Asian Pacific Journal of Cancer Prevention, Vol 14, 2013 7251
Attributable Causes of Liver Cancer Mortality and Incidence in China
Asian Pac J Cancer Prev, 14 (12), 7251-7256
worldwide, and over 85% of liver cancers occur in
developing countries (Ferlay et al., 2010). In China, liver
cancer ranks as the 2nd most common cause of cancer
death, with mortality rates of 37.5/100, 000 in men and
14.4/100, 000 in women (Chen et al., 2010). Liver cancer
mortality has increased rapidly since the 1970s. Over the
past few decades, a number of risk factors for liver cancer
have been identified, including hepatitis B virus (HBV),
hepatitis C virus (HCV), aflatoxin, alcohol drinking,
tobacco smoking, obesity and diabetes (Yu and Yuan,
2004; Chuang et al., 2009). HBV and HCV infection
are major risk factors for live cancer in the Chinese
population, reflecting the elevated prevalence of chronic
HBV and HCV infection in the general population (Liang
et al., 2009).
Several previous studies have estimated the attributable
Liver cancer is the 5th most common cancer in men
1Department of Cancer Epidemiology, Cancer Institute/Hospital, Chinese Academy of Medical Sciences & Peking Union Medical
College, Beijing, 2Department of Epidemiology and Biostatistics, School of Public Health, Zhejiang University, Hangzhou, China,
3Department of Epidemiology, School of Public Health, Harvard University, Boston, MA, 4The Tisch Cancer Institute, Mount Sinai
School of Medicine, New York, NY, USA, 5International Prevention Research Institute, 95 cours Lafayette, Lyon, France &Equal
contributors *For correspondence: email@example.com, firstname.lastname@example.org
(HBV), hepatitis C virus (HCV), aflatoxin exposure, alcohol drinking and smoking in China in 2005. Study
design: Systemic assessment of the burden of five modifiable risk factors on the occurrence of liver cancer in
China using the population attributable fraction. Methods: We estimated the population attributable fraction
of liver cancer caused by five modifiable risk factors using the prevalence data around 1990 and data on relative
risks from meta-analyses, and large-scale observational studies. Liver cancer mortality data were from the 3rd
National Death Causes Survey, and data on liver cancer incidence were estimated from the mortality data from
cancer registries in China and a mortality/incidence ratio calculated. Results: We estimated that HBV infection
was responsible for 65.9% of liver cancer deaths in men and 58.4% in women, while HCV was responsible for
27.3% and 28.6% respectively. The fraction of liver cancer deaths attributable to aflatoxin was estimated to be
25.0% for both men and women. Alcohol drinking was responsible for 23.4% of liver cancer deaths in men and
2.2% in women. Smoking was responsible for 18.7% and 1.0% . Overall, 86% of liver cancer mortality and
incidence (88% in men and 78% in women) was attributable to these five modifiable risk factors. Conclusions:
HBV, HCV, aflatoxin, alcohol drinking and tobacco smoking were responsible for 86% of liver cancer mortality
and incidence in China in 2005. Our findings provide useful data for developing guidelines for liver cancer
prevention and control in China and other developing countries.
Keywords: Population attributable fraction - liver cancer - risk factors - China
Objectives: To estimate the proportion of liver cancer cases and deaths due to infection with hepatitis B virus
Attributable Causes of Liver Cancer Mortality and Incidence
Jin-Hu Fan1&, Jian-Bing Wang1,2&, Yong Jiang1, Wang Xiang3, Hao Liang1, Wen-
Qiang Wei1, You-Lin Qiao1*, Paolo Boffetta4,5*
causes of cancer in western populations (Olsen et al.,
1997; International Agency for Research on Cancer et
al., 2007; Parkin et al., 2011) and Asian populations
(Shin et al., 2011; Inoue et al., 2012; Wang et al., 2012a).
