Epidemiology, and End Results (SEER) Program's Summary Stage (SS) schemes. SS 1977 version was used for cases diagnosed prior to 2001, and SS 2000 was used for subsequent diagnoses (22). The study period of 1988–2012 was divided into three segments: 1988–1995, 1996–2003, and 2004–2012, in order to have sufficient case counts for even the small ethnic populations. Rate estimates based on fewer than 10 cases were withheld from the tabular presentation but included in the graphs for better visualization. Annual Population Estimates We used the annual population estimates for the state of California released by the National Center for Health Statistics with the corresponding racial/ethnic categories of NH white, NH black, Hispanic, and NH API available for 1990–2012 (23). The 1990–2000 linear growth trends by sex, age, and race/ethnicity were extrapolated to obtain 1988–1989 population estimates. The annual population estimates for the Asian subgroups were developed by the CCR using the Asian ethnic-specific population counts from the 1990 STF2 and PUMS, 2000 SF2, and 2010 SF2 census files. Due to the multiracial scheme used in the 2000 and 2010 US census (24), population counts for each Asian subgroup by age and sex were represented by the simple average between the minimum and maximum population counts for each sex-age-ethnicity-specific combination in each census year. Annual population estimates for these Asian subgroups in California from 1988–2012 were obtained by linear interpolation of sex-age-specific population counts between census years 1990–2000 and 2000–2010, and extrapolation of the linear trend in the adjacent decade for 1988–1989 and 2011–2012. Statistical Analysis The percentages of HCC cases by demographic and tumor characteristics for each of the racial/ethnic groups were calculated for the entire study period. Tumor stage distribution was further examined by race/ethnicity and time period. Age-adjusted (2000 US standard) incidence rates (AAIRs) and age-specific incidence rates (ASIRs), along with the 95% confidence intervals (CIs), were calculated by sex, race/ethnicity, and time period. Male to female (M:F) rate ratios and 95% CIs were calculated using the sex-specific AAIRs by race/ethnicity. The average annual percent changes (AAPCs) in annual AAIRs and ASIRs by race/ethnicity and sex from 1988–2012 were estimated using the Joinpoint Regression Program (version 4.1.0, National Cancer Institute) to describe changes in incidence rates over time. AAPC is a weighted average of the segmented annual percent change (APC) over multiple time intervals and offers a valid summary measure for comparing rate changes across groups over the same period of time. The statistical significance of the AAPCs was tested at 95% confidence level based on a two-sided t distribution. Results Demographic Characteristics This analysis included 16 830 NH white, 3295 NH black, 10 634 Hispanic, and 11 170 aggregated NH API HCC patients. The disaggregated Asian ethnic groups comprised 3271 Chinese, 1708 Filipino, 789 Japanese, 1332 Korean, 243 South Asian, 2409 Vietnamese, 276 Cambodian, and 231 Laotian patients (Table 1). Table 1. Demographic and tumor characteristics of invasive HCC patients by race/ethnicity, California, 1988–2012* Characteristics NH white NH black Hispanic NH API Chinese Filipino Japanese Korean South Asian Vietnamese Cambodian Laotian (n = 16 830), % (n = 3295), % (n = 10 634), % (n = 11 170), % (n = 3271), % (n = 1708), % (n = 789), % (n = 1332), % (n = 243), % (n = 2409), % (n = 276), % (n = 231), % Sex  Male 76.1 75.2 73.7 72.3 74.9 74.0 43.5 68.2 71.6 77.3 76.8 79.2  Female 23.9 24.8 26.3 27.7 25.1 26.0 56.5 31.8 28.4 22.7 23.2 20.8 Age group, y  ≤39 1.7 2.2 2.1 4.1 4.6 3.9 0.3 2.6 2.1 4.6 5.8 12.6  40–49 7.2 9.6 11.2 10.2 9.8 9.4 3.7 12.0 4.1 9.8 20.3 13.4  50–59 26.6 33.6 29.1 22.2 19.2 20.5 15.6 24.8 23.9 25.2 33.0 26.0  60–69 27.8 32.4 28.2 27.9 27.3 23.4 33.1 30.9 34.2 29.1 25.7 28.1  70+ 36.7 22.2 29.4 35.5 39.1 42.8 47.4 29.7 35.8 31.3 15.2 19.9 Socioeconomic status  1 (low) 12.5 34.6 35.5 16.1 13.8 14.1 9.9 16.8 10.7 15.5 48.6 46.8  2 19.8 25.0 26.0 19.8 15.1 18.8 17.9 18.8 18.9 26.3 18.8 30.7  3 23.1 18.5 19.2 20.3 18.2 25.3 21.9 16.6 17.7 23.4 13.0 11.7  4 22.9 14.5 12.2 22.8 24.3 26.3 25.5 22.8 31.3 19.2 10.1 9.5  5 (high) 21.7 7.3 7.1 21.1 28.6 15.5 24.8 24.9 21.4 15.6 9.4 1.3 Immigrant status  US-born 85.1 88.5 53.9 9.3 8.7 7.4 35.1 2.5 7.0 2.4 1.4 2.2  Foreign-born 14.2 10.5 44.7 89.9 90.8 91.5 63.4 96.8 90.9 97.3 98.6 97.8  Unknown 0.7 1.0 1.4 0.7 0.6 1.1 1.5 0.7 2.1 0.3 0.0 0.0 Tumor stage  Localized 40.8 37.0 43.0 41.6 41.0 39.0 42.2 39.3 41.2 45.8 38.4 30.3  Regional 21.9 24.0 22.5 22.0 20.6 24.8 20.8 21.9 24.3 22.5 24.3 17.7  Distant 21.7 24.9 19.6 21.7 22.0 24.0 21.5 20.0 22.6 19.3 23.9 32.0  Unknown 15.7 14.1 14.9 14.7 16.4 12.2 15.5 18.7 11.9 12.5 13.4 19.9 Characteristics NH white NH black Hispanic NH API Chinese Filipino Japanese Korean South Asian Vietnamese Cambodian Laotian (n = 16 830), % (n = 3295), % (n = 10 634), % (n = 11 170), % (n = 3271), % (n = 1708), % (n = 789), % (n = 1332), % (n = 243), % (n = 2409), % (n = 276), % (n = 231), % Sex  Male 76.1 75.2 73.7 72.3 74.9 74.0 43.5 68.2 71.6 77.3 76.8 79.2  Female 23.9 24.8 26.3 27.7 25.1 26.0 56.5 31.8 28.4 22.7 23.2 20.8 Age group, y  ≤39 1.7 2.2 2.1 4.1 4.6 3.9 0.3 2.6 2.1 4.6 5.8 12.6  40–49 7.2 9.6 11.2 10.2 9.8 9.4 3.7 12.0 4.1 9.8 20.3 13.4  50–59 26.6 33.6 29.1 22.2 19.2 20.5 15.6 24.8 23.9 25.2 33.0 26.0  60–69 27.8 32.4 28.2 27.9 27.3 23.4 33.1 30.9 34.2 29.1 25.7 28.1  70+ 36.7 22.2 29.4 35.5 39.1 42.8 47.4 29.7 35.8 31.3 15.2 19.9 Socioeconomic status  1 (low) 12.5 34.6 35.5 16.1 13.8 14.1 9.9 16.8 10.7 15.5 48.6 46.8  2 19.8 25.0 26.0 19.8 15.1 18.8 17.9 18.8 18.9 26.3 18.8 30.7  3 23.1 18.5 19.2 20.3 18.2 25.3 21.9 16.6 17.7 23.4 13.0 11.7  4 22.9 14.5 12.2 22.8 24.3 26.3 25.5 22.8 31.3 19.2 10.1 9.5  5 (high) 21.7 7.3 7.1 21.1 28.6 15.5 24.8 24.9 21.4 15.6 9.4 1.3 Immigrant status  US-born 85.1 88.5 53.9 9.3 8.7 7.4 35.1 2.5 7.0 2.4 1.4 2.2  Foreign-born 14.2 10.5 44.7 89.9 90.8 91.5 63.4 96.8 90.9 97.3 98.6 97.8  Unknown 0.7 1.0 1.4 0.7 0.6 1.1 1.5 0.7 2.1 0.3 0.0 0.0 Tumor stage  Localized 40.8 37.0 43.0 41.6 41.0 39.0 42.2 39.3 41.2 45.8 38.4 30.3  Regional 21.9 24.0 22.5 22.0 20.6 24.8 20.8 21.9 24.3 22.5 24.3 17.7  Distant 21.7 24.9 19.6 21.7 22.0 24.0 21.5 20.0 22.6 19.3 23.9 32.0  Unknown 15.7 14.1 14.9 14.7 16.4 12.2 15.5 18.7 11.9 12.5 13.4 19.9 * API = Asian and Pacific Islander; HCC = hepatocellular carcinoma; NH = non-Hispanic. Table 1. Demographic and tumor characteristics of invasive HCC patients by race/ethnicity, California, 1988–2012* Characteristics NH white NH black Hispanic NH API Chinese Filipino Japanese Korean South Asian Vietnamese Cambodian Laotian (n = 16 830), % (n = 3295), % (n = 10 634), % (n = 11 170), % (n = 3271), % (n = 1708), % (n = 789), % (n = 1332), % (n = 243), % (n = 2409), % (n = 276), % (n = 231), % Sex  Male 76.1 75.2 73.7 72.3 74.9 74.0 43.5 68.2 71.6 77.3 76.8 79.2  Female 23.9 24.8 26.3 27.7 25.1 26.0 56.5 31.8 28.4 22.7 23.2 20.8 Age