Trends in hepatocellular carcinoma stage by racial/ethnic group in the United States, 1992–2019

Abstract

Background & Aims

Although incidence rates of hepatocellular carcinoma (HCC) began to decline in the United States in the past decade, disparities in rates among racial/ethnic groups have persisted. Whether disparities in stage at diagnosis have remained over time, however, is unclear.

Methods

National Cancer Institute’s Surveillance, Epidemiology and End Results (SEER) program has created a new staging-over-time variable that facilitates the examination of trends in HCC stage. Thus, the proportions of HCCs diagnosed by stage between 1992 and 2019 were examined among non-Hispanic White, non-Hispanic Black (NHB), Hispanic, Asian/Pacific Islander, and American Indian/Alaska Native (AI/AN) individuals. HCC incidence between 1992 and 2019 was also analysed using Joinpoint regression.

Results

Between 1992 and 2019, the proportion of stage 1 HCCs increased and the proportion of stage 4 HCCs decreased among non-Hispanic White, NHB, Hispanic, and Asian/Pacific Islander individuals. Among AI/AN persons, the proportion of stage 1 tumours remained stable, and the proportion of stage 4 tumours declined. In the most recent time period, NHB individuals had the lowest proportions of stage 1 HCCs (32%) and the highest proportion of stage 4 HCCs (20%) of any group. Joinpoint analysis found that HCC incidence began to decline by 2013 among all groups except AI/AN individuals, the only group that had an increase in incidence.

Conclusions

Despite generally favourable trends in HCC stage and incidence rates, disparities remain. NHB persons continue to have less favourable stages at diagnosis, and incidence rates continue to increase among AI/AN persons.

Impact and implications

HCC incidence rates among most United States racial/ethnic groups began to decline in recent years, but whether stage at diagnosis also improved was unclear. As a result, a new SEER stage variable was used to examine stage trends by race/ethnicity. Although the finding of generally favourable trends in stage as well as incidence is encouraging, continuity disparities in both stage and incidence require serious attention.

Graphical abstract

Highlights

• •From 1992–2019, the proportion of stage 1 HCCs increased and the proportion of stage 4 HCCs decreased among all racial/ethnic groups except American Indians/Alaska Natives.
• •Among American Indians/Alaska Natives, the proportion of stage 1 HCCs remained stable, and the proportion of stage 4 HCCs declined.
• •Non-Hispanic Black persons had the lowest proportion of stage 1 HCCs and the highest proportion of stage 4 HCCs of any racial/ethnic group.
• •Incidence rates of HCC have continued to decline for all racial/ethnic groups except American Indians/Alaska Natives.

Introduction

Hepatocellular carcinoma (HCC) is characterised by sex and racial/ethnic disparities in the USA.¹ Our previous reports from the Surveillance, Epidemiology and End Results (SEER) cancer registries have shown that HCC rates began to decline among both sexes and most racial/ethnic groups in the past decade.^2,3 However, differences in rates among groups have continued to persist.² In addition, differences in HCC stage at diagnosis have been reported by some studies.⁴ HCC staging criteria have changed over time, however, thus suggesting that previous temporal analyses might have been misleading. The development of new SEER staging-over-time variables has enabled us to examine HCC stage by race/ethnicity and sex between 1992 and 2019 in the United States population.

Materials and methods

Data on HCC incidence, including the new staging-over-time variable, were retrieved from the SEER-12 database for 1992–2019.⁵ To derive the new variable, SEER harmonised T, N, and M definitions with data on histology, tumour size, regional nodes positivity, summary stage, and other items. HCCs were identified using the International Classification of Disease for Oncology, third edition, topography code C22 and morphology codes 8170-8174 (code 8175 was not eligible for TNM staging per the American Joint Committee on Cancer eighth edition⁶ guidelines). Single HCC counts were grouped into seven 4-year periods. Proportions of cases diagnosed at stages 1 through 4, and an unknown stage, were calculated by sex and race/ethnicity (non-Hispanic White [NHW], non-Hispanic Black [NHB], Hispanic, Asian/Pacific Islander [API], and American Indian/Alaska Native [AI/AN] [purchased/referred care delivery area only]). 95% CIs for each proportion were estimated using a binomial distribution. In addition, age-standardised incidence rates (ASRs) were calculated by race/ethnicity and sex for the entire study period, and trends in incidence were analysed using Joinpoint regression to estimate annual percent change (APC). All rates were adjusted using the direct method to the 2000 United States standard population (19 age groups).