For example, one report estimated that HBV and HCV
infection, tobacco smoking and alcohol drinking were
responsible for 92% of liver cancer deaths in both men
and women in Japan in 2005. Only one meta-analysis,
reported in a Chinese journal, has estimated the fraction of
liver cancer attributable to lifestyle risk factors in China,
including HBV, HCV, aflatoxin, smoking, drinking, family
history of cancer, and vegetable and fruit intake, but it did
not estimate the combined population attributable fraction
(PAF) (Yao et al., 2002). We previously conducted a
project, aimed at estimating the role of known risk factors
of cancer, such as smoking and alcohol drinking, on the
cancer burden in China in 2005 (Wang et al., 2012a),
which gave us the opportunity to estimate the PAF for
relevant risk factors and liver cancer.
Jin-Hu Fan et al
Asian Pacific Journal of Cancer Prevention, Vol 14, 2013
based assessment of the individual and combined
contributions of HBV, HCV, aflatoxin, alcohol drinking
and tobacco smoking to the burden of liver cancer deaths
and cases in China in 2005.
In the present report, we aim to provide an evidence-
Materials and Methods
This report provides an estimate of numbers and
proportions [population attributable fractions (PAFs)] of
liver cancer deaths and cases in China attributable to HBV,
HCV, aflatoxin, alcohol drinking and smoking. Since part
of the material (PAF for smoking (Wang et al., 2010),
alcohol drinking (Liang et al., 2010), infection (Xiang
et al., 2011), and aflatoxin (Liu et al., 2012)) has already
been published, this paper focuses on the joint effects of
these risk factors on liver cancer and a comparison of these
joint effects with those found in other similar studies.
PAF was defined as the proportion of the cancer burden
in a population which could be eliminated by modifying
or removing the exposure of certain causal factors. We
estimated the PAF based on the counterfactual scenario
of total avoidance of risk factors (such as smoking and
chronic infection). Our estimates were restricted to
hepatocellular carcinoma because cholangiocarcinoma is
rare in most regions of China and limited data are available
at the national level.
Cancer mortality and incidence data
Cancer mortality data were obtained from the 3rd
National Death Cause Survey in China (Ministry of Health
of the People’s Republic of China, 2008). Briefly, this was
a retrospective survey conducted in 160 randomly selected
counties and 53 areas with high cancer incidence between
2004 and 2005. Liver cancer mortality in our study was
estimated based on the 160 randomly selected counties.
Cancer incidence data were not available for the entire
country; thus, cancer incidence was estimated by using
a Mortality/Incidence (M/I) ratio and the mortality data.
The M/I ratio was derived from the data of 32 regional
population-based cancer registry sites in China between
2003 and 2004, and calculated using Poisson regression
adjusted for age, gender and cancer registry site (Chen,
Exposure data for risk factors of liver cancer in China
The current health effects of risk factors reflect past
patterns of exposure to these risk factors (Rothman, 2012).
We estimated an average induction time of 15 years for
risk factors and liver cancer. Therefore, exposure data
were obtained from the early 1990s.
HBV and HCV prevalence: Data on HBV and HCV
prevalence were obtained from a nationwide cross-
sectional seroepidemiologic study in 1992 (Xia et al.,
1996). This study covered 145 disease surveillance
points in 30 provinces of China. Approximately 68 000
subjects were investigated using two-stage cluster random
sampling. A solid-phase radioimmunoassay was used for
detection of hepatitis B surface antigen (HBsAg), antibody
to hepatitis B core antigen (HBcAb), and antibody to
hepatitis B surface antigen (HBsAb); enzyme-linked
immunoassay (EIA) was used to detect hepatitis B e
antigen (HBeAg); and a second-generation UBI EIA was
used to detect antibody to hepatitis C virus.
Aflatoxin prevalence: Few data on aflatoxin exposure
are available at the national level. In this report, a
published estimate of PAF for aflatoxin in China was
abstracted from a worldwide meta-analysis (Liu et al.,
Alcohol drinking prevalence: Data on the prevalence
of alcohol drinking were abstracted from the 1991
National Hypertension Survey of China (PRC National
Blood Pressure Survey Cooperative Group, 1995),
which included 30 provinces, autonomous regions, and
municipalities of China. About 949, 539 persons were
investigated using a multistage cluster random sampling
Smoking prevalence: Data on the prevalence of
smoking were derived from the results of two National
Smoking Surveys in China in 1984 and 1996. Briefly, in
the 1984 national survey, 29 provinces and autonomous
regions were covered (Weng et al., 1987). About 519, 600
individuals (including 258, 422 men and 261, 178 women)
were investigated using stratified random sampling. The
overall smoking prevalence was 33.9% (61.0% in men
and 7.0% in women). In the 1996 national survey (Yang et
al., 1999), 145 disease surveillance points in 30 provinces
of China were included. This population-based survey
covered 120, 298 subjects (63, 793 in men and 56, 020 in
women) using a 3-stage cluster, random sampling method.