group, y  ≤39 1.7 2.2 2.1 4.1 4.6 3.9 0.3 2.6 2.1 4.6 5.8 12.6  40–49 7.2 9.6 11.2 10.2 9.8 9.4 3.7 12.0 4.1 9.8 20.3 13.4  50–59 26.6 33.6 29.1 22.2 19.2 20.5 15.6 24.8 23.9 25.2 33.0 26.0  60–69 27.8 32.4 28.2 27.9 27.3 23.4 33.1 30.9 34.2 29.1 25.7 28.1  70+ 36.7 22.2 29.4 35.5 39.1 42.8 47.4 29.7 35.8 31.3 15.2 19.9 Socioeconomic status  1 (low) 12.5 34.6 35.5 16.1 13.8 14.1 9.9 16.8 10.7 15.5 48.6 46.8  2 19.8 25.0 26.0 19.8 15.1 18.8 17.9 18.8 18.9 26.3 18.8 30.7  3 23.1 18.5 19.2 20.3 18.2 25.3 21.9 16.6 17.7 23.4 13.0 11.7  4 22.9 14.5 12.2 22.8 24.3 26.3 25.5 22.8 31.3 19.2 10.1 9.5  5 (high) 21.7 7.3 7.1 21.1 28.6 15.5 24.8 24.9 21.4 15.6 9.4 1.3 Immigrant status  US-born 85.1 88.5 53.9 9.3 8.7 7.4 35.1 2.5 7.0 2.4 1.4 2.2  Foreign-born 14.2 10.5 44.7 89.9 90.8 91.5 63.4 96.8 90.9 97.3 98.6 97.8  Unknown 0.7 1.0 1.4 0.7 0.6 1.1 1.5 0.7 2.1 0.3 0.0 0.0 Tumor stage  Localized 40.8 37.0 43.0 41.6 41.0 39.0 42.2 39.3 41.2 45.8 38.4 30.3  Regional 21.9 24.0 22.5 22.0 20.6 24.8 20.8 21.9 24.3 22.5 24.3 17.7  Distant 21.7 24.9 19.6 21.7 22.0 24.0 21.5 20.0 22.6 19.3 23.9 32.0  Unknown 15.7 14.1 14.9 14.7 16.4 12.2 15.5 18.7 11.9 12.5 13.4 19.9 Characteristics NH white NH black Hispanic NH API Chinese Filipino Japanese Korean South Asian Vietnamese Cambodian Laotian (n = 16 830), % (n = 3295), % (n = 10 634), % (n = 11 170), % (n = 3271), % (n = 1708), % (n = 789), % (n = 1332), % (n = 243), % (n = 2409), % (n = 276), % (n = 231), % Sex  Male 76.1 75.2 73.7 72.3 74.9 74.0 43.5 68.2 71.6 77.3 76.8 79.2  Female 23.9 24.8 26.3 27.7 25.1 26.0 56.5 31.8 28.4 22.7 23.2 20.8 Age group, y  ≤39 1.7 2.2 2.1 4.1 4.6 3.9 0.3 2.6 2.1 4.6 5.8 12.6  40–49 7.2 9.6 11.2 10.2 9.8 9.4 3.7 12.0 4.1 9.8 20.3 13.4  50–59 26.6 33.6 29.1 22.2 19.2 20.5 15.6 24.8 23.9 25.2 33.0 26.0  60–69 27.8 32.4 28.2 27.9 27.3 23.4 33.1 30.9 34.2 29.1 25.7 28.1  70+ 36.7 22.2 29.4 35.5 39.1 42.8 47.4 29.7 35.8 31.3 15.2 19.9 Socioeconomic status  1 (low) 12.5 34.6 35.5 16.1 13.8 14.1 9.9 16.8 10.7 15.5 48.6 46.8  2 19.8 25.0 26.0 19.8 15.1 18.8 17.9 18.8 18.9 26.3 18.8 30.7  3 23.1 18.5 19.2 20.3 18.2 25.3 21.9 16.6 17.7 23.4 13.0 11.7  4 22.9 14.5 12.2 22.8 24.3 26.3 25.5 22.8 31.3 19.2 10.1 9.5  5 (high) 21.7 7.3 7.1 21.1 28.6 15.5 24.8 24.9 21.4 15.6 9.4 1.3 Immigrant status  US-born 85.1 88.5 53.9 9.3 8.7 7.4 35.1 2.5 7.0 2.4 1.4 2.2  Foreign-born 14.2 10.5 44.7 89.9 90.8 91.5 63.4 96.8 90.9 97.3 98.6 97.8  Unknown 0.7 1.0 1.4 0.7 0.6 1.1 1.5 0.7 2.1 0.3 0.0 0.0 Tumor stage  Localized 40.8 37.0 43.0 41.6 41.0 39.0 42.2 39.3 41.2 45.8 38.4 30.3  Regional 21.9 24.0 22.5 22.0 20.6 24.8 20.8 21.9 24.3 22.5 24.3 17.7  Distant 21.7 24.9 19.6 21.7 22.0 24.0 21.5 20.0 22.6 19.3 23.9 32.0  Unknown 15.7 14.1 14.9 14.7 16.4 12.2 15.5 18.7 11.9 12.5 13.4 19.9 * API = Asian and Pacific Islander; HCC = hepatocellular carcinoma; NH = non-Hispanic. The demographic characteristics of HCC patients varied by race/ethnicity (Table 1). There were striking differences in the proportion of foreign-born patients among the various ethnic groups: 89.9% among NH APIs, 44.7% Hispanics, 10.5% NH blacks, and 14.2% NH whites. Among the Asian groups, only the Japanese had a proportion of foreign-born individuals below 90% (63.4%). The Japanese group also had the highest proportion of patients age 70 years and older (47.4%), which likely caused the higher percentage of female HCC patients (56.5%) among the Japanese due to the higher proportion of older females. Although the aggregated NH API group had a similar SES distribution to that of NH whites (who were more affluent than the Hispanic and NH black groups), there were substantial SES disparities among the Asian subgroups: 48.6% of Cambodians and 46.8% of Laotians were in the lowest SES category, compared with only 9.9% of Japanese and 10.7% of South Asians. Tumor Stage The distribution of disease stage at diagnosis by time period showed encouraging temporal trends, with substantial increases in the proportion of localized disease concomitant with decreases in distant disease across all racial/ethnic groups (Table 2). The percentage of localized stage was more than doubled from 1988–1995 to 2004–2012 for most of the groups examined. The percentage of unknown stage also decreased dramatically by more than 60% across groups. However, stage disparities still existed in the most recent period, with a low proportion of localized and a high proportion of distant stage disease found in Laotians (41.7% localized and 21.9% distant), Cambodians (42.6% vs 16.9%), South Asians (43.8% vs 19.4%), and NH blacks (44.0 vs 17.8%). Table 2. Tumor stage distribution by race/ethnicity and time period, invasive HCC, California, 1988–2012 Time period, % Temporal Race/ethnicity Stage 1988–1995 1996–2003 2004–2012 change* NH white Localized 25.3 37.6 47.4 87.6 Regional 11.6 16.9 27.7 138.3 Distant 32.7 27.0 15.3 −53.2 Unknown 30.3 18.5 9.5 −68.6 NH black Localized 21.8 30.8 44.0 101.9 Regional 9.8 20.5 29.6 201.4 Distant 38.7 31.7 17.8 −54.0 Unknown 29.7 17.0 8.6 −71.1 Hispanic Localized 24.0 38.1 48.6 102.7 Regional 10.8 17.4 26.7 147.3 Distant 30.9 25.4 15.1 −51.2 Unknown 34.4 19.0 9.6 −72.0 NH API Localized 24.9 37.7 49.7 99.9 Regional 12.6 17.9 27.6 118.8 Distant 32.7 28.3 13.9 −57.5 Unknown 29.8 16.1 8.8 −70.6 Chinese Localized 23.8 38.9 50.0 110.4 Regional 12.4 17.6 26.3 112.1 Distant 34.7 27.7 12.5 −63.9 Unknown 29.2 15.8 11.2 −61.6 Filipino Localized 25.7 36.0 45.5 76.8 Regional 14.3 20.0 31.4 119.8 Distant 33.3 30.1 17.1 −48.6 Unknown 26.7 13.9 6.0 −77.5 Japanese Localized 25.6 36.1 54.9 114.3 Regional 15.2 17.3 26.1 71.5 Distant 34.1 28.5 10.1 −70.5 Unknown 25.0 18.1 8.9 −64.4 Korean Localized 26.2 37.8 46.2 76.4 Regional 9.4 17.4 30.8 228.9 Distant 25.0 24.8 14.2 −43.3 Unknown 39.5 20.0 8.8 −77.6 South Asian Localized 20.7 44.4 43.8 111.5 Regional 17.2 13.0 29.4 70.4 Distant 20.7 33.3 19.4 −6.4 Unknown 41.4 9.3 7.5 −81.9 Vietnamese Localized 25.6 39.3 54.0 111.2 Regional 13.8 18.9 26.4 91.8 Distant 32.5 27.4 11.8 −63.7 Unknown 28.2 14.4 7.8 −72.4 Cambodian Localized 29.2 36.3 42.6 45.9 Regional 12.5 13.8 33.8 170.3 Distant 35.4 30.0 16.9 −52.3 Unknown 22.9 20.0 6.8 −70.5 Laotian Localized 17.0 25.6 41.7 145.4 Regional 7.5 15.9 25.0 231.3 Distant 34.0 42.7 21.9 −35.6 Unknown 41.5 15.9 11.5 −72.4 Time period, % Temporal Race/ethnicity Stage 1988–1995 1996–2003 2004–2012 change* NH white Localized 25.3 37.6 47.4 87.6 Regional 11.6 16.9 27.7 138.3 Distant 32.7 27.0 15.3 −53.2 Unknown 30.3 18.5 9.5 −68.6 NH black Localized 21.8 30.8 44.0 101.9 Regional 9.8 20.5 29.6 201.4 Distant 38.7 31.7 17.8 −54.0 Unknown 29.7 17.0 8.6 −71.1 Hispanic Localized 24.0 38.1 48.6 102.7 Regional 10.8 17.4 26.7 147.3 Distant 30.9 25.4 15.1 −51.2 Unknown 34.4 19.0 9.6 −72.0 NH API Localized 24.9 37.7 49.7 99.9 Regional 12.6 17.9 27.6 118.8 Distant 32.7 28.3 13.9 −57.5 Unknown 29.8 16.1 8.8 −70.6 Chinese Localized 23.8 38.9 50.0 110.4 Regional 12.4 17.6 26.3 112.1 Distant 34.7 27.7 12.5 −63.9 Unknown 29.2 15.8 11.2 −61.6 Filipino Localized 25.7 36.0 45.5 76.8 Regional 14.3 20.0 31.4 119.8 Distant 33.3 30.1 17.1 −48.6 Unknown 26.7 13.9 6.0 −77.5 Japanese Localized 25.6 36.1 54.9 114.3 Regional 15.2 17.3 26.1 71.5 Distant 34.1 28.5 10.1 −70.5 Unknown 25.0 18.1 8.9 −64.4 Korean Localized 26.2 37.8 46.2 76.4 Regional 9.4 17.4 30.8 228.9 Distant 25.0 24.8 14.2 −43.3 Unknown 39.5 20.0 8.8 −77.6 South Asian Localized 20.7 44.4 43.8 111.5 Regional 17.2 13.0 29.4 70.4 Distant 20.7 33.3 19.4 −6.4 Unknown 41.4 9.3 7.5 −81.9 Vietnamese Localized 25.6 39.3 54.0 111.2 Regional 13.8 18.9 26.4 91.8 Distant 32.5 27.4 11.8 −63.7 Unknown 28.2 14.4 7.8 −72.4 Cambodian Localized 29.2 36.3 42.6 45.9 Regional 12.5 13.8 33.8 170.3 Distant 35.4 30.0 16.9 −52.3 Unknown 22.9 20.0 6.8 −70.5 Laotian Localized 17.0 25.6 41.7 145.4 Regional 7.5 15.9 25.0 231.3 Distant 34.0 42.7 21.9 −35.6 Unknown 41.5 15.9 11.5 −72.4 * From 1988–1995 to 2004–2012. API = Asian and Pacific Islander; HCC = hepatocellular carcinoma; NH = non-Hispanic. Table 2. Tumor stage distribution by race/ethnicity and time period, invasive HCC, California, 1988–2012 Time period, % Temporal Race/ethnicity Stage 1988–1995 1996–2003 2004–2012 change* NH white Localized 25.3 37.6 47.4 87.6 Regional 11.6 16.9 27.7 138.3 Distant 32.7 27.0 15.3 −53.2 Unknown 30.3 18.5 9.5 −68.6 NH black Localized 21.8 30.8 44.0 101.9 Regional 9.8 20.5 29.6 201.4 Distant 38.7 31.7 17.8 −54.0 Unknown 29.7 17.0 8.6 −71.1 Hispanic Localized 24.0 38.1 48.6 102.7 Regional 10.8 17.4 26.7 147.3 Distant 30.9 25.4 15.1 −51.2 Unknown 34.4 19.0 9.6 −72.0 NH API Localized 24.9 37.7 49.7 99.9 Regional 12.6 17.9 27.6 118.8 Distant 32.7 28.3 13.9 −57.5 Unknown 29.8 16.1 8.8 −70.6 Chinese Localized 23.8 38.9 50.0 110.4 Regional 12.4 17.6 26.3 112.1 Distant 34.7 27.7 12.5 −63.9 Unknown 29.2 15.8 11.2 −61.6 Filipino Localized 25.7 36.0 45.5 76.8 Regional 14.3 20.0 31.4 119.8 Distant 33.3 30.1 17.1 −48.6 Unknown 26.7 13.9 6.0 −77.5 Japanese Localized 25.6 36.1 54.9 114.3 Regional 15.2 17.3 26.1 71.5 Distant 34.1 28.5 10.1 −70.5 Unknown 25.0 18.1 8.9 −64.4 Korean Localized 26.2 37.8 46.2 76.4 Regional 9.4 17.4 30.8 228.9 Distant 25.0 24.8 14.2 −43.3 Unknown 39.5 20.0 8.8 −77.6 South Asian Localized 20.7 44.4 43.8 111.5 Regional 17.2 13.0 29.4 70.4 Distant 20.7 33.3 19.4 −6.4 Unknown 41.4 9.3 7.5 −81.9 Vietnamese Localized 25.6 39.3 54.0 111.2 Regional 13.8 18.9 26.4 91.8 Distant 32.5 27.4 11.8 −63.7 Unknown 28.2 14.4 7.8 −72.4 Cambodian Localized 29.2 36.3 42.6 45.9 Regional 12.5 13.8 33.8 170.3 Distant 35.4 30.0 16.9 −52.3 Unknown 22.9 20.0 6.8 −70.5 Laotian Localized 17.0 25.6 41.7 145.4 Regional 7.5 15.9 25.0 231.3 Distant 34.0 42.7 21.9 −35.6 Unknown 41.5 15.9 11.5 −72.4 Time period, % Temporal Race/ethnicity Stage 1988–1995 1996–2003 2004–2012 change* NH white Localized 25.3 37.6 47.4 87.6 Regional 11.6 16.9 27.7 138.3 Distant 32.7 27.0 15.3 −53.2 Unknown 30.3 18.5 9.5 −68.6 NH black Localized 21.8 30.8 44.0 101.9 Regional 9.8 20.5 29.6 201.4 Distant 38.7 31.7 17.8 −54.0 Unknown 29.7 17.0 8.6 −71.1 Hispanic Localized 24.0 38.1 48.6 102.7 Regional 10.8 17.4 26.7 147.3 Distant 30.9 25.4 15.1 −51.2 Unknown 34.4 19.0 9.6 −72.0 NH API Localized 24.9 37.7 49.7 99.9 Regional 12.6 17.9 27.6 118.8 Distant 32.7 28.3 13.9 −57.5 Unknown 29.8 16.1 8.8 −70.6 Chinese Localized 23.8 38.9 50.0 110.4 Regional 12.4 17.6 26.3 112.1 Distant 34.7 27.7 12.5 −63.9 Unknown 29.2 15.8 11.2 −61.6 Filipino Localized 25.7 36.0 45.5 76.8 Regional 14.3 20.0 31.4 119.8 Distant 33.3 30.1 17.1 −48.6 Unknown 26.7 13.9 6.0 −77.5 Japanese Localized 25.6 36.1 54.9 114.3 Regional 15.2 17.3 26.1 71.5 Distant 34.1 28.5 10.1 −70.5 Unknown 25.0 18.1 8.9 −64.4 Korean Localized 26.2 37.8 46.2 76.4 Regional 9.4 17.4 30.8 228.9 Distant 25.0 24.8 14.2 −43.3 Unknown 39.5 20.0 8.8 −77.6 South Asian Localized 20.7 44.4 43.8 111.5 Regional 17.2 13.0 29.4 70.4 Distant 20.7 33.3 19.4 −6.4 Unknown 41.4 9.3 7.5 −81.9 Vietnamese Localized 25.6 39.3 54.0 111.2 Regional 13.8 18.9 26.4 91.8 Distant 32.5 27.4 11.8 −63.7 Unknown 28.2 14.4 7.8 −72.4 Cambodian Localized 29.2 36.3 42.6 45.9 Regional 12.5 13.8 33.8 170.3 Distant 35.4 30.0 16.9 −52.3 Unknown 22.9 20.0 6.8 −70.5 Laotian Localized 17.0 25.6 41.7 145.4 Regional 7.5 15.9 25.0 231.3 Distant 34.0 42.7 21.9 −35.6 Unknown 41.5 15.9 11.5 −72.4 * From 1988–1995 to 2004–2012. API = Asian and Pacific Islander; HCC = hepatocellular carcinoma; NH = non-Hispanic. Age-Adjusted Incidence Rates The AAIR per 100 000 was highest among aggregated NH APIs in both males (20.6, 95% CI = 20.1 to 21.1) and females (6.7, 95% CI = 6.5 to 6.9), followed by Hispanics (12.9, 95% CI = 12.6 to 13.2, in males; 4.2, 95% CI = 4.0 to 4.4, in females), NH blacks (11.9, 95% CI = 11.4 to 12.4, in males; 3.3, 95% CI = 3.1 to 3.6, in females), and NH whites (5.7, 95% CI = 5.6 to 5.8, in males; 1.5, 95% CI = 1.5 to 1.5, in females) (Table 3, Figure 1). However, AAIRs among the Asian subgroups were far more disparate, with the highest in Vietnamese (47.3, 95% CI = 45.0 to 49.6, in males; 14.4, 95% CI = 13.2 to 15.7, in females), Laotians (45.6, 95% CI = 38.4 to 52.7, in males; 12.3, 95% CI = 8.6 to 16.0, in females), and Cambodians (42.8, 95% CI = 36.3 to 49.3, in males; 11.7, 95% CI = 8.6 to 14.8, in females); the lowest in South Asians (6.7, 95% CI = 5.6 to 7.9, in males; 2.8, 95% CI = 2.1 to 3.5, in females) and Japanese (8.1, 95% CI = 7.2 to 8.9, in males; 6.8, 95% CI = 6.2 to 7.4, in females). When disaggregated, Southeast Asians (Vietnamese, Laotian, Cambodian) had an HCC risk eight to nine times higher than that of NH whites and more than twice that of other ethnic Asians. The M:F ratios of AAIRs indicated that for most of the racial/ethnic populations examined, men had more than 3 times the risk of developing HCC as women (Figure 2). Some Asian ethnic groups exhibited lower M:F rate ratios, including Japanese (2.2, 95% CI = 1.8 to 2.7), South Asians (2.4, 95% CI = 1.8 to 3.3), and Koreans (2.6, 95% CI = 2.3 to 3.0). Table 3. Average annual age-specific incidence rate and age-adjusted incidence rate per 100 000 population by sex, race/ethnicity with average annual percent change in rates, invasive HCC, California, 1988–2012 Race/ethnicity Age ≤ 39 y Age 40–49 y Age 50–59 y Age 60–69 y Age 70+ y All ages ASIR Cases ASIR Cases ASIR Cases ASIR Cases ASIR Cases AAIR Cases Males  NH white 0.2 (0.1 to 0.2) 177 3.1 (2.9 to 3.2) 981 14.6 (14.1 to 15.0) 3776 20.1 (19.5 to 20.8) 3702 22.3 (21.6 to 22.9) 4171 5.7 (5.6 to 5.8) 12 807 AAPC 1.4 (−0.4 to 3.3) 5.1 (2.6 to 7.6)* 9.8 (8.8 to 10.9)* 5.3 (4.5 to 6.1)* 3.0 (2.7 to 3.4)* 5.3 (4.9 to 5.6)*  NH black 0.3 (0.2 to 0.3) 48 6.4 (5.6 to 7.2) 250 32.5 (30.4 to 34.7) 886 50.1 (46.6 to 53.5) 816 39.4 (35.9 to 42.9) 479 11.9 (11.4 to 12.4) 2479 AAPC 0.4 (−3.5 to 4.5) 0.8 (−1.5 to 3.1) 7.4 (5.7 to 9.1)* 5.4 (3.9 to 6.9)* 2.8 (0.6 to 5.0)* 4.6 (3.8 to 5.5)*  Hispanic 0.1 (0.1 to 0.2) 144 6.5 (6.1 to 6.9) 1037 28.6 (27.5 to 29.7) 2579 45.9 (44.0 to 47.8) 2173 56.9 (54.3 to 59.4) 1907 12.9 (12.6 to 13.2) 7840 AAPC −1.3 (−3.2 to 0.8) 5.5 (3.4 to 7.6)* 6.7 (6.0 to 7.3)* 4.3 (3.4 to 5.2)* 4.0 (3.2 to 4.8)* 4.7 (4.1 to 5.2)*  NH API 1.2 (1.1 to 1.4) 375 13.6 (12.7 to 14.4) 958 40.3 (38.5 to 42.0) 2060 69.6 (66.7 to 72.5) 2226 89.9 (86.4 