Results

Between 1992–1995 and 2016–2019, favourable trends in stage distribution were seen among NHW, NHB, Hispanic, and API persons (Table 1). Among these groups, the proportion of HCCs diagnosed at stage 1 increased, whereas the proportions diagnosed at stages 2 and 3 remained stable, and the proportions diagnosed at stage 4 decreased. The largest increase in stage 1, from 20% (95% CI 18–23%) to 39% (95% CI 38–41%), was observed among API persons. The greatest decrease in stage 4 HCCs, from 21 to 14%, was seen among Hispanic persons (Fig. S1). Despite the favourable trends among these groups, in the most recent time period, NHB persons had a lower proportion of stage 1 HCCs (32%) and a higher proportion of stage 4 HCCs (20%) than the other three groups.

Table 1.

Stage-specific proportions and 95% CIs of hepatocellular carcinomas overall and by sex and race/ethnicity in the USA, SEER-12 registries with specialised staging over time fields, 1992–2019.

All		Stage 1			Stage 2			Stage 3			Stage 4			Stage unknown
		Cases	%	95% CI	Cases	%	95% CI	Cases	%	95% CI	Cases	%	95% CI	Cases	%	95% CI
Non-Hispanic White	1992–1995 1996–1999 2000–2003 2004–2007 2008–2011 2012–2015 2016–2019	381 506 756 1,033 1,500 2,052 2,067	22 23 30 31 33 38 39	(20% 24%) (21% 25%) (28% 31%) (29% 32%) (31% 34%) (36% 39%) (38% 41%)	228 385 499 733 1,015 1,157 950	13 18 20 22 22 21 18	(12% 15%) (16% 19%) (18% 21%) (20% 23%) (21% 23%) (20% 22%) (17% 19%)	248 328 430 545 835 973 917	14 15 17 16 18 18 17	(13% 16%) (14% 17%) (15% 18%) (15% 17%) (17% 19%) (17% 19%) (16% 18%)	336 420 465 609 803 825 843	20 19 18 18 18 15 16	(18% 21%) (18% 21%) (17% 20%) (17% 19%) (16% 19%) (14% 16%) (15% 17%)	520 537 396 459 427 461 495	30 25 16 14 9 8 9	(28% 33%) (23% 26%) (14% 17%) (12% 15%) (8% 10%) (8% 9%) (9% 10%)
Non-Hispanic Black	1992–1995 1996–1999 2000–2003 2004–2007 2008–2011 2012–2015 2016–2019	57 80 124 247 345 488 439	19 18 21 28 31 35 32	(14% 23%) (15% 22%) (18% 25%) (25% 31%) (28% 33%) (33% 38%) (30% 35%)	40 93 119 177 225 263 224	13 21 21 20 20 19 16	(9% 17%) (17% 25%) (17% 24%) (17% 23%) (18% 22%) (17% 21%) (14% 18%)	55 79 119 181 232 272 295	18 18 21 20 21 20 22	(14% 22%) (14% 22%) (17% 24%) (18% 23%) (18% 23%) (17% 22%) (19% 24%)	72 99 125 208 218 251 273	24 23 22 23 19 18 20	(19% 28%) (19% 26%) (18% 25%) (21% 26%) (17% 22%) (16% 20%) (18% 22%)	81 89 92 73 105 116 136	27 20 16 8 9 8 10	(22% 32%) (16% 24%) (13% 19%) (6% 10%) (8% 11%) (7% 10%) (8% 12%)