The overall smoking prevalence was 37.6% (66.9% for
men and 4.2% for women). We estimated the prevalence
of smoking in 1990 using a linear interpolation method
from the results of these two national surveys.
Relative risk (RR)
To assess the RR of risk factors and liver cancer
in the Chinese population, we conducted a systematic
search of publications from different sources, including:
PubMed, VIP Information, China National Knowledge
Infrastructure, and other databases (including Springer,
Elsevier, and Science Direct). The search words covered
“HBV”, “HCV”, “hepatitis B virus”, “hepatitis C virus”,
“aflatoxin”, “alcohol drinking”, “alcohol consumption”,
“drinking”, “tobacco smoking”, “smoking”, “meta-
analysis”, “cohort study”, “case-control study” and “liver
cancer”. Studies were included if they included odds
ratios or relative risks and corresponding 95% confidence
intervals. Meta-analyses and large-scale surveys of
representative samples of China were the highest priority.
When such studies were not available, we selected non-
representative samples of Chinese population studies.
RRs for HBV (Zhou and Fang, 2002), HCV (Zhou
and Fang, 2002), alcohol drinking (Pei et al., 2008), were
derived from large Chinese meta-analyses, and the RR
for aflatoxin came from 5 Chinese studies in a worldwide
meta-analysis (Liu et al., 2012). RR for tobacco smoking
was obtained from a large case-control study in China
(Chen et al., 2003).
RRs for liver cancer incidence or mortality were
abstracted separately for men and women; however, RRs
Asian Pacific Journal of Cancer Prevention, Vol 14, 2013 7253
Attributable Causes of Liver Cancer Mortality and Incidence in China
Table 1. Relative Risks (RR) of Selected Risk
Factors and Liver Cancer, Which Were Used in the
Calculation of Population Attributable Fractions
Risk factors RR Source
Men Women Design
Hepatitis B virus†
Hepatitis C virus‡
Alcohol drinking§ 1.87
Case control study Chen et al., 2003
Zhou and Fang, 2002
Zhou and Fang, 2002
Pei et al., 2008
†RR of liver cancer incidence associated with Hepatitis B virus; ‡RR of liver
cancer incidence associated with Hepatitis C virus; §RR of liver cancer incidence
associated with alcohol drinking; ¶RR of liver cancer mortality associated with
Table 2. Liver Cancer Deaths and Cases Attributable to HBV, HCV, Aflatoxin Exposure, Drinking and Smoking
in China in 2005
Risk factors Men Women Total
PAF (%) Deaths Cases PAF (%) Deaths Cases PAF (%) Deaths Cases
†PAF for aflatoxin was obtained from the results of the Chinese population of a meta-analysis (Liu et al., 2012); ‡Combined PAF for
HBV, HCV, aflatoxin, drinking and smoking and liver cancer was calculated using the following formula: PAF=1-(1- PAF1)×(1-
PAF2)×(1- PAF3)×(1- PAF4)×(1- PAF5); HBV, Hepatitis B virus; HCV, Hepatitis C virus; PAF, Population Attributable Fraction
were available for both genders in China in only a few
studies. Therefore, if the RRs for men and women were
not available (such as the RR for HBV or HCV or alcohol
drinking), we assumed equal RRs for men and women and
used the total RRs as the estimate for both genders.
The PAF was calculated based on the relative risk of
a risk factor (RR) and the prevalence of exposure to the
risk factor in the total population (P) using the following
formula, by Levin (Levin, 1953):
from the results of the Chinese population of a worldwide
meta-analysis (Liu et al., 2012). It was estimated based
on the proportion of cases exposed (Pc) and the adjusted
RR using an alternative formula (Darrow and Steenland,
PAF =Pc× RR-1
The PAF for aflatoxin and liver cancer was abstracted
HCV, aflatoxin, alcohol drinking and smoking, we used
the following formula (Ezzati et al., 2003):
To estimate the combined PAF for exposure to HBV,
PAF =1− 1−PAF1
where PAF1 was the PAF for exposure to HBV, PAF2
was the PAF for exposure to HCV, PAF3 was the PAF for
exposure to aflatoxin, PAF4 was the PAF for exposure to
alcohol drinking, and PAF5 was the PAF for exposure to
smoking. This formula assumes independence of exposure
from the five sources.