to 93.5) 2453 20.6 (20.1 to 21.1) 8072 AAPC −2.0 (−3.4 to –0.6)* −0.3 (−1.7 to 1.1) 0.6 (−0.2 to 1.5) 0.4 (−0.6 to 1.4) 1.3 (0.6 to 2.0)* 0.5 (0.0 to 1.1)*  Chinese 1.8 (1.5 to 2.1) 128 13.9 (12.2 to 15.6) 263 36.4 (33.3 to 39.5) 528 70.4 (65.1 to 75.7) 678 93.5 (87.2 to 99.8) 854 20.8 (20.0 to 21.6) 2451 AAPC −2.3 (−4.6 to 0.1) −1.7 (−3.4 to 0.1) −0.9 (−2.4 to 0.6) −1.7 (−3.0 to – 0.4)* −0.6 (−1.5 to 0.4) −1.3 (−2.0 to –0.6)*  Filipino 0.7 (0.5 to 0.9) 54 8.0 (6.6 to 9.4) 134 23.5 (20.8 to 26.1) 298 37.6 (33.4 to 41.8) 303 69.9 (63.6 to 76.2) 475 13.5 (12.8 to 14.3) 1264 AAPC −4.4 (−7.3 to –1.5)* −0.5 (−3.7 to 2.9) 3.0 (0.1 to 5.9)* 0.3 (−1.4 to 2.2) 1.9 (0.5 to 3.4)* 1.2 (0.3 to 2.1)*  Japanese — — 3.9 (2.3 to 5.4) 23 17.2 (13.4 to 21.0) 79 28.4 (22.8 to 34.0) 98 37.7 (31.5 to 43.9) 142 8.1 (7.2 to 8.9) 343 AAPC — — 0.1 (−3.4 to 3.7) 3.5 (0.0 to 7.0)* 2.3 (−0.6 to 5.3) 3.0 (0.4 to 5.6)*  Korean 0.8 (0.4 to 1.1) 20 20.2 (16.7 to 23.7) 127 55.7 (49.0 to 62.4) 264 98.2 (86.8 to 109.5) 288 98.7 (85.3 to 112.1) 209 26.1 (24.3 to 27.9) 908 AAPC −2.7 (−5.9 to 0.6) −1.8 (−4.6 to 1.2) −1 (−2.8 to 0.8) −1.8 (−4.0 to 0.5) 0.5 (−2.1 to 3.2) −0.5 (−1.8 to 0.7)  South Asian — — — — 8.8 (6.1 to 11.5) 41 22.9 (17.2 to 28.6) 61 37.2 (27.7 to 46.7) 59 6.7 (5.6 to 7.9) 174 AAPC — — — — — 1.8 (−1.6 to 5.2)  Vietnamese 2.6 (2.1 to 3.1) 96 26.6 (23.1 to 30.1) 218 93.6 (85.6 to 101.6) 524 160.8 (147.1 to 174.5) 531 215.9 (196.9 to 234.9 494 47.3 (45.0 to 49.6) 1863 AAPC −1.0 (−4.0 to 2.2) −1.1 (−3.5 to 1.4) 1.9 (0.1 to 3.8)* 1.1 (−0.8 to 3.1) 0.8 (−1.2 to 2.8) 0.3 (−0.8 to 1.4)  Cambodian 2.0 (1.0 to 3.1) 14 45.6 (32.5 to 58.8) 46 106.5 (82.2 to 130.8) 74 138.8 (101.1 to 176.5) 52 114.4 (70.4 to 158.3) 26 42.8 (36.3 to 49.3) 212 AAPC — — −0.7 (−3.4 to 1.9) — — 2.4 (−0.8 to 5.7)  Laotian 4.2 (2.5 to 5.9) 23 29.8 (17.9 to 41.7) 24 101.8 (74.9 to 128.7) 55 159.5 (113.9 to 205.1) 47 174.4 (115.8 to 233.1) 34 45.6 (38.4 to 52.7) 183 AAPC — — −1.6 (−4.6 to 1.5) — — −0.4 (−2.7 to 1.9) Females  NH white 0.1 (0.1 to 0.1) 104 0.8 (0.7 to 0.9) 236 2.7 (2.5 to 2.9) 693 4.9 (4.6 to 5.2) 980 7.4 (7.1 to 7.7) 2010 1.5 (1.5 to 1.5) 4023 AAPC −0.1 (−2.7 to 2.6) 2.2 (0.4 to 3.9)* 6.0 (4.3 to 7.8)* 3.9 (2.6 to 5.2)* 3.5 (2.8 to 4.3)* 3.8 (3.3 to 4.3)*  NH black 0.1 (0.1 to 0.2) 26 1.6 (1.2 to 2.0) 65 7.5 (6.5 to 8.5) 221 13.0 (11.4 to 14.6) 252 13.2 (11.5 to 14.8) 252 3.3 (3.1 to 3.6) 816 AAPC −1.7 (−4.5 to 1.1) 0.4 (−3.0 to 3.8) 7.3 (4.7 to 10.0)* 5.3 (2.8 to 7.9)* 1.6 (−0.2 to 3.4) 3.5 (2.6 to 4.4)*  Hispanic 0.1 (0.1 to 0.1) 84 1.0 (0.8 to 1.1) 149 5.4 (4.9 to 5.9) 515 14.8 (13.8 to 15.8) 831 24.8 (23.4 to 26.2) 1215 4.2 (4.0 to 4.4) 2794 AAPC 0.9 (−1.9 to 3.8) 1.4 (−1.8 to 4.7) 5.8 (3.9 to 7.7)* 4.7 (3.0 to 6.5)* 3.7 (2.3 to 5.2)* 4.0 (3.1 to 4.8)*  NH API 0.3 (0.2 to 0.3) 80 2.3 (1.9 to 2.6) 183 7.1 (6.4 to 7.8) 423 22.5 (21.0 to 23.9) 895 40.9 (38.9 to 43.0) 1517 6.7 (6.5 to 6.9) 3098 AAPC 0.5 (−2.1 to 3.2) 0.0 (−2.5 to 2.6) −1.8 (−3.3 to –0.3)* 0.3 (−1.5 to 2.1) 2.3 (1.1 to 3.6)* 0.8 (0.1 to 1.5)*  Chinese 0.3 (0.2 to 0.4) 21 2.7 (2.0 to 3.3) 59 6.0 (4.8 to 7.2) 99 19.4 (16.8 to 22.0) 215 37.4 (33.9 to 41.0) 426 6.2 (5.7 to 6.6) 820 AAPC — −3.0 (−6.2 to 0.3) −1.3 (−4.6 to 2.1) 0.0 (−2.2 to 2.3) 1.4 (−0.5 to 3.3) 0.8 (−0.4 to 1.9)  Filipino 0.2 (0.1 to 0.2) 12 1.3 (0.8 to 1.7) 27 3.1 (2.2 to 3.9) 52 8.4 (6.8 to 10.1) 97 26.3 (23.1 to 29.5) 256 3.7 (3.3 to 4.0) 444 AAPC — — −3.4 (−6.1 to –0.6)* −1.7 (−5.4 to 2.2) 2.3 (−0.4 to 5) 1.1 (−1.1 to 3.3)  Japanese — — — — 7.5 (5.3 to 9.7) 44 31.5 (26.7 to 36.4) 163 38.2 (33.3 to 43.2) 232 6.8 (6.2 to 7.4) 446 AAPC — — — −6.5 (−10.1 to –2.8)* 6.5 (3.9 to 9.1)* 1.0 (−0.7 to 2.8)  Korean 0.5 (0.3 to 0.8) 15 4.2 (2.7 to 5.6) 33 11.4 (8.6 to 14.1) 66 33.2 (27.3 to 39.0) 124 58.4 (50.0 to 66.7) 186 10.0 (9.0 to 11.0) 424 AAPC — — −4.4 (−7.4 to –1.3)* −2.6 (−5.9 to 0.9) 0.3 (−2.2 to 3.0) −0.9 (−2.8 to 1.1)  South Asian — — — — 4.3 (2.3 to 6.4) 17 8.8 (5.1 to 12.5) 22 16.6 (10.5 to 22.7) 28 2.8 (2.1 to 3.5) 69 AAPC — — — — — 0.6 (−2.9 to 4.1)  Vietnamese 0.4 (0.2 to 0.6) 14 2.3 (1.2 to 3.3) 19 13.7 (10.7 to 16.7) 82 48.3 (41.1 to 55.6) 170 95.5 (83.9 to 107.1) 261 14.4 (13.2 to 15.7) 546 AAPC — — −3.6 (−6.4 to –0.7)* 1.3 (−1.9 to 4.6) 2.6 (0.1 to 5.2)* 4.5 (0.7 to 8.5)*  Cambodian — — 8.5 (3.2 to 13.8) 10 20.8 (10.9 to 30.7) 17 43.4 (23.9 to 62.9) 19 47.7 (24.3 to 71.1) 16 11.7 (8.6 to 14.8) 64 AAPC — — — — — 0.2 (−3.0 to 3.6)  Laotian — — — — — — 62.3 (33.5 to 91.1) 18 49.2 (21.4 to 77.0) 12 12.3 (8.6 to 16.0) 48 AAPC — — — — — 3.4 (0.1 to 6.8)* Race/ethnicity Age ≤ 39 y Age 40–49 y Age 50–59 y Age 60–69 y Age 70+ y All ages ASIR Cases ASIR Cases ASIR Cases ASIR Cases ASIR Cases AAIR Cases Males  NH white 0.2 (0.1 to 0.2) 177 3.1 (2.9 to 3.2) 981 14.6 (14.1 to 15.0) 3776 20.1 (19.5 to 20.8) 3702 22.3 (21.6 to 22.9) 4171 5.7 (5.6 to 5.8) 12 807 AAPC 1.4 (−0.4 to 3.3) 5.1 (2.6 to 7.6)* 9.8 (8.8 to 10.9)* 5.3 (4.5 to 6.1)* 3.0 (2.7 to 3.4)* 5.3 (4.9 to 5.6)*  NH black 0.3 (0.2 to 0.3) 48 6.4 (5.6 to 7.2) 250 32.5 (30.4 to 34.7) 886 50.1 (46.6 to 53.5) 816 39.4 (35.9 to 42.9) 479 11.9 (11.4 to 12.4) 2479 AAPC 0.4 (−3.5 to 4.5) 0.8 (−1.5 to 3.1) 7.4 (5.7 to 9.1)* 5.4 (3.9 to 6.9)* 2.8 (0.6 to 5.0)* 4.6 (3.8 to 5.5)*  Hispanic 0.1 (0.1 to 0.2) 144 6.5 (6.1 to 6.9) 1037 28.6 (27.5 to 29.7) 2579 45.9 (44.0 to 47.8) 2173 56.9 (54.3 to 59.4) 1907 12.9 (12.6 to 13.2) 7840 AAPC −1.3 (−3.2 to 0.8) 5.5 (3.4 to 7.6)* 6.7 (6.0 to 7.3)* 4.3 (3.4 to 5.2)* 4.0 (3.2 to 4.8)* 4.7 (4.1 to 5.2)*  NH API 1.2 (1.1 to 1.4) 375 13.6 (12.7 to 14.4) 958 40.3 (38.5 to 42.0) 2060 69.6 (66.7 to 72.5) 2226 89.9 (86.4 to 93.5) 2453 20.6 (20.1 to 21.1) 8072 AAPC −2.0 (−3.4 to –0.6)* −0.3 (−1.7 to 1.1) 0.6 (−0.2 to 1.5) 0.4 (−0.6 to 1.4) 1.3 (0.6 to 2.0)* 0.5 (0.0 to 1.1)*  Chinese 1.8 (1.5 to 2.1) 128 13.9 (12.2 to 15.6) 263 36.4 (33.3 to 39.5) 528 70.4 (65.1 to 75.7) 678 93.5 (87.2 to 99.8) 854 20.8 (20.0 to 21.6) 2451 AAPC −2.3 (−4.6 to 0.1) −1.7 (−3.4 to 0.1) −0.9 (−2.4 to 0.6) −1.7 (−3.0 to – 0.4)* −0.6 (−1.5 to 0.4) −1.3 (−2.0 to –0.6)*  Filipino 0.7 (0.5 to 0.9) 54 8.0 (6.6 to 9.4) 134 23.5 (20.8 to 26.1) 298 37.6 (33.4 to 41.8) 303 69.9 (63.6 to 76.2) 475 13.5 (12.8 to 14.3) 1264 AAPC −4.4 (−7.3 to –1.5)* −0.5 (−3.7 to 2.9) 3.0 (0.1 to 5.9)* 0.3 (−1.4 to 2.2) 1.9 (0.5 to 3.4)* 1.2 (0.3 to 2.1)*  Japanese — — 3.9 (2.3 to 5.4) 23 17.2 (13.4 to 21.0) 79 28.4 (22.8 to 34.0) 98 37.7 (31.5 to 43.9) 142 8.1 (7.2 to 8.9) 343 AAPC — — 0.1 (−3.4 to 3.7) 3.5 (0.0 to 7.0)* 2.3 (−0.6 to 5.3) 3.0 (0.4 to 5.6)*  Korean 0.8 (0.4 to 1.1) 20 20.2 (16.7 to 23.7) 127 55.7 (49.0 to 62.4) 264 98.2 (86.8 to 109.5) 288 98.7 (85.3 to 112.1) 209 26.1 (24.3 to 27.9) 908 AAPC −2.7 (−5.9 to 0.6) −1.8 (−4.6 to 1.2) −1 (−2.8 to 0.8) −1.8 (−4.0 to 0.5) 0.5 (−2.1 to 3.2) −0.5 (−1.8 to 0.7)  South Asian — — — — 8.8 (6.1 to 11.5) 41 22.9 (17.2 to 28.6) 61 37.2 (27.7 to 46.7) 59 6.7 (5.6 to 7.9) 174 AAPC — — — — — 1.8 (−1.6 to 5.2)  Vietnamese 2.6 (2.1 to 3.1) 96 26.6 (23.1 to 30.1) 218 93.6 (85.6 to 101.6) 524 160.8 (147.1 to 174.5) 531 215.9 (196.9 to 234.9 494 47.3 (45.0 to 49.6) 1863 AAPC −1.0 (−4.0 to 2.2) −1.1 (−3.5 to 1.4) 1.9 (0.1 to 3.8)* 