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Characteristics of incident liver cancer 
cases in the District of Columbia 
metropolitan area 
Nandita Krishnan1*, Lorien C Abroms1,2, Kim Robien2,3, Daisy Le1,2,4, Y Tony Yang2,4,5, Farshad Aduli6 

1 Department of Prevention and Community Health, Milken Institute School of Public Health, The George 
Washington University, Washington, D.C. 20052, USA 2 The George Washington University Cancer Center, 
The George Washington University, Washington, D.C. 20052, USA 3 Department of Exercise and Nutrition 
Sciences, Milken Institute School of Public Health, The George Washington University, Washington, D.C. 
20052, USA 4 Department of Policy, Populations, and Systems, The George Washington University School 
of Nursing, Washington, D.C. 20052, USA 5 Department of Health Policy and Management, Milken Institute 
School of Public Health, The George Washington University, Washington, D.C. 20052, USA 6Division of 
Gastroenterology and Hepatology, Howard University Hospital, Washington, D.C. 20060, USA 
*Corresponding author: Nandita Krishnan, nkrishnan@gwu.edu. 

ABSTRACT 
The District of Columbia (D.C.) has the highest liver cancer incidence in the United States (U.S.), but the reasons 
for this are not fully known. We examined socio-demographic, clinical and behavioral characteristics of incident 
liver cancer cases in D.C., Maryland (MD) and Virginia (VA) to identify potential risk factors. We obtained data 
from D.C., MD and VA cancer registries for individuals diagnosed with hepatocellular carcinoma (HCC) or 
intrahepatic cholangiocarcinoma (ICC) between 2013 and 2016. We estimated age-adjusted incidence rates 
and conducted descriptive analyses stratified by state/territory, sex, stage at diagnosis, and race/ethnicity. 5,928 
incident HCC/ICC cases occurred between 2013-2016. Age-adjusted incidence rates (per 100,000) for HCC/ICC 
were highest in D.C. (12.2, 95% CI=10.9, 13.5), for males (12.6, 95% CI=12.2, 12.9), and non-Hispanic Blacks (11.3, 
95% CI=10.8, 11.8) and Asian/Pacific Islanders (APIs) (10.8, 95% CI=9.7, 11.9). Racial disparities in HCC/ICC 
incidence were widest in D.C. A substantial proportion of cases were missing data on country of birth and 
behavioral risk factors. Mean age at diagnosis, marital status, country of birth, insurance status, and alcohol 
and tobacco use history varied across analytic sub-groups. Non-Hispanic Blacks, APIs and males experience a 
high burden of liver cancer in the D.C. metropolitan area. There are several socio-demographic disparities by 
state/territory, sex, and race/ethnicity. More data on country of birth, behavioral risk factors, and comorbidities 
are urgently needed to understand their contribution to the burden of liver cancer in the D.C. metropolitan 
area. 

KEYWORDS: Hepatocellular carcinoma, intrahepatic cholangiocarcinoma, epidemiology, disparities. 

Citation: Krishnan N et al (2022) Characteristics of incident liver cancer cases in the District of Columbia 
metropolitan area. Cancer Health Disparities. 6:e1-12. doi:10.9777/chd.2021.1005   



 
 
 
 
 

 
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INTRODUCTION 
Liver cancer incidence has been increasing in the 
United States (U.S.) (Siegel et al., 2020). In 2020, it 
accounted for 30,160 deaths and was the fifth 
leading cause of cancer deaths for men and the 
seventh leading cause of cancer deaths for women 
(Siegel et al., 2020). Liver and intrahepatic bile duct 
cancers are projected to become the third leading 
cause of cancer deaths in the U.S. by 2040 (Rahib 
et al., 2021). Between 2014 and 2018, the District of 
Columbia (D.C.) had the highest age-adjusted liver 
cancer incidence rate (per 100,000) in the U.S. (12.4 
(overall), 19.5 (males), 6.6 (females)) (USCS, 2021). In 
contrast, the surrounding states of Maryland (MD) 
and Virginia (VA) had relatively lower incidence 
rates (MD: 8.8 (overall), 13.5 (males), 4.8 (females); 
VA: 7.5 (overall), 11.6 (males), 4.1 (females)) (USCS, 
2021). While there are several hypotheses for the 
high incidence of liver cancer in D.C., little is 
definitively known about the populations 
experiencing the burden of liver cancer, as well as 
factors that could account for these differences in 
liver cancer incidence rates between D.C. and its 
neighboring states, and the clinical and behavioral 
risk factors driving liver cancer incidence in the D.C. 
metropolitan area. 

Current data indicates that there are racial and 
ethnic disparities in liver cancer incidence in D.C. 
Non-Hispanic Blacks (17.0/100,000, 95% CI=15.2, 
18.9) have an age-adjusted incidence rate three 
times higher than non-Hispanic Whites 
(5.3/100,000, 95% CI=4.1, 6.8) (USCS, 2021). 
Hepatitis B virus (HBV) and hepatitis C virus (HCV) 
are prominent clinical risk factors for hepatocellular 
carcinoma (HCC) and intrahepatic 
cholangiocarcinoma (ICC) (de Martel et al., 2015; 
Massarweh & El-Serag, 2017), the two most 
common types of liver cancer. HBV and HCV are 
endemic in several countries in Africa and Asia 
(World Health Organization, 2021a, 2021b). 

Approximately 15% of the D.C. population is 
estimated to be foreign born (Tatian et al., 2018; The 
Metropolitan Washington Council of Governments, 
2017), and migration of individuals from HBV and 
HCV endemic countries to D.C. could be 
contributing to the high incidence of liver cancer. 
Behavioral risk factors may also play a role. Tobacco 
use and heavy alcohol use are recognized risk 
factors for HCC and ICC (Petrick et al., 2018), and 
there is also evidence that links obesity to a higher 
liver cancer risk (Campbell et al., 2016). D.C. has one 
of the highest rates of binge drinking in the U.S. 
(Centers for Disease Control and Prevention, 2020). 
Additionally, almost a quarter of adults in D.C. are 
obese, with a particularly high prevalence among 
non-Hispanic Blacks (38%) (Centers for Disease 
Control and Prevention, 2021). 

While state level liver cancer incidence data is 
publicly available from USCS, several gaps exist in 
the information provided by current data. One 
limitation is that USCS estimates aggregate HCC 
and ICC. Although these two types of liver cancers 
share several risk factors, they also have unique risk 
factors and etiologies (Massarweh & El-Serag, 
2017). Thus, there is a need to independently 
monitor HCC and ICC trends to better inform 
prevention and control efforts. USCS enables 
comparisons of liver cancer incidence and mortality 
only across select socio-demographic 
characteristics, such as sex and race/ethnicity. More 
research that examines a wider range of factors is 
needed to characterize the liver cancer population 
in the D.C. area and identify prevailing risk factors 
to inform the development of targeted 
interventions. Additionally, owing to the proximity 
of D.C. to MD and VA, and fluid population 
movement between D.C. and these neighboring 
states (Maciag, 2018; Rabinowitz, 2017), 
understanding the profile of liver cancer cases in 
MD and VA can provide a more comprehensive 
picture of risk factors for liver cancer in the D.C. 