339, 308, including 246, 808 in men and 92, 500 in
women, and the number of incident liver cancer cases
was estimated to be 370, 236, including 274, 562 in men
and 95, 674 in women.
The number of liver cancer deaths in China in 2005was
Estimates of prevalence
The prevalence of HBV infection was 11.3% in men
and 8.2% in women, and the prevalence of HCV infection
was 3.1% in men and 3.3% in women (Xia et al., 1996).
The overall prevalence of alcohol drinking was 17.9%
(35.1% in men and 2.6% in women) (PRC National Blood
Pressure Survey Cooperative Group, 1995). The estimated
overall smoking prevalence in 1990 was 35.8% (64.0%
in men and 5.6% in women) (Wang et al., 2010).
Estimates of relative risk
For HBV infection, the overall RR was 18.1. For HCV
infection, the overall RR was 13.1. For alcohol drinking,
the overall RR was 1.87 (95% CI: 1.36-2.57). The RRs
for smoking among men and women were 1.36 (95% CI:
1.29-1.43) and 1.17 (95%CI: 1.06-1.29), respectively
HBV infection contributed to 63.9% of liver cancer
deaths and cases, including 65.9% in men and 58.4%
in women, respectively. For HCV, the corresponding
figures were 27.7% overall, 27.3% among men and
28.6% among women. Liu et al. (2012) estimated the
fraction of liver cancer attributable to aflatoxin exposure
was 25.0% for both men and women. The proportion of
liver cancer attributable to alcohol drinking was 15.7%
overall, including 23.4% in men and 2.2% in women. In
addition, tobacco smoking was responsible for 13.9% of
liver cancer overall, including 18.7% in men and 1.0%
in women. Overall, we estimate that 290, 698 (85.7%) of
the total liver cancer deaths, including 218, 178 (88.4%)
of the deaths in men and 72, 520 (78.4%) of the deaths in
women, and 317, 720 incident liver cancer cases (242, 712
in men and 75, 008 in women) in 2005 were attributable
to the combined effects of HBV, HCV, aflatoxin, drinking
and smoking (Table 2).
Jin-Hu Fan et al
Asian Pacific Journal of Cancer Prevention, Vol 14, 2013
This report provides an estimate of the contribution of
five known modifiable risk factors to the burden of liver
cancer deaths and cases in China in 2005. We estimate
that 85.7% of liver cancer deaths in that year were due
to the combined effects of HBC, HCV, aflatoxin, alcohol
drinking and tobacco smoking. Liver cancer deaths
attributable to these risk factors in China represent about
42% of all liver cancer deaths worldwide (Ferlay et al.,
2010). Our results may be informative for policies and
programs on reducing the burden of liver cancer in China
and other developing countries.
We compared our estimates of the combined PAFs
with similar estimates published from previous studies
in different countries (Table 3). The PAFs in our analysis
were much higher than the corresponding figures in France
(64.4%) (International Agency for Research on Cancer et
al., 2007) and the UK (41.6%) (Parkin et al., 2011), but
were comparable with the estimates from Japan (92.1%)
(Inoue et al., 2012). HBV and HCV infection are the major
risk factors for liver cancer in China, accounting for over
70% of the liver cancer burden. In contrast, in the western
populations, HBV and HCV are less important risk factors
for liver cancer due to the relatively low prevalence of
these infections in these populations.
We estimated that the combined PAF for HBV and
HCV infection and liver cancer was nearly 75%, which
was comparable with the findings in Korea (74%) (Shin
et al., 2011). A more recent global study (de Martel et
al., 2012) indicated that 76.9% of incident liver cancer
(including cholangiocarcinoma) were attributable to HBV,
HCV and liver flukes worldwide, with approximately 88%
of cases due to these infections in less developed regions.