1.1 (−0.8 to 3.1) 0.8 (−1.2 to 2.8) 0.3 (−0.8 to 1.4)  Cambodian 2.0 (1.0 to 3.1) 14 45.6 (32.5 to 58.8) 46 106.5 (82.2 to 130.8) 74 138.8 (101.1 to 176.5) 52 114.4 (70.4 to 158.3) 26 42.8 (36.3 to 49.3) 212 AAPC — — −0.7 (−3.4 to 1.9) — — 2.4 (−0.8 to 5.7)  Laotian 4.2 (2.5 to 5.9) 23 29.8 (17.9 to 41.7) 24 101.8 (74.9 to 128.7) 55 159.5 (113.9 to 205.1) 47 174.4 (115.8 to 233.1) 34 45.6 (38.4 to 52.7) 183 AAPC — — −1.6 (−4.6 to 1.5) — — −0.4 (−2.7 to 1.9) Females  NH white 0.1 (0.1 to 0.1) 104 0.8 (0.7 to 0.9) 236 2.7 (2.5 to 2.9) 693 4.9 (4.6 to 5.2) 980 7.4 (7.1 to 7.7) 2010 1.5 (1.5 to 1.5) 4023 AAPC −0.1 (−2.7 to 2.6) 2.2 (0.4 to 3.9)* 6.0 (4.3 to 7.8)* 3.9 (2.6 to 5.2)* 3.5 (2.8 to 4.3)* 3.8 (3.3 to 4.3)*  NH black 0.1 (0.1 to 0.2) 26 1.6 (1.2 to 2.0) 65 7.5 (6.5 to 8.5) 221 13.0 (11.4 to 14.6) 252 13.2 (11.5 to 14.8) 252 3.3 (3.1 to 3.6) 816 AAPC −1.7 (−4.5 to 1.1) 0.4 (−3.0 to 3.8) 7.3 (4.7 to 10.0)* 5.3 (2.8 to 7.9)* 1.6 (−0.2 to 3.4) 3.5 (2.6 to 4.4)*  Hispanic 0.1 (0.1 to 0.1) 84 1.0 (0.8 to 1.1) 149 5.4 (4.9 to 5.9) 515 14.8 (13.8 to 15.8) 831 24.8 (23.4 to 26.2) 1215 4.2 (4.0 to 4.4) 2794 AAPC 0.9 (−1.9 to 3.8) 1.4 (−1.8 to 4.7) 5.8 (3.9 to 7.7)* 4.7 (3.0 to 6.5)* 3.7 (2.3 to 5.2)* 4.0 (3.1 to 4.8)*  NH API 0.3 (0.2 to 0.3) 80 2.3 (1.9 to 2.6) 183 7.1 (6.4 to 7.8) 423 22.5 (21.0 to 23.9) 895 40.9 (38.9 to 43.0) 1517 6.7 (6.5 to 6.9) 3098 AAPC 0.5 (−2.1 to 3.2) 0.0 (−2.5 to 2.6) −1.8 (−3.3 to –0.3)* 0.3 (−1.5 to 2.1) 2.3 (1.1 to 3.6)* 0.8 (0.1 to 1.5)*  Chinese 0.3 (0.2 to 0.4) 21 2.7 (2.0 to 3.3) 59 6.0 (4.8 to 7.2) 99 19.4 (16.8 to 22.0) 215 37.4 (33.9 to 41.0) 426 6.2 (5.7 to 6.6) 820 AAPC — −3.0 (−6.2 to 0.3) −1.3 (−4.6 to 2.1) 0.0 (−2.2 to 2.3) 1.4 (−0.5 to 3.3) 0.8 (−0.4 to 1.9)  Filipino 0.2 (0.1 to 0.2) 12 1.3 (0.8 to 1.7) 27 3.1 (2.2 to 3.9) 52 8.4 (6.8 to 10.1) 97 26.3 (23.1 to 29.5) 256 3.7 (3.3 to 4.0) 444 AAPC — — −3.4 (−6.1 to –0.6)* −1.7 (−5.4 to 2.2) 2.3 (−0.4 to 5) 1.1 (−1.1 to 3.3)  Japanese — — — — 7.5 (5.3 to 9.7) 44 31.5 (26.7 to 36.4) 163 38.2 (33.3 to 43.2) 232 6.8 (6.2 to 7.4) 446 AAPC — — — −6.5 (−10.1 to –2.8)* 6.5 (3.9 to 9.1)* 1.0 (−0.7 to 2.8)  Korean 0.5 (0.3 to 0.8) 15 4.2 (2.7 to 5.6) 33 11.4 (8.6 to 14.1) 66 33.2 (27.3 to 39.0) 124 58.4 (50.0 to 66.7) 186 10.0 (9.0 to 11.0) 424 AAPC — — −4.4 (−7.4 to –1.3)* −2.6 (−5.9 to 0.9) 0.3 (−2.2 to 3.0) −0.9 (−2.8 to 1.1)  South Asian — — — — 4.3 (2.3 to 6.4) 17 8.8 (5.1 to 12.5) 22 16.6 (10.5 to 22.7) 28 2.8 (2.1 to 3.5) 69 AAPC — — — — — 0.6 (−2.9 to 4.1)  Vietnamese 0.4 (0.2 to 0.6) 14 2.3 (1.2 to 3.3) 19 13.7 (10.7 to 16.7) 82 48.3 (41.1 to 55.6) 170 95.5 (83.9 to 107.1) 261 14.4 (13.2 to 15.7) 546 AAPC — — −3.6 (−6.4 to –0.7)* 1.3 (−1.9 to 4.6) 2.6 (0.1 to 5.2)* 4.5 (0.7 to 8.5)*  Cambodian — — 8.5 (3.2 to 13.8) 10 20.8 (10.9 to 30.7) 17 43.4 (23.9 to 62.9) 19 47.7 (24.3 to 71.1) 16 11.7 (8.6 to 14.8) 64 AAPC — — — — — 0.2 (−3.0 to 3.6)  Laotian — — — — — — 62.3 (33.5 to 91.1) 18 49.2 (21.4 to 77.0) 12 12.3 (8.6 to 16.0) 48 AAPC — — — — — 3.4 (0.1 to 6.8)* * Indicates statistical significance at 95% confidence level. — = data withheld if based on less than 10 cases; AAIR = age-adjusted incidence rate; AAPC = average annual percent change; API = Asian and Pacific Islander; ASIR = age-specific incidence rate; HCC = hepatocellular carcinoma; NH = non-Hispanic. Table 3. Average annual age-specific incidence rate and age-adjusted incidence rate per 100 000 population by sex, race/ethnicity with average annual percent change in rates, invasive HCC, California, 1988–2012 Race/ethnicity Age ≤ 39 y Age 40–49 y Age 50–59 y Age 60–69 y Age 70+ y All ages ASIR Cases ASIR Cases ASIR Cases ASIR Cases ASIR Cases AAIR Cases Males  NH white 0.2 (0.1 to 0.2) 177 3.1 (2.9 to 3.2) 981 14.6 (14.1 to 15.0) 3776 20.1 (19.5 to 20.8) 3702 22.3 (21.6 to 22.9) 4171 5.7 (5.6 to 5.8) 12 807 AAPC 1.4 (−0.4 to 3.3) 5.1 (2.6 to 7.6)* 9.8 (8.8 to 10.9)* 5.3 (4.5 to 6.1)* 3.0 (2.7 to 3.4)* 5.3 (4.9 to 5.6)*  NH black 0.3 (0.2 to 0.3) 48 6.4 (5.6 to 7.2) 250 32.5 (30.4 to 34.7) 886 50.1 (46.6 to 53.5) 816 39.4 (35.9 to 42.9) 479 11.9 (11.4 to 12.4) 2479 AAPC 0.4 (−3.5 to 4.5) 0.8 (−1.5 to 3.1) 7.4 (5.7 to 9.1)* 5.4 (3.9 to 6.9)* 2.8 (0.6 to 5.0)* 4.6 (3.8 to 5.5)*  Hispanic 0.1 (0.1 to 0.2) 144 6.5 (6.1 to 6.9) 1037 28.6 (27.5 to 29.7) 2579 45.9 (44.0 to 47.8) 2173 56.9 (54.3 to 59.4) 1907 12.9 (12.6 to 13.2) 7840 AAPC −1.3 (−3.2 to 0.8) 5.5 (3.4 to 7.6)* 6.7 (6.0 to 7.3)* 4.3 (3.4 to 5.2)* 4.0 (3.2 to 4.8)* 4.7 (4.1 to 5.2)*  NH API 1.2 (1.1 to 1.4) 375 13.6 (12.7 to 14.4) 958 40.3 (38.5 to 42.0) 2060 69.6 (66.7 to 72.5) 2226 89.9 (86.4 to 93.5) 2453 20.6 (20.1 to 21.1) 8072 AAPC −2.0 (−3.4 to –0.6)* −0.3 (−1.7 to 1.1) 0.6 (−0.2 to 1.5) 0.4 (−0.6 to 1.4) 1.3 (0.6 to 2.0)* 0.5 (0.0 to 1.1)*  Chinese 1.8 (1.5 to 2.1) 128 13.9 (12.2 to 15.6) 263 36.4 (33.3 to 39.5) 528 70.4 (65.1 to 75.7) 678 93.5 (87.2 to 99.8) 854 20.8 (20.0 to 21.6) 2451 AAPC −2.3 (−4.6 to 0.1) −1.7 (−3.4 to 0.1) −0.9 (−2.4 to 0.6) −1.7 (−3.0 to – 0.4)* −0.6 (−1.5 to 0.4) −1.3 (−2.0 to –0.6)*  Filipino 0.7 (0.5 to 0.9) 54 8.0 (6.6 to 9.4) 134 23.5 (20.8 to 26.1) 298 37.6 (33.4 to 41.8) 303 69.9 (63.6 to 76.2) 475 13.5 (12.8 to 14.3) 1264 AAPC −4.4 (−7.3 to –1.5)* −0.5 (−3.7 to 2.9) 3.0 (0.1 to 5.9)* 0.3 (−1.4 to 2.2) 1.9 (0.5 to 3.4)* 1.2 (0.3 to 2.1)*  Japanese — — 3.9 (2.3 to 5.4) 23 17.2 (13.4 to 21.0) 79 28.4 (22.8 to 34.0) 98 37.7 (31.5 to 43.9) 142 8.1 (7.2 to 8.9) 343 AAPC — — 0.1 (−3.4 to 3.7) 3.5 (0.0 to 7.0)* 2.3 (−0.6 to 5.3) 3.0 (0.4 to 5.6)*  Korean 0.8 (0.4 to 1.1) 20 20.2 (16.7 to 23.7) 127 55.7 (49.0 to 62.4) 264 98.2 (86.8 to 109.5) 288 98.7 (85.3 to 112.1) 209 26.1 (24.3 to 27.9) 908 AAPC −2.7 (−5.9 to 0.6) −1.8 (−4.6 to 1.2) −1 (−2.8 to 0.8) −1.8 (−4.0 to 0.5) 0.5 (−2.1 to 3.2) −0.5 (−1.8 to 0.7)  South Asian — — — — 8.8 (6.1 to 11.5) 41 22.9 (17.2 to 28.6) 61 37.2 (27.7 to 46.7) 59 6.7 (5.6 to 7.9) 174 AAPC — — — — — 1.8 (−1.6 to 5.2)  Vietnamese 2.6 (2.1 to 3.1) 96 26.6 (23.1 to 30.1) 218 93.6 (85.6 to 101.6) 524 160.8 (147.1 to 174.5) 531 215.9 (196.9 to 234.9 494 47.3 (45.0 to 49.6) 1863 AAPC −1.0 (−4.0 to 2.2) −1.1 (−3.5 to 1.4) 1.9 (0.1 to 3.8)* 1.1 (−0.8 to 3.1) 0.8 (−1.2 to 2.8) 0.3 (−0.8 to 1.4)  Cambodian 2.0 (1.0 to 3.1) 14 45.6 (32.5 to 58.8) 46 106.5 (82.2 to 130.8) 74 138.8 (101.1 to 176.5) 52 114.4 (70.4 to 158.3) 26 42.8 (36.3 to 49.3) 212 AAPC — — −0.7 (−3.4 to 1.9) — — 2.4 (−0.8 to 5.7)  Laotian 4.2 (2.5 to 5.9) 23 29.8 (17.9 to 41.7) 24 101.8 (74.9 to 128.7) 55 159.5 (113.9 to 205.1) 47 174.4 (115.8 to 233.1) 34 45.6 (38.4 to 52.7) 183 AAPC — — −1.6 (−4.6 to 1.5) — — −0.4 (−2.7 to 1.9) Females  NH white 0.1 (0.1 to 0.1) 104 0.8 (0.7 to 0.9) 236 2.7 (2.5 to 2.9) 693 4.9 (4.6 to 5.2) 980 7.4 (7.1 to 7.7) 2010 1.5 (1.5 to 1.5) 4023 AAPC −0.1 (−2.7 to 2.6) 2.2 (0.4 to 3.9)* 6.0 (4.3 to 7.8)* 3.9 (2.6 to 5.2)* 3.5 (2.8 to 4.3)* 3.8 (3.3 to 4.3)*  NH black 0.1 (0.1 to 0.2) 26 1.6 (1.2 to 2.0) 65 7.5 (6.5 to 8.5) 221 13.0 (11.4 to 14.6) 252 13.2 (11.5 to 14.8) 252 3.3 (3.1 to 3.6) 816 AAPC −1.7 (−4.5 to 1.1) 0.4 (−3.0 to 3.8) 7.3 (4.7 to 10.0)* 5.3 (2.8 to 7.9)* 1.6 (−0.2 to 3.4) 3.5 (2.6 to 4.4)*  Hispanic 0.1 (0.1 to 0.1) 84 1.0 (0.8 