 
 
 
 
 

 
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metropolitan area. Therefore, the objective of this 
study was to identify socio-demographic, clinical, 
and behavioral characteristics of incident liver 
cancer cases in D.C., MD and VA over a four-year 
period (2013-2016). Additionally, we aimed to 
examine characteristics of incident liver cancer 
cases stratified by sex, stage at diagnosis, and 
race/ethnicity. 

METHODS 
Data and sample 
Data were requested and obtained from the DC, 
MD, and VA cancer registries. The inclusion criteria 
for this analysis were a diagnosis: (i) of HCC (ICD-
10-CM code: C22.0) or ICC (ICD-10-CM code: 
C22.1), (ii) in D.C., MD or VA, (iii) between 2013 and 
2016. A total of 5,928 incident HCC/ICC cases were 
identified during this period and included in the 
analysis. 

Measures 
For each incident HCC/ICC case, the following 
variables were requested from the respective 
cancer registry: 

Socio-demographic characteristics: age at diagnosis, 
sex, race, ethnicity, marital status, country of birth, 
and health insurance based on primary payer at 
diagnosis. 

Clinical characteristics: primary cancer site, stage at 
diagnosis based on SEER summary stage 2000, 
family history, and comorbid complications, 
obtained as ICD-9-CM codes. 

Behavioral risk factors: alcohol and tobacco use 
history 

Analysis 
Data cleaning included recoding and creating 
calculated variables. The following variables were 
collapsed and/or recoded as follows: combined 
race and ethnicity (non-Hispanic White, non-

Hispanic Black, Hispanic, Asian/Pacific Islander 
(API), and other); marital status (single (including 
unmarried and domestic partner), married 
(including common law), and separated, divorced 
or widowed); U.S. born (yes/no); health insurance 
(not insured, private insurance, Medicaid, Medicare, 
uniformed services (including TRICARE, Military and 
VA), and other); stage at diagnosis (localized, 
regional, and distant); family history of cancer (no 
history, history of liver cancer (including liver cancer 
only or liver and other cancer), and history of other 
cancer only (including type of cancer not specified)); 
alcohol history (never use, current use, and past 
use); tobacco history (never use, current use 
(including combustible only, smokeless only, and 
combination tobacco product use), and past use). 
As a different number of comorbidity fields were 
provided by each registry, this variable was not 
included in the analysis and instead summarized 
based on the primary comorbidity recorded. For all 
variables, unknown or missing was treated as an 
independent category, except for race/ethnicity 
and health insurance, where it was combined with 
“other”. 

Age-adjusted incidence rates for 2013-2016 were 
calculated for all sites (HCC and ICC) combined and 
by primary site (HCC or ICC) across state/territory, 
sex, and race/ethnicity. Additionally age-adjusted 
incidence rates were calculated by sex and 
race/ethnicity within each state/territory. Incidence 
rates were age-adjusted to the 2000 U.S. standard 
population using 19 age groups, and confidence 
intervals (CIs) for incidence rates were estimated 
using the method proposed by Keyfitz (1966). Rates 
were suppressed for sub-groups with 1-15 cases 
due to low reliability, and counts for variables by 
state/territory were suppressed for cells with <10 
cases for confidentiality. 

Descriptive analyses, stratified by state/territory, sex, 
stage at diagnosis, and race/ethnicity were 



 
 
 
 
 

 
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conducted. Tests for statistically significant 
differences between groups were conducted using 
chi-square tests for categorical variables and t-tests 
or ANOVA for continuous variables. All analyses 
were conducted using Stata version 14. A p-value of 
0.05 was considered statistically significant. 

Ethical approval 
This research was approved by the George 
Washington Cancer Center Protocol Review and 
Monitoring Committee, and the Institutional Review 
Boards of the George Washington University, and 
the D.C., MD and VA Departments of Health 

RESULTS 
A summary of sample characteristics is provided in 
Table 1. Several variables had missing data. Family 
history, alcohol history, and tobacco history data 
were not available for MD and were missing for a 
large proportion of cases in D.C. and VA (>34%). 
Country of birth was missing for almost half the 
overall sample (48.5%), and for a majority of cases 
from VA (70.8%). A sizable proportion of cases were 
also missing data for stage at diagnosis (31.1%). 

 

Table 1. Characteristics of incident liver cancer cases in D.C., Maryland and Virginia by state/territory and sex 
(2013-2016). 

Variable State/territory Sex 

 Total 
(N=5,928) 

D.C. 
(N=343) 

Maryland 
(N=2,559) 

Virginia 
(N=3,026) 

Male 
(N=4,209) 

Female 
(N=1,719) 

Incidence rate/100,000 (95% 
CI)a (HCC and ICC) 

8.2 
(8.0, 8.4) 

12.2 
(10.9, 13.5) 

8.8 
(8.5, 9.2) 

7.6 
(7.3, 7.8) 

12.6 
(12.2, 12.9) 

4.5 
(4.3 – 4.7) 

Incidence rate/100,000 (95% 
CI)a (HCC only) 

7.0 
(6.8, 7.2) 

10.7 
(9.5, 11.9) 

7.5 
(7.2, 7.8) 

6.4 
(6.1, 6.6) 

11.2 
(10.8, 11.5) 

3.4 
(3.2 – 3.6) 

Incidence rate/100,000 (95% 
CI)a (ICC only) 

1.2 
(1.1, 1.3) 

1.5 
(1.0, 1.9) 

1.3 
(1.2, 1.4) 

1.2 
(1.1 – 1.3) 

1.4 
(1.2 – 1.5) 

1.1 
(1.0 – 1.2) 

Socio-demographics 

Age at diagnosis, mean (SD) 64.6 (11.7) 62.7 (11.8) 64.7 (11.8) 64.7 (11.7)* 63.8 (10.9) 66.7 (13.3)**b 

Male, n (%) 4,209 (71.0) 245 (71.4) 1,809 (70.7) 2,155 (71.2) -- -- 

Race/ethnicity, n (%) 
Non-Hispanic White 
Non-Hispanic Black 
Hispanic 
API 
Other/Unknown/Missing 

 
3,312 (55.9) 
1,928 (32.5) 

181 (3.1) 
367 (6.2) 
140 (2.4) 

 
35 (10.2) 

286 (83.4) 
10 (2.9) 

<10 
<10 

 
1,359 (53.1) 
932 (36.4) 
89 (3.5) 

s 
s 

 
1,918 (63.4)** 

710 (23.5) 
82 (2.7) 
207 (6.8) 
109 (3.6) 

 
2,339 (55.6) 
1,418 (33.7) 

107 (2.5) 
251 (6.0) 
94 (2.2) 

 
973 (56.6)** 
510 (29.7) 
74 (4.3) 
116 (6.8) 
46 (2.7) 

Marital status, n (%) 
Single 
Married  

 
1,275 (21.5) 
2,462 (41.5) 

 
160 (46.7) 
85 (24.8) 

 
579 (22.6) 

1,030 (40.3) 

 
536 (17.7)** 
1,347 (44.5) 

 
966 (23.0) 

1,875 (44.6) 

 
309 (18.0)** 
587 (34.2) 



 
 
 
 
 

 
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Separated/Divorced/ 
Widowed 
Unknown/Missing 

1,241 (20.9) 
950 (16.0) 

82 (23.9) 
16 (4.7) 

458 (17.9) 
492 (19.2) 

701 (23.2) 
442 (14.6) 

745 (17.7) 
623 (14.8) 

496 (28.9) 
327 (19.0) 