In China, it has been demonstrated that immunization of
infants with a HBV vaccine is beneficial for the primary
prevention of HBV infection. HBV infection is the main
risk factor of liver cancer in China, so HBV vaccination
should greatly reduce the future liver cancer burden. Our
results reinforce the idea that control of HBV and HCV
infection are an important strategy for reducing the burden
of liver cancer mortality and incidence in China.
Aflatoxin has been identified as a carcinogen by the
International Agency for Research on Cancer (IARC)
(Baan et al., 2009). China and many other developing
nations have both high aflatoxin exposure and high HBV
prevalence (Lu et al., 2010). The combined PAF for
HBV and aflatoxin exposure in our study was over 70%.
Public health strategies for reducing the risk of aflatoxin
in the body and the burden of liver cancer can be grouped
into three categories: agricultural, dietary and clinical.
Agricultural intervention may include planting pest-
resistant crops, lowering mold growth in harvested crops,
and improving storage methods. Dietary and clinical
interventions can be considered secondary interventions.
One effective clinical intervention to reduce the burden of
aflatoxin-related liver cancer could be HBV vaccination,
since there is a multiplicative interaction between aflatoxin
and HBV on the risk of liver cancer (Omer et al., 2004;
Wu et al., 2009).
Alcohol drinking accounted for 15.7% of liver cancer
deaths and cases in China. Boffetta and his colleagues
(Boffetta et al., 2006) calculated the burden of cancer
deaths and cases attributable to alcohol drinking by WHO
sub-region in 2002, and showed that alcohol drinking
caused by 9.4% of all liver cancer deaths and cases
worldwide. Danaei and colleagues reported that alcohol
drinking was responsible for 25% of all liver cancer
deaths in seven World Bank regions in 2001 (Danaei et
al., 2005). Therefore, our PAF for alcohol was between
those reported in previous studies. Alcohol drinking is
an especially important risk factor for liver cancer in
populations with low prevalence of HBV and HCV, such
as the USA and Europe. One potential mechanism for
alcohol-related liver carcinogenesis is chronic oxidative
stress. As the prevalence of drinking in China is increasing,
it is expected that the burden of alcohol related-cancer will
increase in the future.
Our estimates for smoking were similar to those
reported in previous studies in China (Liu et al., 1998;
Gu et al., 2009). Liu and his colleagues (Liu et al., 1998)
estimated that smoking contributed to 20.2% of liver
cancer deaths among men and 2.4% among women, and
Gu and his colleagues (Gu et al., 2009) showed that 20.3%
of liver cancer deaths among men and 2.9% among women
were attributable to smoking in a prospective study. The
corresponding figures in our study were 18.7% for men
and 1.0% for women, which were slightly lower than those
of the previous studies. The differences in these estimates
are related to differences in the RRs, smoking prevalence
estimates and methods used for calculating PAFs.
Strengths of our study include the use of nationally-
representative data on the prevalence of risk factors,
evidence-based data on relative risk of liver cancer, new
national data on liver cancer mortality and incidence,
and systematic assessment of the burden of liver cancer.
Several limitations should also be considered. First, we did
not assess the effects of some other known or suspected
risk factors, including diabetes and overweight/obesity,
because of the lack of appropriate data from China. Recent
data indicated diabetes may contribute to the increasing
occurrence of liver cancer (Polesel et al., 2009; Yang et
al., 2011; Lai et al., 2012; Wang et al., 2012b), and recent
meta-analyses show a two-fold increase in the risk of live
Table 3. Comparison of the Population Attributable
Fraction (PAF, %) of Liver Cancer Deaths or New
Cases Attributable to the Combined Effects of Known
Study Country Men Women Total
IARC study (International Agency France
for Research on Cancer et al., 2007)‡
Parkin et al (Parkin et al., 2011)§
Inoue et al (Inoue et al., 2012)¶
†PAF of liver cancer was calculated for the combined effects of
HBV, HCV, aflatoxin, drinking and smoking; ‡PAF of liver cancer
was estimated for the combined effects of HBV, HCV, drinking and
smoking; §PAF of liver cancer was estimated for the combined effects
of HBV, HCV, ionizing radiation, occupation, drinking and smoking;
¶PAF of liver cancer was estimated for the combined effects of HBV,
HCV, drinking and smoking; HBV, Hepatitis B virus; HCV, Hepatitis
Asian Pacific Journal of Cancer Prevention, Vol 14, 2013 7255
Attributable Causes of Liver Cancer Mortality and Incidence in China
assessment of the burden of HBV, HCV, aflatoxin
exposure, alcohol drinking and tobacco smoking on the
occurrence of liver cancer in China. These five modifiable
lifestyle risk factors contributed to about 86% of liver
cancer deaths and cases in 2005. Our estimates may have
implications for policies aimed at liver cancer prevention
and control in China and other developing countries.