to 1.1) 149 5.4 (4.9 to 5.9) 515 14.8 (13.8 to 15.8) 831 24.8 (23.4 to 26.2) 1215 4.2 (4.0 to 4.4) 2794 AAPC 0.9 (−1.9 to 3.8) 1.4 (−1.8 to 4.7) 5.8 (3.9 to 7.7)* 4.7 (3.0 to 6.5)* 3.7 (2.3 to 5.2)* 4.0 (3.1 to 4.8)*  NH API 0.3 (0.2 to 0.3) 80 2.3 (1.9 to 2.6) 183 7.1 (6.4 to 7.8) 423 22.5 (21.0 to 23.9) 895 40.9 (38.9 to 43.0) 1517 6.7 (6.5 to 6.9) 3098 AAPC 0.5 (−2.1 to 3.2) 0.0 (−2.5 to 2.6) −1.8 (−3.3 to –0.3)* 0.3 (−1.5 to 2.1) 2.3 (1.1 to 3.6)* 0.8 (0.1 to 1.5)*  Chinese 0.3 (0.2 to 0.4) 21 2.7 (2.0 to 3.3) 59 6.0 (4.8 to 7.2) 99 19.4 (16.8 to 22.0) 215 37.4 (33.9 to 41.0) 426 6.2 (5.7 to 6.6) 820 AAPC — −3.0 (−6.2 to 0.3) −1.3 (−4.6 to 2.1) 0.0 (−2.2 to 2.3) 1.4 (−0.5 to 3.3) 0.8 (−0.4 to 1.9)  Filipino 0.2 (0.1 to 0.2) 12 1.3 (0.8 to 1.7) 27 3.1 (2.2 to 3.9) 52 8.4 (6.8 to 10.1) 97 26.3 (23.1 to 29.5) 256 3.7 (3.3 to 4.0) 444 AAPC — — −3.4 (−6.1 to –0.6)* −1.7 (−5.4 to 2.2) 2.3 (−0.4 to 5) 1.1 (−1.1 to 3.3)  Japanese — — — — 7.5 (5.3 to 9.7) 44 31.5 (26.7 to 36.4) 163 38.2 (33.3 to 43.2) 232 6.8 (6.2 to 7.4) 446 AAPC — — — −6.5 (−10.1 to –2.8)* 6.5 (3.9 to 9.1)* 1.0 (−0.7 to 2.8)  Korean 0.5 (0.3 to 0.8) 15 4.2 (2.7 to 5.6) 33 11.4 (8.6 to 14.1) 66 33.2 (27.3 to 39.0) 124 58.4 (50.0 to 66.7) 186 10.0 (9.0 to 11.0) 424 AAPC — — −4.4 (−7.4 to –1.3)* −2.6 (−5.9 to 0.9) 0.3 (−2.2 to 3.0) −0.9 (−2.8 to 1.1)  South Asian — — — — 4.3 (2.3 to 6.4) 17 8.8 (5.1 to 12.5) 22 16.6 (10.5 to 22.7) 28 2.8 (2.1 to 3.5) 69 AAPC — — — — — 0.6 (−2.9 to 4.1)  Vietnamese 0.4 (0.2 to 0.6) 14 2.3 (1.2 to 3.3) 19 13.7 (10.7 to 16.7) 82 48.3 (41.1 to 55.6) 170 95.5 (83.9 to 107.1) 261 14.4 (13.2 to 15.7) 546 AAPC — — −3.6 (−6.4 to –0.7)* 1.3 (−1.9 to 4.6) 2.6 (0.1 to 5.2)* 4.5 (0.7 to 8.5)*  Cambodian — — 8.5 (3.2 to 13.8) 10 20.8 (10.9 to 30.7) 17 43.4 (23.9 to 62.9) 19 47.7 (24.3 to 71.1) 16 11.7 (8.6 to 14.8) 64 AAPC — — — — — 0.2 (−3.0 to 3.6)  Laotian — — — — — — 62.3 (33.5 to 91.1) 18 49.2 (21.4 to 77.0) 12 12.3 (8.6 to 16.0) 48 AAPC — — — — — 3.4 (0.1 to 6.8)* Race/ethnicity Age ≤ 39 y Age 40–49 y Age 50–59 y Age 60–69 y Age 70+ y All ages ASIR Cases ASIR Cases ASIR Cases ASIR Cases ASIR Cases AAIR Cases Males  NH white 0.2 (0.1 to 0.2) 177 3.1 (2.9 to 3.2) 981 14.6 (14.1 to 15.0) 3776 20.1 (19.5 to 20.8) 3702 22.3 (21.6 to 22.9) 4171 5.7 (5.6 to 5.8) 12 807 AAPC 1.4 (−0.4 to 3.3) 5.1 (2.6 to 7.6)* 9.8 (8.8 to 10.9)* 5.3 (4.5 to 6.1)* 3.0 (2.7 to 3.4)* 5.3 (4.9 to 5.6)*  NH black 0.3 (0.2 to 0.3) 48 6.4 (5.6 to 7.2) 250 32.5 (30.4 to 34.7) 886 50.1 (46.6 to 53.5) 816 39.4 (35.9 to 42.9) 479 11.9 (11.4 to 12.4) 2479 AAPC 0.4 (−3.5 to 4.5) 0.8 (−1.5 to 3.1) 7.4 (5.7 to 9.1)* 5.4 (3.9 to 6.9)* 2.8 (0.6 to 5.0)* 4.6 (3.8 to 5.5)*  Hispanic 0.1 (0.1 to 0.2) 144 6.5 (6.1 to 6.9) 1037 28.6 (27.5 to 29.7) 2579 45.9 (44.0 to 47.8) 2173 56.9 (54.3 to 59.4) 1907 12.9 (12.6 to 13.2) 7840 AAPC −1.3 (−3.2 to 0.8) 5.5 (3.4 to 7.6)* 6.7 (6.0 to 7.3)* 4.3 (3.4 to 5.2)* 4.0 (3.2 to 4.8)* 4.7 (4.1 to 5.2)*  NH API 1.2 (1.1 to 1.4) 375 13.6 (12.7 to 14.4) 958 40.3 (38.5 to 42.0) 2060 69.6 (66.7 to 72.5) 2226 89.9 (86.4 to 93.5) 2453 20.6 (20.1 to 21.1) 8072 AAPC −2.0 (−3.4 to –0.6)* −0.3 (−1.7 to 1.1) 0.6 (−0.2 to 1.5) 0.4 (−0.6 to 1.4) 1.3 (0.6 to 2.0)* 0.5 (0.0 to 1.1)*  Chinese 1.8 (1.5 to 2.1) 128 13.9 (12.2 to 15.6) 263 36.4 (33.3 to 39.5) 528 70.4 (65.1 to 75.7) 678 93.5 (87.2 to 99.8) 854 20.8 (20.0 to 21.6) 2451 AAPC −2.3 (−4.6 to 0.1) −1.7 (−3.4 to 0.1) −0.9 (−2.4 to 0.6) −1.7 (−3.0 to – 0.4)* −0.6 (−1.5 to 0.4) −1.3 (−2.0 to –0.6)*  Filipino 0.7 (0.5 to 0.9) 54 8.0 (6.6 to 9.4) 134 23.5 (20.8 to 26.1) 298 37.6 (33.4 to 41.8) 303 69.9 (63.6 to 76.2) 475 13.5 (12.8 to 14.3) 1264 AAPC −4.4 (−7.3 to –1.5)* −0.5 (−3.7 to 2.9) 3.0 (0.1 to 5.9)* 0.3 (−1.4 to 2.2) 1.9 (0.5 to 3.4)* 1.2 (0.3 to 2.1)*  Japanese — — 3.9 (2.3 to 5.4) 23 17.2 (13.4 to 21.0) 79 28.4 (22.8 to 34.0) 98 37.7 (31.5 to 43.9) 142 8.1 (7.2 to 8.9) 343 AAPC — — 0.1 (−3.4 to 3.7) 3.5 (0.0 to 7.0)* 2.3 (−0.6 to 5.3) 3.0 (0.4 to 5.6)*  Korean 0.8 (0.4 to 1.1) 20 20.2 (16.7 to 23.7) 127 55.7 (49.0 to 62.4) 264 98.2 (86.8 to 109.5) 288 98.7 (85.3 to 112.1) 209 26.1 (24.3 to 27.9) 908 AAPC −2.7 (−5.9 to 0.6) −1.8 (−4.6 to 1.2) −1 (−2.8 to 0.8) −1.8 (−4.0 to 0.5) 0.5 (−2.1 to 3.2) −0.5 (−1.8 to 0.7)  South Asian — — — — 8.8 (6.1 to 11.5) 41 22.9 (17.2 to 28.6) 61 37.2 (27.7 to 46.7) 59 6.7 (5.6 to 7.9) 174 AAPC — — — — — 1.8 (−1.6 to 5.2)  Vietnamese 2.6 (2.1 to 3.1) 96 26.6 (23.1 to 30.1) 218 93.6 (85.6 to 101.6) 524 160.8 (147.1 to 174.5) 531 215.9 (196.9 to 234.9 494 47.3 (45.0 to 49.6) 1863 AAPC −1.0 (−4.0 to 2.2) −1.1 (−3.5 to 1.4) 1.9 (0.1 to 3.8)* 1.1 (−0.8 to 3.1) 0.8 (−1.2 to 2.8) 0.3 (−0.8 to 1.4)  Cambodian 2.0 (1.0 to 3.1) 14 45.6 (32.5 to 58.8) 46 106.5 (82.2 to 130.8) 74 138.8 (101.1 to 176.5) 52 114.4 (70.4 to 158.3) 26 42.8 (36.3 to 49.3) 212 AAPC — — −0.7 (−3.4 to 1.9) — — 2.4 (−0.8 to 5.7)  Laotian 4.2 (2.5 to 5.9) 23 29.8 (17.9 to 41.7) 24 101.8 (74.9 to 128.7) 55 159.5 (113.9 to 205.1) 47 174.4 (115.8 to 233.1) 34 45.6 (38.4 to 52.7) 183 AAPC — — −1.6 (−4.6 to 1.5) — — −0.4 (−2.7 to 1.9) Females  NH white 0.1 (0.1 to 0.1) 104 0.8 (0.7 to 0.9) 236 2.7 (2.5 to 2.9) 693 4.9 (4.6 to 5.2) 980 7.4 (7.1 to 7.7) 2010 1.5 (1.5 to 1.5) 4023 AAPC −0.1 (−2.7 to 2.6) 2.2 (0.4 to 3.9)* 6.0 (4.3 to 7.8)* 3.9 (2.6 to 5.2)* 3.5 (2.8 to 4.3)* 3.8 (3.3 to 4.3)*  NH black 0.1 (0.1 to 0.2) 26 1.6 (1.2 to 2.0) 65 7.5 (6.5 to 8.5) 221 13.0 (11.4 to 14.6) 252 13.2 (11.5 to 14.8) 252 3.3 (3.1 to 3.6) 816 AAPC −1.7 (−4.5 to 1.1) 0.4 (−3.0 to 3.8) 7.3 (4.7 to 10.0)* 5.3 (2.8 to 7.9)* 1.6 (−0.2 to 3.4) 3.5 (2.6 to 4.4)*  Hispanic 0.1 (0.1 to 0.1) 84 1.0 (0.8 to 1.1) 149 5.4 (4.9 to 5.9) 515 14.8 (13.8 to 15.8) 831 24.8 (23.4 to 26.2) 1215 4.2 (4.0 to 4.4) 2794 AAPC 0.9 (−1.9 to 3.8) 1.4 (−1.8 to 4.7) 5.8 (3.9 to 7.7)* 4.7 (3.0 to 6.5)* 3.7 (2.3 to 5.2)* 4.0 (3.1 to 4.8)*  NH API 0.3 (0.2 to 0.3) 80 2.3 (1.9 to 2.6) 183 7.1 (6.4 to 7.8) 423 22.5 (21.0 to 23.9) 895 40.9 (38.9 to 43.0) 1517 6.7 (6.5 to 6.9) 3098 AAPC 0.5 (−2.1 to 3.2) 0.0 (−2.5 to 2.6) −1.8 (−3.3 to –0.3)* 0.3 (−1.5 to 2.1) 2.3 (1.1 to 3.6)* 0.8 (0.1 to 1.5)*  Chinese 0.3 (0.2 to 0.4) 21 2.7 (2.0 to 3.3) 59 6.0 (4.8 to 7.2) 99 19.4 (16.8 to 22.0) 215 37.4 (33.9 to 41.0) 426 6.2 (5.7 to 6.6) 820 AAPC — −3.0 (−6.2 to 0.3) −1.3 (−4.6 to 2.1) 0.0 (−2.2 to 2.3) 1.4 (−0.5 to 3.3) 0.8 (−0.4 to 1.9)  Filipino 0.2 (0.1 to 0.2) 12 1.3 (0.8 to 1.7) 27 3.1 (2.2 to 3.9) 52 8.4 (6.8 to 10.1) 97 26.3 (23.1 to 29.5) 256 3.7 (3.3 to 4.0) 444 AAPC — — −3.4 (−6.1 to –0.6)* −1.7 (−5.4 to 2.2) 2.3 (−0.4 to 5) 1.1 (−1.1 to 3.3)  Japanese — — — — 7.5 (5.3 to 9.7) 44 31.5 (26.7 to 36.4) 163 38.2 (33.3 to 43.2) 232 6.8 (6.2 to 7.4) 446 AAPC — — — −6.5 (−10.1 to –2.8)* 6.5 (3.9 to 9.1)* 1.0 (−0.7 to 2.8)  Korean 0.5 (0.3 to 0.8) 15 4.2 (2.7 to 5.6) 33 11.4 (8.6 to 14.1) 66 33.2 (27.3 to 39.0) 124 58.4 (50.0 to 66.7) 186 10.0 (9.0 to 11.0) 424 AAPC — — −4.4 (−7.4 to –1.3)* −2.6 (−5.9 to 0.9) 0.3 (−2.2 to 3.0) −0.9 (−2.8 to 1.1)  South Asian — — — — 4.3 (2.3 to 6.4) 17 8.8 (5.1 to 12.5) 22 16.6 (10.5 to 22.7) 28 2.8 (2.1 to 3.5) 69 AAPC — — — — — 0.6 (−2.9 to 4.1)  Vietnamese 0.4 (0.2 to 0.6) 14 2.3 (1.2 to 3.3) 19 13.7 (10.7 to 16.7) 82 48.3 (41.1 to 55.6) 170 95.5 (83.9 to 107.1) 261 14.4 (13.2 to 15.7) 546 AAPC — — −3.6 (−6.4 to –0.7)* 1.3 (−1.9 to 4.6) 2.6 (0.1 to 5.2)* 4.5 (0.7 to 8.5)*  Cambodian — — 8.5 (3.2 to 13.8) 10 20.8 (10.9 to 30.7) 17 43.4 (23.9 to 62.9) 19 47.7 (24.3 to 71.1) 16 11.7 (8.6 to 14.8) 64 AAPC — — — — — 0.2 (−3.0 to 3.6)  Laotian — — — — — — 62.3 (33.5 to 91.1) 18 49.2 (21.4 to 77.0) 12 12.3 (8.6 to 16.0) 48 AAPC — — — — — 3.4 (0.1 to 6.8)* * Indicates statistical significance at 95% confidence level. — = data withheld if based on less than 10 cases; AAIR = age-adjusted incidence rate; AAPC = average annual percent change; API = Asian and Pacific Islander; ASIR = age-specific incidence rate; HCC = hepatocellular carcinoma; NH = non-Hispanic. Figure 1. View largeDownload slide Age-adjusted (2000 US standard) incidence rates by sex and race/ethnicity, invasive hepatocellular carcinoma, California, 1988–2012. The error bars represent 95% confidence intervals. API = Asian and Pacific Islander; NH = non-Hispanic. Figure 1. View largeDownload slide Age-adjusted (2000 US standard) incidence rates by sex and race/ethnicity, invasive hepatocellular carcinoma, California, 1988–2012. The error bars represent 95% confidence intervals. API = Asian and Pacific Islander; NH = non-Hispanic. Figure 2. View largeDownload slide Male-to-female (M:F) ratios of age-adjusted incidence rates by race/ethnicity, invasive hepatocellular carcinoma, California, 1988–2012. The error bars represent 95% confidence intervals. API = Asian and Pacific Islander; F = female; M = male; NH = non-Hispanic. Figure 2. View largeDownload slide Male-to-female (M:F) ratios of age-adjusted incidence rates by race/ethnicity, invasive hepatocellular carcinoma, California, 1988–2012. The error bars represent 95% confidence intervals. API = Asian and Pacific Islander; F = female; M = male; NH = non-Hispanic. Trend tests of the AAPCs from 1988–2012 showed a statistically significant (P < .05) rise in HCC incidence for all of the aggregated racial/ethnic populations and some of the Asian subgroups in both males and females, as indicated by the AAPCs (NH whites: +5.3%, 95% CI = 4.9 to 5.6, for males; +3.8%, 95% CI = 3.3 to 4.3, for females; NH blacks: +4.6%, 95% CI = 3.8 to 5.5, for males; +3.5%, 95% CI = 2.6 to 4.4, for females; Hispanics: +4.7%, 95% CI = 4.1 to 5.2, for males; +4.0%, 95% CI = 3.1 to 4.8, for females; NH API: +0.5%, 95% CI = 0.0 to 1.1, for males; +0.8%, 95% CI = 0.1 to 1.5, for females) (Table 3). Among the Asian subgroups, statistically significantly rising AAPCs over the study period were also found in Filipino males (+1.2%, 95% CI = 0.3 to 2.1), Japanese males (+3.0%, 95% CI = 0.4 to 5.6), Vietnamese females (+4.5%, 95% CI = 0.7 to 8.5), and Laotian females (+3.4%, 95% CI = 0.1 to 6.8) (Table 3), despite the downward trends in AAIRs in some ethnic groups in recent years (Table 3, Figure 3, A and B). Chinese males were the only group to experience consistent decline in AAIR, with a statistically significant AAPC of −1.3% (95% CI = −2.0 to −0.6) (Table 3, Figure 3A). Figure 3. View largeDownload slide Age-adjusted incidence rates by sex, race/ethnicity, and time period, invasive hepatocellular carcinoma, California, 1988–2012. Results are shown separately for (A) males and (B) females. API = Asian and Pacific Islander; NH = non-Hispanic. Figure 3. View largeDownload slide Age-adjusted incidence rates by sex, race/ethnicity, and time period, invasive hepatocellular carcinoma, California, 1988–2012. Results are shown separately for (A) males and (B) females. API = Asian and Pacific Islander; NH = non-Hispanic. Age-Specific Incidence Rates Similar to the racial/ethnic risk patterns in the AAIRs, NH whites and South Asians had the lowest ASIRs across all age groups (Table 3, Figure 4, A and B). Furthermore, the ASIRs revealed that the HCC risk increased with age in most racial/ethnic groups and the risk disparities between groups also grew markedly with age. Although based on small numbers, Cambodians and Laotians younger than age 60 years appeared to have higher HCC risk than Vietnamese (Figure 4, A and B). Figure 4. View largeDownload slide Age-specific incidence rates by sex and race/ethnicity, invasive hepatocellular carcinoma, California, 1988–2012. Results are shown separately for (A) males and (B) females. API = Asian and Pacific Islander; NH = non-Hispanic. Figure 4. View largeDownload slide Age-specific incidence rates by sex and race/ethnicity, invasive hepatocellular carcinoma, California, 1988–2012. Results are shown separately for (A) males and (B) females. API = Asian and Pacific Islander; NH = non-Hispanic. The trend analysis in ASIR among NH whites, NH blacks, and Hispanics underscored the statistically significant increasing temporal trends in most age groups, with the largest AAPCs found in the age group 50–59 years (Table 3). However, while decreasing trends in ASIRs were observed in some of the Asian ethnic groups, especially in males (Chinese, Filipino, Korean), rising temporal trends were noted in some older females (Chinese, Filipina) and males as well (Japanese, Vietnamese). ASIRs based on fewer than 10 cases and associated AAPCs were not shown in Table 3 for groups including South Asians, Cambodians, and Laotians. Discussion Using population-based CCR data, we conducted a systematic and focused evaluation of HCC incidence rates and temporal trends in four aggregated racial/ethnic groups and eight disaggregated Asian ethnic groups during a 25-year span of 1988–2012. As a whole, APIs had statistically significantly higher HCC risk than NH whites, NH blacks, and Hispanics, regardless of sex. When disaggregated, Southeast Asians (Vietnamese, Cambodian, and Laotian) had exceedingly high overall HCC incidence rates, eight to nine times higher than those of NH whites and more than twice as high as other ethnic Asians. Japanese and South Asians had the lowest HCC risk among ethnic Asians, and both groups also had lower M:F rate ratios. Statistically significant rising temporal trends of HCC were found in NH whites, NH blacks, and Hispanics overall, especially those age 50–59 years. Although overall HCC risk declined statistically significantly in Chinese males, it rose statistically significantly in Filipino and Japanese males and Vietnamese and Laotian females. There are few population-based reports on liver cancer or HCC incidence rates and trends for disaggregated Asian-American subgroups (17–19,25–28). One major study examined incidence rates in disaggregated Asians in the California Bay Area, but it was not age specific, had fewer subgroups than the present study, and did not include Southern California, home to one of the largest Asian-American populations in the United States (28). Another study disaggregated Asian data but was not age specific (27). Others have conducted similarly diverse disaggregated studies that examined survival and treatment differences (29,30). To our knowledge, the present study provides the most comprehensive examination of HCC incidence temporal trends and