Hispanic	1992–1995 1996–1999 2000–2003 2004–2007 2008–2011 2012–2015 2016–2019	120 206 333 519 728 1,051 1,038	22 24 28 31 32 37 36	(19% 26%) (22% 27%) (26% 31%) (28% 33%) (30% 34%) (35% 39%) (34% 37%)	91 152 256 360 517 573 568	17 18 22 21 23 20 19	(14% 20%) (15% 21%) (19% 24%) (19% 23%) (21% 24%) (19% 22%) (18% 21%)	71 122 185 308 373 465 473	13 14 16 18 16 16 16	(10% 16%) (12% 17%) (14% 18%) (16% 20%) (15% 18%) (15% 18%) (15% 18%)	113 157 194 297 368 406 412	21 19 17 17 16 14 14	(17% 24%) (16% 21%) (14% 19%) (16% 19%) (15% 18%) (13% 16%) (13% 15%)	145 205 207 217 287 349 427	27 24 18 13 13 12 15	(23% 31%) (21% 27%) (15% 20%) (11% 14%) (11% 14%) (11% 13%) (13% 16%)
Asian/Pacific Islander	1992–1995 1996–1999 2000–2003 2004–2007 2008–2011 2012–2015 2016–2019	229 342 504 720 870 1,057 993	20 23 27 32 34 40 39	(18% 23%) (21% 25%) (25% 29%) (30% 34%) (32% 36%) (38% 41%) (38% 41%)	192 302 395 483 509 459 397	17 20 22 21 20 17 16	(15% 19%) (18% 22%) (20% 23%) (20% 23%) (18% 22%) (16% 19%) (14% 17%)	225 324 404 480 511 526 525	20 22 22 21 20 20 21	(18% 22%) (19% 24%) (20% 24%) (20% 23%) (19% 22%) (18% 21%) (19% 22%)	188 272 292 350 356 383 348	17 18 16 16 14 14 14	(14% 19%) (16% 20%) (14% 18%) (14% 17%) (13% 15%) (13% 16%) (12% 15%)	295 266 242 221 297 250 251	26 18 13 10 12 9 10	(24% 29%) (16% 20%) (12% 15%) (9% 11%) (10% 13%) (8% 10%) (9% 11%)
American Indian/Alaska Native	1992–1995 1996–1999 2000–2003 2004–2007 2008–2011 2012–2015 2016–2019	15 15 30 35 63 94 90	32 34 40 28 34 43 35	(19% 45%) (20% 48%) (29% 51%) (20% 36%) (27% 41%) (36% 49%) (29% 41%)	6 10 9 33 30 40 56	13 23 12 26 16 18 22	(3% 22%) (10% 35%) (5% 19%) (19% 34%) (11% 22%) (13% 23%) (17% 27%)	9 6 16 18 30 39 31	19 14 21 14 16 18 12	(8% 30%) (3% 24%) (12% 31%) (8% 21%) (11% 22%) (13% 23%) (8% 16%)	11 ≤5 12 20 35 29 33	23 9 16 16 19 13 13	(11% 36%) (1% 18%) (8% 24%) (10% 22%) (13% 25%) (9% 18%) (9% 17%)	6 9 8 19 26 19 47	13 20 11 15 14 9 18	(3% 22%) (9% 32%) (4% 18%) (9% 21%) (9% 19%) (5% 12%) (14% 23%)
Men
Non-Hispanic White	1992–1995 1996–1999 2000–2003 2004–2007 2008–2011 2012–2015 2016–2019	278 362 547 786 1,157 1,575 1,558	22 23 29 30 32 36 38	(20% 25%) (21% 25%) (27% 31%) (28% 32%) (30% 33%) (35% 38%) (36% 39%)	169 285 388 572 797 933 753	14 18 20 22 22 21 18	(12% 15%) (16% 20%) (19% 22%) (20% 23%) (21% 23%) (20% 23%) (17% 19%)	173 236 327 432 666 806 728	14 15 17 16 18 19 18	(12% 16%) (13,% .17%) (15% 19%) (15% 18%) (17% 20%) (17% 20%) (17% 19%)	254 328 355 486 653 662 690	20 21 19 18 18 15 17	(18% 23%) (19% 23%) (17% 20%) (17% 20%) (17% 19%) (14% 16%) (16% 18%)	376 386 286 356 347 365 388	30 24 15 14 10 8 9	(28% 33%) (22% 26%) (13% 17%) (12% 15%) (9% 11%) (8% 9%) (9% 10%)
Non-Hispanic Black	1992–1995 1996–1999 2000–2003 2004–2007 2008–2011 2012–2015 2016–2019	39 50 85 184 255 358 312	17 16 19 27 29 33 31	(13% 22%) (12% 20%) (15% 23%) (24% 30%) (26% 32%) (31% 36%) (28% 33%)	33 66 93 136 187 198 167	15 21 21 20 21 19 16	(13% 17%) (19% 23%) (19% 22%) (18% 21%) (20% 23%) (17% 20%) (15% 18%)	46 64 91 137 187 217 216	21 20 20 20 21 20 21	(18% 23%) (18% 22%) (18% 22%) (18% 21%) (20% 23%) (19% 21%) (20% 22%)	48 70 105 170 182 206 211	22 22 23 25 21 19 21	(19% 24%) (20% 24%) (21% 25%) (23% 26%) (19% 22%) (18% 20%) (19% 22%)	57 66 76 59 70 91 114	26 21 17 9 8 9 11	(23% 28%) (19% 23%) (15% 19%) (8% 10%) (7% 9%) (8% 9%) (10% 12%)