U.S. born, n (%) 
No 
Yes 
Unknown/Missing 

 
353 (6.0) 

2,699 (45.5) 
2,876 (48.5) 

 
38 (11.1) 

182 (53.1) 
123 (35.9) 

 
146 (5.7) 

1,801 (70.4) 
612 (23.9) 

 
169 (5.6)** 
716 (23.7) 

2,141 (70.8) 

 
222 (5.3) 

1,981 (47.1) 
2,006 (47.7) 

 
131 (7.6)** 
718 (41.8) 
870 (50.6) 

Health insurance, n (%) 
Not insured 
Private Insurance 
Medicaid 
Medicare 
Uniformed services 
Other/Unknown/Missing 

 
258 (4.4) 

1,420 (24.0) 
529 (8.9) 

2,377 (40.1) 
235 (4.0) 

1,109 (18.7) 

 
<10 

66 (19.2) 
91 (26.5) 
104 (30.3) 

<10 
70 (20.4) 

 
s 

636 (24.9) 
258 (10.1) 

1,059 (41.4) 
s 

483 (18.9) 

 
192 (6.4)** 
718 (23.7) 
180 (6.0) 

1,214 (40.1) 
166 (5.5) 
556 (18.4) 

 
206 (4.9) 

1,026 (24.4) 
401 (9.5) 

1,611 (38.3) 
219 (5.2) 
746 (17.7) 

 
52 (3.0)** 
394 (22.9) 
128 (7.5) 

766 (44.6) 
16 (1.0) 

363 (21.1) 

Clinical 
HCC, n (%) 5,082 (85.7) 304 (88.6) 2,196 (85.8) 2,582 (85.3) 3,788 (90.0) 1,294 (75.3)** 

Stage at diagnosis, n (%) 

Localized 
Regional 
Distant 
Unknown/Missing 

 
2,043 (34.5) 
1,187 (20.0) 
854 (14.4) 
1,844 (31.1) 

 
127 (37.0) 
58 (16.9) 
48 (14.0) 
110 (32.1) 

 
926 (36.2) 
546 (21.3) 
380 (14.9) 
707 (27.6) 

 
990 (32.7)** 
583 (19.3) 
426 (14.1) 

1,027 (33.9) 

 
1,495 (35.5) 
880 (20.9) 
592 (14.1) 

1,242 (29.5) 

 
548 (31.9)** 
307 (17.9) 
262 (15.2) 
602 (35.0) 

Family history, n (%)  
No history 
Liver cancerc 

Other cancer only/not 
specified 
Unknown/Missing 

 
(N=3,369) 
864 (25.7) 

65 (1.9) 
845 (25.1) 

1,595 (47.3) 

 
78 (22.7) 
0 (0.0) 

69 (20.1) 
196 (57.1) 

  
786 (26.0)** 

65 (2.2) 
776 (25.6) 

1,399 (46.2) 

 
652 (27.2) 
49 (2.0) 

550 (22.9) 
1,149 (47.9) 

 
212 (21.9)** 

16 (1.7) 
295 (30.4) 
446 (46.0) 

Behavioral 
Alcohol history, n (%)  

Never use 
Current use 
Past use 
Unknown/Missing 

(N=3,369) 
879 (26.1) 

1,200 (35.6) 
57 (1.7) 

1,233 (36.6) 

 
50 (14.6) 

s 
s 

169 (49.3) 

  
829 (27.4)** 

s 
<10 

1,064 (35.2) 

 
502 (20.9) 
979 (40.8) 

46 (1.9) 
873 (36.4) 

 
377 (38.9)** 
221 (22.8) 

11 (1.1) 
360 (37.2) 

Tobacco history, n (%)  
Never user 
Current user 
Past user 
Unknown/Missing 

(N=3,369) 
670 (19.9) 
709 (21.0) 
823 (24.4) 
1,167 (34.6) 

 
50 (14.6) 
63 (18.4) 
63 (18.4) 
167 (48.7) 

  
620 (20.5)** 
646 (21.4) 
760 (25.1) 

1,000 (33.1) 

 
349 (14.5) 
581 (24.2) 
637 (26.5) 
833 (34.7) 

 
321 (33.1)** 
128 (13.2) 
186 (19.2) 
334 (34.5) 

Notes. % = column totals; blank cells = data not available; <10 = case counts of 1-9 are suppressed for 
confidentiality; s = case counts are suppressed to prevent back calculation of counts in other cell(s); 
SD=standard deviation; *p<0.05, **p<0.0001  



 
 
 
 
 

 
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aIncidence rate age-adjusted to the 2000 U.S. standard population; bOne-way ANOVA with post-hoc 
Bonferroni adjustment indicated that mean age in DC was significantly different from MD and VA; cIncludes 
liver cancer only or liver and other cancer 
 
The overall age-adjusted incidence rate of HCC/ICC 
for D.C., MD and VA between 2013-2016 was 
8.2/100,000 (95% CI=8.0, 8.4), with a higher 
incidence rate for HCCs (7.0/100,000, 95% CI=6.8, 
7.2) than for ICCs (1.2/100,000, 95% CI=1.1, 1.3). The 
mean age at diagnosis was 64.6 years (standard 
deviation (SD)=11.7). The majority of cases were 
male (71%) and non-Hispanic White (55.9%). 
Almost half the sample was U.S. born (45.5%). A 
large proportion of cases were married at the time 
of diagnosis (41.5%), and a sizable proportion of 
cases had Medicare insurance (40.1%). In terms of 
clinical characteristics, a majority of cases were 
HCCs (85.7%) and commonly diagnosed at the 
localized stage (34.5%). The most commonly 
recorded primary comorbidities were hypertension 
(6.3%), HCV (4%), alcoholic liver cirrhosis (3.3%), 
and diabetes (3%). A larger proportion of 
individuals currently used alcohol (35.6%) 
compared to tobacco (21%). 

Differences in characteristics between incident 
HCC/ICC cases in D.C., MD and VA are also 
provided in Table 1. Of the 5,928 HCC/ICC cases, 
343 occurred in D.C., 2,559 occurred in MD, and 
3,026 occurred in VA. The HCC/ICC incidence rate 
was highest in D.C. (12.2/100,000, 95% CI=10.9, 13.5) 
and lowest in VA (7.6/100,000, 95% CI=7.3, 7.8). 
Similar trends in HCC and ICC incidence rates were 
observed when evaluated separately, although 
differences in ICC incidence rates across D.C., MD, 
and VA were not statistically significant. Incidence 
rates in D.C., MD and VA did differ by sex and 
race/ethnicity. Incidence rates were higher for 
males in all 3 states/territories, and incidence rates 
for males (18.9/100,000, 95% CI=16.5, 21.3) and 
females (6.6/100,000, 95% CI=5.3, 7.9) were highest 

in D.C. (Figure 1). Racial disparities were wider in 
D.C. compared to MD and VA (Figure 2). Socio-
demographic characteristics of liver cancer cases in 
D.C. were also significantly different from MD and 
VA with regard to mean age of diagnosis, which was 
lower (62.7 years (D.C.) vs 64.7 years (MD, VA)). D.C. 
had a higher proportion of individuals who were 
single or unmarried (46.7% (D.C.) vs 22.6% (MD), 
17.7% (VA)), non-U.S. born (11.1 (D.C.) vs 5.7% (MD), 
5.6% (VA)), and covered by Medicaid (26.5% (D.C.) 
vs 10.1% (MD), 6% (VA)). 