characteristics in the United States, including subgroups of Asian Americans. Our findings confirmed the rising AAIR trends in NH whites, NH blacks, and Hispanics reported by others (9). The HCC risk in these groups statistically significantly increased at nearly all ages during the past 25 years, likely due to rises in alcoholic liver disease, nonalcoholic steatohepatitis, and chronic HCV infection. Obesity and diabetes have also been linked to HCC (2,31,32). Recent studies have suggested that HCC incidence rates in APIs were decreasing or stable (9,33), but the wide variation in incidence rates and temporal trends among Asian subgroups found in our study further highlights the importance of disaggregating APIs in order to reveal the group’s heterogeneity and more precisely identify the people in highest need of targeted interventions. The differences in HCC risk among Asian subgroups correlate with prevalence of HBV among these groups. Among foreign-born Asians in the United States, HBV prevalence rates range from 0.6% among Japanese to 12.5% in Vietnamese and 13.6% in Laotians (11). The high HCC risk among Southeast Asians is directly attributable to their high proportion (more than 97%) of foreign-born individuals from one of the highest-risk regions in the world. In contrast to Southeast Asians, we found that the proportion of foreign-born individuals was lowest in Japanese HCC patients (63.4%), which is consistent with previous findings (27,34). The most commonly implicated cause of HCC among native Japanese is HCV (35), which is also likely the leading cause in foreign-born Japanese in the United States (35–38). The HCC incidence rate has been rising statistically significantly in Japanese males overall and in older Japanese females age 70 years and older. The higher percentage of female HCC patients (56.5%) among Japanese maybe due to the higher proportion of females in older age groups. While the androgen-driven nature of HCC (39) can partially explain the male predominance in HCC incidence, the varying M:F rate ratios by race/ethnicity are of great interest but poorly understood at this point. The lower M:F ratios in Japanese and South Asians may be related to their lowest HCC risk among nonwhites and lower prevalence of HBV as compared with other Asian ethnic groups. Sex differences in cancer susceptibility are understudied but important, as they may hold important clues regarding the etiology of cancer (40). Similar to previous reports (13,41), we also saw marked increases of early-stage HCC diagnosis with a concomitant decrease in late- and unknown-stage diseases across all racial/ethnic groups, especially in the high-risk Vietnamese. These observations likely indicate the successes of outreach efforts promoting HBV testing and vaccination and improved staging of HCC, as well as heightened surveillance imaging in patients with underlying chronic liver disease. However, such progress was not as pronounced in Laotians, whose percentage of distant diagnoses was the highest in 2004–2012. Laotians had the second-highest concentration of patients with low SES, and one of the highest HCC risks for those younger than age 60 years. While the Laotian staging and age disparities may be artifacts of low case counts, they may also reflect the large proportion of low-SES Laotians who lack access to health care. Nevertheless, this highlights the need for targeted interventions in this ethnic group. HCC outreach efforts need to target individual ethnic Asian immigrant communities considering their specific needs, for which disaggregated research can provide much needed information. However, the importance of disaggregated analysis as shown in our study is not limited to Asian Americans. Every major racial/ethnic population, whether it is white, black, or Hispanic, includes heterogeneous subgroups of different backgrounds and disease profiles. This issue is particularly relevant to Hispanics, as recent research has revealed cancer incidence and mortality disparities among disaggregated Hispanic subgroups (42,43). The limitations of our study are inherent to using cancer registry data, the accuracy of which largely depends on the quality of information reported from medical facilities. Nonetheless, the CCR has been consistently recognized by NAACCR as having the highest quality of data. There were relatively fewer cases in specific Asian subgroups, but these remain the most robust published data to date. The change from SS 1977 to SS 2000 has been found to cause a stage distribution shift for liver cancer resulting in an increase in regional disease and decrease in distant disease (44), which may trigger concern for bias in our findings of stage improvement. However, the substantial increases in the proportion of localized disease observed in our analysis across racial/ethnic groups should be independent of the known “stage migration” between the two versions of the summary staging systems, indicating real progress in early detection of HCC. Misclassification of race/ethnicity may occur in cancer registry data, which would likely result in underestimated risk for minority groups, particularly Vietnamese (45), and actually underestimate their already disproportionate HCC risk. Given the general agreement between our findings and those reported by others on the same population groups, we feel confident in our results. In summary, our findings demonstrate the striking HCC risk disparities and temporal trends among the diverse racial/ethnic populations in California, especially the heterogeneous Asian subgroups. The statistically significant rises in overall HCC incidence across all major aggregated racial/ethnic groups highlight the urgency for continued HCC prevention and surveillance efforts. The importance of disaggregated examinations in health research by population subgroup has implications for all other aggregated groups, particularly Hispanics. Funding The collection of cancer incidence data used in this study was supported by the California Department of Public Health pursuant to California Health and Safety Code Section 103885; the Centers for Disease Control and Prevention’s National Program of Cancer Registries, under cooperative agreement 5NU58DP003862-04/DP003862; and the National Cancer Institute’s Surveillance, Epidemiology, and End Results Program under contract HHSN261201000140C, awarded to the Cancer Prevention Institute of California; contract HHSN261201000035C, awarded to the University of Southern California; and contract HHSN261201000034C, awarded to the Public Health Institute. Notes Affiliations of authors: The Doctor of Medicine Program (CP), Division of Gastrointestinal and Liver Diseases, Department of Medicine (TLF), Los Angeles Cancer Surveillance Program, Department of Preventive Medicine (JZ, LL), Keck School of Medicine, University of Southern California, Los Angeles, CA. 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JNCI: Journal of the National Cancer InstituteOxford University Press

Published: Mar 30, 2018

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