Hispanic	1992–1995 1996–1999 2000–2003 2004–2007 2008–2011 2012–2015 2016–2019	75 134 233 360 536 733 702	17 16 19 27 29 33 31	(15% 23%) (19% 25%) (24% 30%) (26% 30%) (29% 33%) (33% 37%) (31% 35%)	68 120 187 288 388 423 416	17 20 22 22 23 20 19	(14% 20%) (17% 22%) (19% 24%) (20% 24%) (21% 24%) (18% 22%) (18% 21%)	56 84 148 236 299 363 367	14 14 17 18 17 17 17	(12% 16%) (12% 16%) (15% 19%) (16% 20%) (16% 19%) (16% 19%) (15% 19%)	89 123 140 242 291 319 323	22 20 16 19 17 15 15	(19% 25%) (18% 23%) (14% 18%) (17% 21%) (15% 19%) (14% 17%) (13% 17%)	110 148 158 158 209 265 330	28 24 18 12 12 13 15	(25% 31%) (22% 27%) (16% 20%) (11% 14%) (11% 14%) (11% 14%) (14% 17%)
Asian/Pacific Islander	1992–1995 1996–1999 2000–2003 2004–2007 2008–2011 2012–2015 2016–2019	163 251 319 495 587 714 689	20 23 24 30 32 37 38	(17% 23%) (21% 26%) (22% 27%) (28% 33%) (30% 34%) (35% 39%) (35% 40%)	139 213 287 351 359 343 298	17 20 22 22 20 18 16	(3% 31%) (4% 35%) (11% 33%) (13% 30%) (13% 27%) (12% 24%) (11% 22%)	164 240 305 373 385 398 395	20 22 23 23 21 21 22	(5% 35%) (6% 38%) (12% 35%) (14% 32%) (14% 28%) (14% 27%) (16% 28%)	134 203 229 269 285 313 267	16 19 18 17 16 16 15	(2% 30%) (3% 34%) (7% 28%) (9% 24%) (9% 22%) (10% 22%) (9% 20%)	214 183 168 142 201 158 183	26 17 13 9 11 8 10	(10% 43%) (2% 31%) (4% 22%) (3% 15%) (6% 16%) (4% 13%) (6% 14%)
American Indian/Alaska Native	1992–1995 1996–1999 2000–2003 2004–2007 2008–2011 2012–2015 2016–2019	8 8 23 24 50 56 55	30 32 43 28 38 37 31	(12% 47%) (14% 50%) (30% 57%) (18% 37%) (30% 47%) (30% 45%) (24% 37%)	≤5 6 ≤5 23 19 29 44	19 24 9 26 15 19 25	(13% 24%) (19% 29%) (7% 12%) (23% 30%) (12% 17%) (17% 22%) (22% 27%)	≤5 ≤5 13 12 18 31 23	15 12 25 14 14 21 13	(10% 19%) (8% 16%) (21% 29%) (11% 16%) (12% 16%) (18% 23%) (11% 15%)	8 ≤5 7 16 29 24 25	30 8 13 18 22 16 14	(24% 36%) (5% 11%) (10% 16%) (15% 21%) (20% 25%) (14% 18%) (12% 16%)	≤5 6 ≤5 12 14 10 32	7 24 9 14 11 7 18	(4% 11%) (19% 29%) (7% 12%) (11% 16%) (9% 13%) (5% 8%) (16% 20%)
Women
Non-Hispanic White	1992–1995 1996–1999 2000–2003 2004–2007 2008–2011 2012–2015 2016–2019	103 144 209 247 343 477 509	22 25 33 33 36 42 44	(18% 26%) (21% 28%) (29% 36%) (30% 36%) (33% 39%) (39% 45%) (41% 47%)	59 100 111 161 218 224 197	13 17 17 22 23 20 17	(10% 16%) (14% 20%) (14% 20%) (19% 25%) (20% 25%) (18% 22%) (15% 19%)	75 92 103 113 169 167 189	16 16 16 15 18 15 16	(13% 20%) (13% 19%) (13% 19%) (13% 18%) (15% 20%) (13% 17%) (14% 18%)	82 92 110 123 150 163 153	18 16 17 16 16 14 13	(14% 21%) (13% 19%) (14% 20%) (14% 19%) (13% 18%) (12% 17%) (11% 15%)	144 151 110 103 80 96 107	31 26 17 14 8 9 9	(27% 35%) (23% 30%) (14% 20%) (11% 16%) (7% 10%) (7% 10%) (8% 11%)