Figure 1. Age-adjusted incidence rate of liver 
cancer (2013-2016) in D.C., Maryland and Virginia 
by sex 

 



 
 
 
 
 

 
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Figure 2. Age-adjusted incidence rate of liver 
cancer in D.C., Maryland and Virginia by 
race/ethnicity 

 

Note. Rates for Hispanics and APIs in D.C. were 
suppressed for reliability as the number of cases 
was below 15. 

Sex-stratified analyses are also presented in Table 1. 
The incidence rate for males (12.6/100,000, 95% 
CI=12.2, 12.9) was almost three times the rate for 
females (4.5/100,000, 95% CI=4.3, 4.7). This trend 
held for HCCs, but the ICC incidence rate was only 
marginally higher for males (1.4/100,000, 95% 
CI=1.2, 1.5) compared to females (1.1/100,000, 95% 

CI=1.0, 1.2). Males differed from females with 
respect to younger age at diagnosis (63.8 years vs 
66.7 years). Males were more likely to be non-
Hispanic Black compared to females (33.7% vs 
29.7%), while females were more likely to be 
Hispanic than males (4.3% vs 2.5%). A higher 
proportion of males were married (44.6% vs 34.2%), 
whereas a higher proportion of females were 
separated, divorced or widowed (28.9% vs 17.7%). 
ICCs made up a larger share of liver cancers for 
females compared to males (24.7% vs 10%). 
Females were more likely than males to have 
Medicare insurance (44.6% vs 38.3%), and report 
never use of alcohol (38.9% vs 20.9%) and tobacco 
(33.1% vs 14.5%). 

Characteristics of cases by stage at diagnosis are 
presented in Table 2. A slightly higher proportion of 
uninsured individuals were diagnosed at the 
regional and distant (5.9%) stages vs localized stage 
(3.3%). ICCs were more likely to be diagnosed at the 
distant stage (30.7%) than the localized (7.7%) and 
regional (15.7%) stages. 

 

Table 2: Characteristics of incident liver cancer cases in D.C., Maryland and Virginia (2013-2016) by stage at 
diagnosis 

Variable 
Total 

(N=4,084†) 
Localized 
(N=2,043) 

Regional 
(N=1,187) 

Distant 
(N=854) 

Socio-demographics 

Age at diagnosis, mean (SD) 63.8 (11.4) 64.0 (10.7) 63.3 (11.7) 64.1 (12.5) 
Race/ethnicity, n (%) 

Non-Hispanic White 
Non-Hispanic Black 
Hispanic 
API 
Other/Unknown/Missing 

 
2,301 (56.3) 
1,296 (31.7) 
133 (3.3) 
267 (6.5) 
87 (2.1) 

 
1,122 (54.9) 
671 (32.8) 
71 (3.5) 
131 (6.4) 
48 (2.4) 

 
683 (57.5) 
356 (30.0) 
30 (2.5) 
96 (8.1) 
22 (1.9) 

 
496 (58.1)* 
269 (31.5) 
32 (3.8) 
40 (4.7) 
17 (2.0) 

Marital status, n (%) 
Single 
Married 
Separated/Divorced/Widowed 

 
980 (24.0) 
1,964 (48.1) 
930 (22.8) 

 
514 (25.2) 
950 (46.5) 
481 (23.5) 

 
279 (23.5) 
591 (49.8) 
258 (21.7) 

 
187 (21.9) 
423 (49.5) 
191(22.4) 



 
 
 
 
 

 
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Unknown/Missing 210 (5.1) 98 (4.8) 59 (5.0) 53 (6.2) 

U.S. born, n (%) 
No 
Yes 
Unknown/Missing 

261 (6.4) 
1,807 (44.3) 
2,016 (49.4) 

120 (5.9) 
847 (41.5) 
1,076 (52.7) 

92 (7.8) 
547 (46.1) 
548 (46.2) 

 
49 (5.7)** 
413 (48.4) 
392 (45.9) 

Health insurance, n (%) 
Not insured 
Private Insurance 
Medicaid 
Medicare 
Uniformed services 
Other/Unknown/Missing 

187 (4.6) 
1,126 (27.6) 
415 (10.2) 
1,840 (45.1) 
200 (4.9) 
316 (7.7) 

 
67 (3.3) 
506 (24.8) 
197 (9.6) 
970 (47.5) 
133 (6.5) 
170 (8.3) 

 
70 (5.9) 
379 (31.9) 
129 (10.9) 
493 (41.5) 
44 (3.7) 
72 (6.1) 

 
50 (5.9)** 
241 (28.2) 
89 (10.4) 
377 (44.2) 
23 (2.7) 
74 (8.7) 

Clinical 
HCC, n (%) 3,478 (85.2) 1,885 (92.3) 1,001 (84.3) 592 (69.3)** 
Family history, n (%) 

No history 
Liver cancera 

Other cancer/ not specified 
Unknown/Missing 

(N=2,232) 
666 (29.8) 
43 (1.9) 
651 (29.2) 
872 (39.1) 

 
337 (30.2) 
20 (1.8) 
285 (25.5) 
475 (42.5) 

 
182 (28.4) 
13 (2.0) 
203 (31.7) 
243 (37.9) 

 
147 (31.0)* 
10 (2.1) 
163 (34.4) 
154 (32.5) 

Behavioral 
Alcohol history, n (%) 

Never use 
Current use 
Past use 
Unknown/Missing 

(N=2,232) 
629 (28.2) 
877 (39.3) 
42 (1.9) 
684 (30.7) 

 
294 (26.3) 
418 (37.4) 
22 (2.0) 
383 (34.3) 

 
180 (28.1) 
270 (42.1) 
12 (1.9) 
179 (27.9) 

 
155 (32.7)* 
189 (39.9) 
8 (1.7) 
122 (25.7) 

Tobacco history, n (%) 
Never user 
Current user 
Past user 
Unknown/Missing 

(N=2,232) 
488 (21.9) 
505 (22.6) 
606 (27.2) 
633 (28.4) 

 
224 (20.1) 
244 (21.8) 
288 (25.8) 
361 (32.3) 

 
141 (22.0) 
150 (23.4) 
185 (28.9) 
165 (25.7) 

 
123 (26.0)* 
111 (23.4) 
133 (28.1) 
107 (22.6) 

Notes. †Stage unknown or missing for n=1,844; % = column totals; SD=standard deviation; *p<0.05, 
**p<0.0001; a Includes liver cancer only or liver and other cancer. 

Analyses of characteristics stratified by 
race/ethnicity are presented in Table 3. Across D.C., 
MD and VA, incidence rates for HCC/ICC and HCCs 
only were highest among non-Hispanic Blacks 
(HCC/ICC: 11.3/100,000, 95% CI=10.8, 11.8; HCC: 
10.1/100,000, 95% CI=9.6, 10.6), followed by APIs 
(HCC/ICC: 10.8/100,000, 95% CI=9.7, 11.9; HCC: 
9.4/100,000, 95% CI=8.3, 10.4). ICC incidence rates 
were highest for APIs (1.5/100,000, 95% CI=1.1, 1.9), 

although differences were not statistically 
significant. Hispanics (62.1 years) and non-Hispanic 
Blacks (62.4 years) had the youngest average age 
at diagnosis. Non-Hispanic Blacks were most likely 
to be single or unmarried (34.1%), while APIs were 
most likely to be married (65.1%). Hispanics were 
most likely to be uninsured (14.4%). Non-Hispanic 
Blacks were least likely to report never use of 
alcohol (18.4%) or tobacco (15.4%), and Hispanics 



 
 
 
 
 

 
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(40.2%) and APIs (40.7%) were more likely to report 
never use of alcohol. Hispanics were also most likely 
to report never use of tobacco (41.3%). 