Non-Hispanic Black	1992–1995 1996–1999 2000–2003 2004–2007 2008–2011 2012–2015 2016–2019	18 30 39 63 90 130 127	22 24 30 32 37 41 37	(13% 31%) (17% 32%) (22% 38%) (25% 38%) (31% 43%) (35% 46%) (32% 42%)	7 27 26 41 38 65 57	9 22 20 21 16 20 16	(2% 15%) (15% 29%) (13% 27%) (15% 26%) (11% 20%) (16% 25%) (13% 20%)	9 15 28 44 45 55 79	11 12 22 22 18 17 23	(4% 18%) (6% 18%) (15% 29%) (16% 28%) (14% 23%) (13% 21%) (18% 27%)	24 29 20 38 36 45 62	29 23 16 19 15 14 18	(19% 39%) (16% 31%) (9% 22%) (14% 24%) (10% 19%) (10% 18%) (14% 22%)	24 23 16 14 35 25 22	29 19 12 7 14 8 6	(19% 39%) (12% 25%) (7% 18%) (3% 11%) (10% 19%) (5% 11%) (4% 9%)
Hispanic	1992–1995 1996–1999 2000–2003 2004–2007 2008–2011 2012–2015 2016–2019	45 72 100 159 192 318 336	32 31 32 38 35 43 43	(24% 39%) (25% 37%) (27% 38%) (33% 43%) (31% 39%) (39% 46%) (40% 47%)	23 32 69 72 129 150 152	16 14 22 17 23 20 19	(10% 22%) (9% 18%) (18% 27%) (14% 21%) (20% 27%) (17% 23%) (17% 22%)	15 38 37 72 74 102 106	11 16 12 17 13 14 14	(6% 16%) (12% 21%) (8% 16%) (14% 21%) (11% 16%) (11% 16%) (11% 16%)	24 34 54 55 77 87 89	17 15 17 13 14 12 11	(11% 23%) (10% 19%) (13% 22%) (10% 16%) (11% 17%) (9% 14%) (9% 14%)	35 57 49 59 78 84 97	25 24 16 14 14 11 12	(18% 32%) (19% 30%) (12% 20%) (11% 17%) (11% 17%) (9% 14%) (10% 15%)
Asian/Pacific Islander	1992–1995 1996–1999 2000–2003 2004–2007 2008–2011 2012–2015 2016–2019	66 91 185 225 283 343 304	21 22 35 36 39 46 45	(16% 25%) (18% 26%) (31% 39%) (32% 40%) (35% 43%) (42% 49%) (41% 48%)	53 89 108 132 150 116 99	17 21 20 21 21 15 15	(13% 21%) (17% 25%) (17% 24%) (18% 24%) (18% 24%) (13% 18%) (12% 17%)	61 84 99 107 126 128 130	19 20 19 17 17 17 19	(15% 24%) (16% 24%) (15% 22%) (14% 20%) (15% 20%) (14% 20%) (16% 22%)	54 69 63 81 71 70 81	17 17 12 13 10 9 12	(13% 21%) (13% 20%) (9% 15%) (10% 16%) (8% 12%) (7% 11%) (9% 14%)	≤5 ≤5 ≤5 7 12 9 15	26 20 14 13 13 12 10	(21% 31%) (16% 24%) (11% 17%) (10% 15%) (11% 16%) (10% 15%) (8% 12%)
American Indian/Alaska Native	1992–1995 1996–1999 2000–2003 2004–2007 2008–2011 2012–2015 2016–2019	7 7 7 11 13 38 35	35 37 32 29 24 54 45	(14% 56%) (15% 59%) (12% 51%) (15% 43%) (13% 35%) (42% 65%) (34% 56%)	≤5 ≤5 ≤5 10 11 11 12	5 21 18 26 20 15 15	(0% 15%) (3% 39%) (2% 34%) (12% 40%) (10% 31%) (7% 24%) (7% 23%)	≤5 ≤5 ≤5 6 12 8 8	25 16 14 16 22 11 10	(6% 44%) (0% 32%) (0% 28%) (4% 27%) (11% 33%) (4% 19%) (4% 17%)	≤5 ≤5 ≤5 ≤5 6 ≤5 8	15 11 23 11 11 7 10	(0% 31%) (0% 24%) (5% 40%) (1% 20%) (3% 19%) (1% 13%) (4% 17%)	≤5 ≤5 ≤5 7 12 9 15	20 16 14 18 22 13 19	(2% 38%) (0% 32%) (0% 28%) (6% 31%) (11% 33%) (5% 20%) (10% 28%)