Table 3: Characteristics of incident liver cancer cases in D.C., Maryland and Virginia (2013-2016) by 
race/ethnicity. 

Variable 
Total 

(N=5,788†) 
NH White 
(N=3,312) 

NH Black 
(N=1,928) 

Hispanic 
(N=181) 

API 
(N=367) 

Incidence rate/100,000 (95% CI)a 

(HCC and ICC) 
 6.9 

(6.6, 7.1) 
11.3 
(10.8, 11.8) 

7.0 
(6.0, 8.0) 

10.8 
(9.7, 11.9) 

Incidence rate/100,000 (95% CI)a 

(HCC only) 
 5.6 

(5.4, 5.9) 
10.1 
(9.6, 10.6) 

5.8 
(4.9, 6.7) 

9.4 
(8.3, 10.4) 

Incidence rate/100,000 (95% CI)a 

(ICC only) 
 1.2 

(1.1, 1.3) 
1.2 
(1.0, 1.3) 

1.2 
(0.8, 1.6) 

1.5 
(1.1, 1.9) 

Socio-demographics 

Age at diagnosis, mean (SD)  64.6 (11.8) 65.9 (12.0) 62.4 (10.2) 62.1 (15.4) 65.6 (13.0)**b 
Marital status, n (%) 

Single 
Married 
Separated/Divorced/Widowed 
Unknown/Missing 

1,247 (21.5) 
2,401 (41.5) 
1,219 (21.1) 
921 (15.9) 

522 (15.8) 
1,535 (46.4) 
738 (22.3) 
517 (15.6) 

657 (34.1) 
551 (28.6) 
402 (20.9) 
318 (16.5) 

41 (22.7) 
76 (42.0) 
34 (18.8) 
30 (16.6) 

27 (7.4)** 
239 (65.1) 
45 (12.3) 
56 (15.3) 

Health insurance, n (%) 
Not insured 
Private Insurance 
Medicaid 
Medicare 
Uniformed services 
Other/Unknown/Missing 

 
247 (4.3) 
1,390 (24.0) 
521 (9.0) 
2,322 (40.1) 
227 (3.9) 
1,081 (18.7) 

 
95 (2.9) 
799 (24.1) 
193 (5.8) 
1,518 (45.8) 
109 (3.3) 
598 (18.1) 

 
101 (5.2) 
450 (23.3) 
279 (14.5) 
616 (32.0) 
106 (5.5) 
376 (19.5) 

 
26 (14.4) 
36 (19.9) 
25 (13.8) 
50 (27.6) 
5 (2.8) 
39 (21.6) 

 
25 (6.8)** 
105 (28.6) 
24 (6.5) 
138 (37.6) 
7 (1.9) 
68 (18.5) 

Clinical 
HCC, n (%)  4,959 (85.7) 2,740 (82.7) 1,751 (90.8) 149 (82.3) 319 (86.9)** 
Family history, n (%) 

No history 
Liver cancerc 
Other cancer/not specified 
Unknown/Missing 

(N=3,257) 
841 (25.8) 
63 (1.9) 
827 (25.4) 
1,526 (46.9) 

491 (25.1) 
38 (2.0) 
561 (28.7) 
863 (44.2) 

251 (25.2) 
17 (1.7) 
224 (22.5) 
504 (50.6) 

30 (32.6) 
1 (1.1) 
14 (15.2) 
47 (51.1) 

69 (31.9)** 
7 (3.2) 
28 (13.0) 
112 (51.9) 

Behavioral 
Alcohol history, n (%) 

Never use 
Current use 
Past use 
Unknown/Missing 

(N=3,257) 
846 (26.0) 
1,177 (36.1) 
56 (1.7) 
1,178 (36.2) 

538 (27.6) 
756 (38.7) 
6 (0.3) 
653 (33.4) 

183 (18.4) 
361 (36.2) 
48 (4.8) 
404 (40.6) 

37 (40.2) 
19 (20.7) 
2 (2.2) 
34 (37.0) 

88 (40.7)** 
41 (19.0) 
0 (0.0) 
87 (40.3) 

Tobacco history, n (%) (N=3,257)     



 
 
 
 
 

 
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Never user 
Current user 
Past user 
Unknown/Missing 

650 (20.0) 
694 (21.3) 
796 (24.4) 
1,117 (34.3) 

393 (20.1) 
421 (21.6) 
524 (26.8) 
615 (31.5) 

153 (15.4) 
250 (25.1) 
210 (21.1) 
383 (38.5) 

38 (41.3) 
4 (4.4) 
16 (17.4) 
34 (37.0) 

66 (30.6)** 
19 (8.8) 
46 (21.3) 
85 (39.4) 

Notes. †Race and ethnicity unknown or missing for n=140; % = column totals; NH=non-Hispanic; 
SD=standard deviation; *p<0.05, **p<0.0001; aIncidence rate age-adjusted to the 2000 U.S. standard 
population; bOne-way ANOVA with post-hoc Bonferroni adjustment indicated that mean age was 
significantly different for NH White vs NH Black, NH White vs Hispanic, NH Black vs API, and API vs Hispanic; 
cIncludes liver cancer only or liver and other cancer. 

DISCUSSION 
This analysis examined socio-demographic and 
clinical characteristics, and behavioral risk factors 
that could potentially explain the high liver cancer 
incidence in the D.C. metropolitan area. The overall 
incidence rate of liver cancer between 2013-2016 in 
the D.C. metropolitan area (8.2/100,000) was similar 
to the national incidence rate during a similar 
period (2014-2018) (8.6/100,000) (USCS, 2021). 
Incidence rates by sex (males: 12.6/100,000, females: 
4.5/100,000) also mirrored national rates (males 
13.1/100,000, females 4.7/100,000) (USCS, 2021), but 
patterns in incidence rates by race/ethnicity 
somewhat differed from national patterns. Like in 
the U.S., the incidence rate in the D.C. metropolitan 
area was also high among APIs (10.8/100,000 (D.C. 
region) vs 12.3/100,000 (U.S.)). However, non-
Hispanic Blacks had the highest incidence rate in the 
D.C. metropolitan area (11.3/100,000), in contrast to 
the overall U.S., where Hispanics have the highest 
incidence rate (13.7/100,000) (USCS, 2021). 

Stratified analyses revealed several other notable 
disparities by state/territory, sex, stage at diagnosis, 
and race/ethnicity. Racial disparities were far more 
pronounced in D.C., relative to MD and VA. In D.C., 
the incidence rate for non-Hispanic Blacks was 
more than four times the rate for non-Hispanic 
Whites. These geographic, sex and racial disparities 
in liver cancer incidence are likely driven by 
disparities in HCV. A previous study found patterns 
of HCV prevalence that correspond to our findings 

on HCC/ICC incidence by state/territory, sex, and 
race/ethnicity. D.C. had the highest HCV prevalence 
among males (3.1/100) and females (1.8/100) 
(Bradley et al., 2020). Furthermore, in D.C., the 
prevalence ratio of HCV for non-Hispanic Blacks to 
other racial and ethnic groups was 12.4, compared 
to a prevalence ratio of 2.2 for non-Hispanic Blacks 
nationally (all U.S. states and D.C) (Bradley et al., 
2020). In our sample, HCV was the second most 
common primary comorbidity, reported in 4% of 
cases. Future studies could examine whether 
disparities in HCV incidence are in fact a key driver 
of racial disparities in liver cancer incidence. 

Although a substantial proportion of cases were 
missing data on country of birth, and any findings 
pertaining to this variable should be interpreted 
with caution, it is noteworthy that D.C. had a higher 
proportion of foreign-born cases (11.1%) compared 
to MD (5.7%) and VA (5.6%). In immigrant 
populations, HBV is thought to be a key risk factor 
for liver cancer and studies conducted in the D.C. 
area have found a high prevalence of HBV in 
foreign-born individuals, particularly those born in 
Asia (Ha et al., 2019; Juon et al., 2019). In addition to 
hepatitis exposures, dietary exposure to aflatoxin is 
another known HCC risk factor for people born 
outside of the U.S. (Hamid et al., 2013; Smith et al., 
2017). However, lack of adequate data on 
comorbidities, country of birth, and dietary 
exposures did not allow us to examine the 
associations between these variables. More 



 
 
 
 
 

 
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complete and systematic collection of these 
variables by state cancer registries and hospital-
based registries is needed. Partnering with 
community-based organizations that serve 
immigrant populations in the D.C. metropolitan 
area could help to ascertain the burden of liver 
cancer in foreign-born individuals. Additionally, this 
data could inform screening efforts for HBV and 
other known exposures, such as dietary aflatoxin. 
Prospective studies that monitor foreign-born 
individuals for the development of liver cancer or its 
intermediate markers are needed to determine the 
contribution of these risk factors to liver cancer 
incidence in the D.C. metropolitan area. 

Consistent with previous studies, we found that 
males with HCC/ICC were diagnosed at a younger 
age, and were more likely to have a history of 
alcohol and tobacco use compared to females with 
HCC/ICC (Ladenheim et al., 2016; Wu et al., 2018). 
We also found that Hispanics made up a slightly 
higher proportion of cases among females 
compared to males. Two analyses using national 
data found that the incidence of liver cancer has 
stabilized in Hispanic men, but continues to 
increase in Hispanic women (Ryerson et al., 2016; 
Salvatore et al., 2019). However, the reason for this 
finding is unclear and more research is needed to 
identify sex differences in risk factors across racial 
and ethnic groups. 

Other racial disparities identified included a lower 
mean age at diagnosis for non-Hispanic Blacks and 
Hispanics than other groups, which correspond with 
findings on racial and ethnic disparities in mortality 
(Ryerson et al., 2016). However, a large 
retrospective cohort study found that, on average, 
Hispanic patients had an older age at diagnosis 
compared to non-Hispanic Whites (Pomenti et al., 
2020). A few studies among HCC patients have 
found that compared to other racial and ethnic 
groups, Hispanics are more likely to have 

modifiable metabolic risk factors, such as diabetes 
and hyperlipidemia, and less likely to have HCV or 
a history of tobacco use (Pomenti et al., 2020; 
Venepalli et al., 2017). Although we were unable to 
examine racial and ethnic differences in the 
distribution of comorbidities, we found that 
hypertension and diabetes were among the most 
commonly reported primary comorbidities overall. 
We also found that Hispanics were less likely to have 
a history of tobacco use. Thus, it is likely that 
different risk factors are relevant for different racial 
and ethnic groups in the D.C. metropolitan region, 
which has implications for liver cancer prevention 
approaches. In light of the growing evidence for the 
association between metabolic (Ren et al., 2019; 
Welzel et al., 2011) and behavioral risk factors 
(Petrick et al., 2018) and liver cancer risk, more data 
is urgently needed to identify their contribution to 
the increasing burden of liver cancer in the D.C. 
metropolitan area and inform tailored intervention 
approaches. 

Disparities by stage at diagnosis included cancer 
site and insurance status. ICCs tended to be 
diagnosed at a later stage, likely owing to a lack of 
clear symptoms (Blechacz et al., 2011; Zhang et al., 
2016). Consistent with previous research, we found 
that uninsured individuals more likely to be 
diagnosed at later stages (Wang et al., 2018). Lack 
of insurance may contribute to delays in seeking 
care and reduced utilization of preventative 
services, such as screening, which could lead to 
delayed detection of cancer. 

Limitations 
This analysis had several limitations. Lack of 
adequate data on several important variables, 
including country of birth, comorbidities, metabolic 
factors, and alcohol and tobacco use hindered our 
ability to examine differences in their distributions 
by state/territory, sex, stage of diagnosis, and 
race/ethnicity. As this analysis was cross-sectional 



 
 
 
 
 

 
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and lacked a non-cancer comparison group, no 
causal conclusions can be made regarding the 
association between any risk factors and liver 
cancer incidence. 

Strengths of this analysis included a large sample 
size. Additionally, the inclusion of cases from MD 
and VA provided a broader snapshot of the burden 
of liver cancer in the D.C. metropolitan area and 
highlighted differences in the profile of liver cases 
between D.C. and neighboring states, which can 
inform intervention approaches. We also separately 
estimated incidence rates for HCCs and ICCs. 
Although we did not identify major differences in 
ICC incidence rates across socio-demographic 
groups, other studies have documented sex and 
racial/ethnic differences in ICC incidence 
(Mosadeghi et al., 2016), highlighting the need to 
independently monitor HCC and ICC trends and risk 
factors. 

Conclusions 
Males, non-Hispanic Blacks and APIs are priority 
populations for liver cancer control efforts in the 
D.C. metropolitan area. Data on country of birth, 
comorbidities, and alcohol and tobacco use are 
urgently needed to inform tailored intervention 
approaches by state/territory, sex, and 
race/ethnicity. To address limitations in data 
availability from state cancer registries, hospital-
based case control or cohort studies could provide 
more robust evidence for the association between 
a wider range of well-established and emerging 
socio-demographic, clinical and behavioral risk 
factors and the increasing burden of liver cancer in 
the D.C. metropolitan area. 

Acknowledgments 
Cancer data was provided by: the District of 
Columbia Cancer Registry, District of Columbia 
Department of Health; the Maryland Cancer 
Registry, Center for Cancer Prevention and Control, 

Maryland Department of Health, with funding from 
the State of Maryland and the Maryland Cigarette 
Restitution Fund; and the Virginia Cancer Registry, 
Virginia Department of Health, Office of Family 
Health Services (OFHS), Division of Chronic Disease 
Prevention and Control 

Authors’ contributions 
Research design, data acquisition, data analysis and 
writing of the manuscript: Krishnan, N. 
Research design and critical revision: Robien, K., 
Abroms, L.C. 
Critical revision: Le, D., Yang, Y.T., Aduli, F. 
All authors approved the final version of the 
manuscript. 

Availability of data and materials 
Data cannot be shared due to the terms of the data 
use agreements with the D.C, MD and VA cancer 
registries 

FUNDING SOURCES 
This research was supported by a Grant from the 
GW Cancer Center and the Dr. Cyrus and Myrtle 
Katzen Cancer Research Center at The George 
Washington University (PI Abroms) 

Conflicts of interest 
All authors declared that there are no conflicts of 
interest 

REFERENCES 
Blechacz, B., Komuta, M., Roskams, T., & Gores, G. J. (2011). 