SEER, Surveillance, Epidemiology and End Results.

HCC stage trends among AI/AN persons were less favourable than those among the other four groups. The proportion of stage 1 disease remained stable, whereas the proportion of stage 2 HCCs increased from 13% (95% CI 3–22%) to 22% (95% CI 17–27%). The proportions of stages 3 and 4 HCCs both declined, from 19% (95% CI 8–30%) to 12% (95% CI 8–16%) and from 23% (95% CI 11–36%) to 13% (95% CI 9–17%), respectively. Even with less favourable trends, however, AI/AN persons still had a higher proportion of stage 1 HCCs (35%; 95% CI 29–41%) and a lower proportion of stage 4 HCCs (13%; 95% CI 9–17%) than did NHB persons.

Stratification by sex found that API women had the largest increase in stage 1 HCC, from 21% (95% CI 16–25%) to 45% (95% CI 41–48%), whereas the greatest decrease in stage 4 HCC, from 29% (95% CI 19–39%) to 18% (95% CI 14–22%), was observed among NHB women. No reduction in stage 4 HCC was observed among NHB or API men.

The Joinpoint regression analyses found that HCC incidence rates significantly declined between 2015 and 2019 (APC -4.6%) (Table S1). The decline occurred in both sexes, but the decrease was greater among men (APC_2015–2019 -5.4%) than among women (APC_2013–2019 -2.8%). Significant declines in incidence rates were observed among API (APC_2010-2019 -4.6%), Hispanic (APC_2012–2019 -2.9%), and NHW individuals (APC_2013-2019 -2.7%). Although a slight decline (APC_2009–2019 -1.0%) was observed among NHB persons, the result was not statistically significant. In contrast to the trends among the other groups, rates among AI/AN persons significantly increased (APC_1992–2019 4.0%). In 2019, HCC incidence rates were highest in AI/AN persons (ASR 12.12), followed by Hispanic persons (ASR 9.33).

Discussion

Our findings, using the new SEER staging-over-time variable, are consistent with some, but not all, prior analyses of racial/ethnic differences in SEER data. For example, a previous study in which HCC stage was categorised as local, regional, distant, and unstaged did not examine trends over time, but it did report that NHB persons had the highest proportion of distant-stage HCC during the period 2000–2015.⁷ The finding of NHB persons being less likely than other groups to have early-stage disease has been replicated in a number of other studies, as reported by a recent meta-analysis.⁸ In contrast, a study that used SEER data to examine HCC stage between 2004 and 2019 reported that although local-stage HCC significantly declined in all groups, distant-stage HCC increased among NHW persons between 2014 and 2019.⁵ This finding could differ from that of the current study owing to less precise stage data than are available in the new staging-over-time variable.

Although the current study found favourable HCC stage trends among most groups, differences in stage among the groups were evident. These differences could be related to disparities in surveillance. A recent study reported that NHB persons were less likely than other groups to be screened for HCC, whereas persons with HBV infection were more likely to be screened.⁹ As HBV has been a dominant risk factor among API persons, screening in this group may be substantially more likely.¹⁰

In conclusion, although favourable trends in HCC stage were seen for many racial/ethnic groups, differences in the stage distribution of HCC were apparent. Particular attention should be paid to rectifying the lower proportion of stage 1 disease and higher proportion of stage 4 disease among NHB persons and the less favourable trends in stage seen among AI/AN persons. Efforts to reduce the HCC burden among all segments of the American population are clearly warranted.

Financial support

This study was supported by the NIH Intramural Research Program.

Authors’ contributions

Conception: KAM. Data analysis: CSA. Data acquisition: JR. Data manipulation: GF. Supervision: BIG, KAM. Writing of the manuscript: CSA. Editing of the manuscript: CSA. Reading of the manuscript: GF. Reviewing of the manuscript: JR, GF, BIG, KAM.

Data availability statement

Data used in this study are publicly available at www.seer.cancer.gov. SEER∗Stat Database: Incidence – SEER Research Data, 12 Registries, Nov 2021 Sub (1992–2019).

Conflicts of Interest

None of the authors have any conflicts of interest.

Please refer to the accompanying ICMJE disclosure forms for further details.

Supplementary data

The following are the supplementary data to this article.