Clinical diagnosis and staging of cholangiocarcinoma. Nat 
Rev Gastroenterol Hepatol. 8(9), 512–522. 
https://doi.org/10.1038/nrgastro. 
2011.131 

Bradley, H., Hall, E. W., Rosenthal, E. M., Sullivan, P. S., Ryerson, 
A. B., & Rosenberg, E. S. (2020). Hepatitis C Virus 
Prevalence in 50 U.S. States and D.C. by Sex, Birth Cohort, 
and Race: 2013-2016. Hepatol Commun. 4(3), 355–370. 
https://doi.org/10.1002/hep4.1457 

Campbell, P. T., Newton, C. C., Freedman, N. D., Koshiol, J., 
Alavanja, M. C., Beane Freeman, L. E., Buring, J. E., Chan, 

https://doi.org/10.1002/hep4.1457


 
 
 
 
 

 
www.companyofscientists.com/index.php/chd e13 Cancer Health Disparities 

RESEARCH 

A. T., Chong, D. Q., Datta, M., Gaudet, M. M., Gaziano, J. 
M., Giovannucci, E. L., Graubard, B. I., Hollenbeck, A. R., 
King, L., Lee, I. M., Linet, M. S., Palmer, J. R., Petrick, J. L., … 
McGlynn, K. A. (2016). Body Mass Index, Waist 
Circumference, Diabetes, and Risk of Liver Cancer for U.S. 
Adults. Cancer Res. 76(20), 6076–6083. 
https://doi.org/10.1158/0008-5472.CAN-16-0787 

Centers for Disease Control and Prevention. (2020). Alcohol 
and Public Health. Data on excessive drinking. 
https://www.cdc.gov/alcohol/data-stats.htm 

Centers for Disease Control and Prevention. (2021). Overweight 
and Obesity. Adult obesity prevalence maps. 
https://www.cdc.gov/obesity/data/prevalence-
maps.html#nonhispanic-black-adults. 

de Martel, C., Maucort-Boulch, D., Plummer, M., & Franceschi, 
S. (2015). World-wide relative contribution of hepatitis B 
and C viruses in hepatocellular carcinoma. Hepatology. 
62(4), 1190–1200. https://doi.org/10.1002/hep.27969 

Ha, E., Kim, F., Blanchard, J., & Juon, H. S. (2019). Prevalence of 
Chronic Hepatitis B and C Infection in Mongolian 
Immigrants in the Washington, District of Columbia, 
Metropolitan Area, 2016-2017. Prev Chronic Dis. 16 E08. 
https://doi.org/10.5888/pcd16.180104 

Hamid, A. S., Tesfamariam, I. G., Zhang, Y., & Zhang, Z. G. 
(2013). Aflatoxin B1-induced hepatocellular carcinoma in 
developing countries: Geographical distribution, 
mechanism of action and prevention. Oncol Lett. 5(4), 
1087–1092. https://doi.org/10.3892/ol.2013.1169 

Juon, H. S., Ha, E., Kim, F., Trang, A., Pan, J., & Blanchard, J. 
(2019). Prevalence of Viral Hepatitis in Foreign-Born 
Populations in the Baltimore-Washington Metropolitan 
Area, 2009-2015. J Community Health. 44(2), 203–207. 
https://doi.org/10.1007/s10900-018-0573-2 

Ladenheim, M. R., Kim, N. G., Nguyen, P., Le, A., Stefanick, M. 
L., Garcia, G., & Nguyen, M. H. (2016). Sex differences in 
disease presentation, treatment and clinical outcomes of 
patients with hepatocellular carcinoma: a single-centre 
cohort study. BMJ Open Gastroenterol. 3(1), e000107. 
https://doi.org/10.1136/bmjgast-2016-000107 

Keyfitz N. (1966). 3. Sampling variance of standardized mortality 
rates. Human Biol. 38(3), 309–317. 

Maciag, M. (2018, December 13). Made in D.C.: Which areas 
have the highest share of D.C.-born residents. D.C. Policy 
Center. 
https://www.dcpolicycenter.org/publications/which-
areas-have-the-highest-share-of-d-c-born-residents/ 

Massarweh, N. N., & El-Serag, H. B. (2017). Epidemiology of 
Hepatocellular Carcinoma and Intrahepatic 
Cholangiocarcinoma. Cancer Control. 24(3), 
1073274817729245. 
https://doi.org/10.1177/1073274817729245 

Mosadeghi, S., Liu, B., Bhuket, T., & Wong, R. J. (2016). Sex-
specific and race/ethnicity-specific disparities in 
cholangiocarcinoma incidence and prevalence in the USA: 
An updated analysis of the 2000-2011 Surveillance, 
Epidemiology and End Results registry. Hepatology Res. 
46(7), 669–677. https://doi.org/10.1111/hepr.12605 

Petrick, J. L., Campbell, P. T., Koshiol, J., Thistle, J. E., Andreotti, 
G., Beane-Freeman, L. E., Buring, J. E., Chan, A. T., Chong, 
D. Q., Doody, M. M., Gapstur, S. M., Gaziano, J. M., 
Giovannucci, E., Graubard, B. I., Lee, I. M., Liao, L. M., Linet, 
M. S., Palmer, J. R., Poynter, J. N., Purdue, M. P., … 
McGlynn, K. A. (2018). Tobacco, alcohol use and risk of 
hepatocellular carcinoma and intrahepatic 
cholangiocarcinoma: The Liver Cancer Pooling Project. Br 
J Cancer. 118(7), 1005–1012. https://doi.org/10.1038/ 
s41416-018-0007-z 

Pomenti, S., Gandle, C., Abu Sbeih, H., Phipps, M., Livanos, A., 
Guo, A., Yeh, J., Burney, H., Liu, H., Dakhoul, L., Kettler, C., 
Gawrieh, S., deLemos, A., Scanga, A., Chalasani, N., Miller, 
E., & Wattacheril, J. (2020). Hepatocellular Carcinoma in 
Hispanic Patients: Trends and Outcomes in a Large United 
States Cohort. Hepatology Commun. 4(11), 1708–1716. 
https://doi.org/10.1002/hep4.1575 

Rabinowitz, K. (2017, May 11). Prince George’s County a popular 
home for many former D.C. residents. D.C. Policy Center. 
https://www.dcpolicycenter.org/publications/dc-metro-
region-migration-prince-georges-county-popular-
destination/ 

Rahib, L., Wehner, M. R., Matrisian, L. M., & Nead, K. T. (2021). 
Estimated Projection of US Cancer Incidence and Death to 
2040. JAMA Netw Open. 4(4), e214708. 
https://doi.org/10.1001/jamanetworkopen.2021.4708 

Ren, H., Wang, J., Gao, Y., Yang, F., & Huang, W. (2019). 
Metabolic syndrome and liver-related events: a systematic 
review and meta-analysis. BMC Endocr Disord. 19(1), 40. 
https://doi.org/10.1186/s12902-019-0366-3 

Ryerson, A. B., Eheman, C. R., Altekruse, S. F., Ward, J. W., Jemal, 
A., Sherman, R. L., Henley, S. J., Holtzman, D., Lake, A., 
Noone, A. M., Anderson, R. N., Ma, J., Ly, K. N., Cronin, K. 
A., Penberthy, L., & Kohler, B. A. (2016). Annual Report to 
the Nation on the Status of Cancer, 1975-2012, featuring 
the increasing incidence of liver cancer. Cancer. 122(9), 
1312–1337. https://doi.org/10.1002/cncr.29936 

Salvatore, M., Jeon, J., & Meza, R. (2019). Changing trends in 
liver cancer incidence by race/ethnicity and sex in the US: 
1992-2016. Cancer Causes Control. 30(12), 1377–1388. 
https://doi.org/10.1007/s10552-019-01237-4 

Siegel, R. L., Miller, K. D., & Jemal, A. (2020). Cancer statistics, 
2020. CA Cancer J Clin. 70(1), 7–30. 
https://doi.org/10.3322/caac.21590 

Smith, J. W., Kroker-Lobos, M. F., Lazo, M., Rivera-Andrade, A., 
Egner, P. A., Wedemeyer, H., Torres, O., Freedman, N. D., 

https://doi.org/10.1158/0008-5472.CAN-16-0787
https://www.cdc.gov/alcohol/data-stats.htm
https://www.cdc.gov/obesity/data/prevalence-maps.html#nonhispanic-black-adults
https://www.cdc.gov/obesity/data/prevalence-maps.html#nonhispanic-black-adults
https://doi.org/10.3892/ol.2013.1169
https://doi.org/10.1007/s10900-018-0573-2
https://doi.org/10.1136/bmjgast-2016-000107
https://www.dcpolicycenter.org/publications/which-areas-have-the-highest-share-of-d-c-born-residents/
https://www.dcpolicycenter.org/publications/which-areas-have-the-highest-share-of-d-c-born-residents/
https://doi.org/10.1177/1073274817729245
https://doi.org/10.1111/hepr.12605
https://www.dcpolicycenter.org/publications/dc-metro-region-migration-prince-georges-county-popular-destination/
https://www.dcpolicycenter.org/publications/dc-metro-region-migration-prince-georges-county-popular-destination/
https://www.dcpolicycenter.org/publications/dc-metro-region-migration-prince-georges-county-popular-destination/
https://doi.org/10.1001/jamanetworkopen.2021.4708
https://doi.org/10.1186/s12902-019-0366-3
https://doi.org/10.1002/cncr.29936
https://doi.org/10.1007/s10552-019-01237-4
https://doi.org/10.3322/caac.21590


 
 
 
 
 

 
www.companyofscientists.com/index.php/chd e14 Cancer Health Disparities 

RESEARCH 

McGlynn, K. A., Guallar, E., Groopman, J. D., & Ramirez-
Zea, M. (2017). Aflatoxin and viral hepatitis exposures in 
Guatemala: Molecular biomarkers reveal a unique profile 
of risk factors in a region of high liver cancer incidence. 
PloS One. 12(12), e0189255. 
https://doi.org/10.1371/journal.pone.0189255 

Tatian, P.A., McTarnaghan, S., Arena, O., & Su, Y. (2018). State 
of immigrants in the District of Columbia. Urban Institute. 
https://www.urban.org/sites/default/files/publication/990
31/state_of_immigrants_in_dc_brief_2.pdf 

The Metropolitan Washington Council of Governments. (2017). 
State of the region: human capital report. 
https://www.mwcog.org/documents/2017/02/06/state-
of-the-region-human-capital-report. 

U.S. Cancer Statistics (USCS) Working Group. U.S. Cancer 
Statistics Data Visualizations Tool, based on 2020 
submission data (1999-2018): U.S. Department of Health 
and Human Services, Centers for Disease Control and 
Prevention and National Cancer Institute; 
www.cdc.gov/cancer/dataviz, released in June 2021. 

Venepalli, N. K., Modayil, M. V., Berg, S. A., Nair, T. D., Parepally, 
M., Rajaram, P., Gaba, R. C., Bui, J. T., Huang, Y., & Cotler, 
S. J. (2017). Features of hepatocellular carcinoma in 
Hispanics differ from African Americans and non-Hispanic 
Whites. World J Hepatol. 9(7), 391–400. 
https://doi.org/10.4254/wjh.v9.i7.391 

Wang, J., Ha, J., Lopez, A., Bhuket, T., Liu, B., & Wong, R. J. 
(2018). Medicaid and Uninsured Hepatocellular Carcinoma 
Patients Have More Advanced Tumor Stage and Are Less 
Likely to Receive Treatment. J Clin Gastroenterol. 52(5), 
437–443. https://doi.org/10.1097/ 
MCG.0000000000000859 

Welzel, T. M., Graubard, B. I., Zeuzem, S., El-Serag, H. B., Davila, 
J. A., & McGlynn, K. A. (2011). Metabolic syndrome 
increases the risk of primary liver cancer in the United 
States: a study in the SEER-Medicare database. 
Hepatology. 54(2), 463–471. https://doi.org/ 
10.1002/hep.24397 

World Health Organization. (2021a). Hepatitis B. 
https://www.who.int/news-room/fact-
sheets/detail/hepatitis-b 

World Health Organization. (2021b) Hepatitis C. 
https://www.who.int/news-room/fact-
sheets/detail/hepatitis-c 

Wu, E. M., Wong, L. L., Hernandez, B. Y., Ji, J. F., Jia, W., Kwee, 
S. A., & Kalathil, S. (2018). Gender differences in 
hepatocellular cancer: disparities in nonalcoholic fatty liver 
disease/steatohepatitis and liver transplantation. 
Hepatoma Res. 4, 66. https://doi.org/10.20517/2394-
5079.2018.87 

Zhang, H., Yang, T., Wu, M., & Shen, F. (2016). Intrahepatic 
cholangiocarcinoma: Epidemiology, risk factors, diagnosis 

and surgical management. Cancer Lett. 379(2), 198–205. 
https://doi.org/10.1016/j.canlet.2015.09.008 

 

https://doi.org/10.1371/journal.pone.0189255
https://www.urban.org/sites/default/files/publication/99031/state_of_immigrants_in_dc_brief_2.pdf
https://www.urban.org/sites/default/files/publication/99031/state_of_immigrants_in_dc_brief_2.pdf
https://www.mwcog.org/documents/2017/02/06/state-of-the-region-human-capital-report
https://www.mwcog.org/documents/2017/02/06/state-of-the-region-human-capital-report
https://www.cdc.gov/cancer/dataviz
https://doi.org/10.4254/wjh.v9.i7.391
https://www.who.int/news-room/fact-sheets/detail/hepatitis-b
https://www.who.int/news-room/fact-sheets/detail/hepatitis-b
https://www.who.int/news-room/fact-sheets/detail/hepatitis-c
https://www.who.int/news-room/fact-sheets/detail/hepatitis-c
https://doi.org/10.20517/2394-5079.2018.87
https://doi.org/10.20517/2394-5079.2018.87
https://doi.org/10.1016/j.canlet.2015.09.008

	INTRODUCTION
	METHODS
	Data and sample
	Measures
	Analysis
	Ethical approval

	RESULTS
	DISCUSSION
	Limitations
	Conclusions
	Acknowledgments
	Authors’ contributions
	Availability of data and materials
	FUNDING SOURCES
	Conflicts of interest