cancer among diabetics (Yang et al., 2011; Wang et al.,
2012b). If this association is causal, and we assume a
prevalence of 2.5%, based on a national survey of diabetes
mellitus in the 1990s (Pan et al., 1997), diabetes mellitus
was responsible for 2.4% of liver cancer in China in 2005.
Evidence also shows that the rapidly growing obesity
epidemic may contribute to the rising incidence of liver
cancer. The Cancer Prevention studyⅡ found that obesity
was positively associated with liver cancer deaths in the
US population, with an RR of 4.52 among men who had
a BMI of 35 kg/m2 or above (Calle et al., 2003). If this
association is causal and we assume a prevalence among
men of 1.0% with a BMI of 35 kg/m2 or above, based on
the National Nutrition Survey in China in 1992 (Ge, 1997),
obesity was responsible for 3.4% of liver cancer among
men in China in 2005.
Another limitation of our study was possible
uncertainty in the relative risks that we used in making our
PAF estimates. The RRs of alcohol drinking and of HBV
and HCV were derived from meta-analyses, and some
of the original studies included in these meta-analyses
may not have been adjusted for confounding factors.
Moreover, for alcohol, HBV and HCV, the total RR was
used for both genders, and there was uncertainty in the
extrapolation of these RRs to categorize each gender
individually. A third limitation was that we were not able
to find information on the exposure data of aflatoxin in
the Chinese population at large, so we were unable to
calculate a nationwide PAF for aflatoxin based on data that
was as representative of the whole Chinese population as
the data on the other exposures that we analyzed. Instead,
we abstracted aflatoxin exposure from the results of 5
previous observational studies in China that were reported
in a worldwide meta-analysis, and these data may not
have been totally accurate for the Chinese population
at the national level. Another limitation was that the
possible interaction of these risk factors on the risk of liver
cancer mortality and incidence was not considered in our
estimates because of the lack of available data in China
at the national level. But we estimated the joint effects of
these risk factors on liver cancer instead. Finally, data on
liver cancer incidence in China were not available, and
had to be estimated from mortality data and a mortality-
to-incidence ratio. This ratio was calculated by Poisson
regression models, adjusted for age, gender and cancer
registry site, but it was not adjusted for other potentially
relevant factors such as socioeconomic status because of
The incidence of liver cancer is approximately three
times higher in Chinese men than in Chinese women. Our
PAF estimates for the five risk factors combined were 88%
in men and 78% in women, which may not different from
each other. If it is true, these would leave some 33, 000
cases in men and 21, 000 cases in women (in 2005) that
cannot be attributed to the five risk factors (i.e., a ratio of
about 1.5). This suggests that either the other (suspected
and unknown) causes of liver cancer are more important
in men than women, or that our gender-specific PAF
estimates (based on total rather than gender-specific RRs)
are not completely accurate.
In summary, the present results provide a systemic
This research was supported in part by International
Agency for Research on Cancer (Lyon, France; Grant
number: CRA No GEE/08/19); in part by the Cancer
Hospital/Institute, Chinese Academy of Medical
Sciences (Beijing, China; Grant number: JK2011B19).
The author(s) declare that they have no competing
Baan R, Grosse Y, Straif K, et al (2009). A review of
human carcinogens--Part F: chemical agents and related
occupations. Lancet Oncol, 10, 1143-4.
Boffetta P, Hashibe M, La Vecchia C, et al (2006). The burden
of cancer attributable to alcohol drinking. Int J Cancer,
Calle EE, Rodriguez C, Walker-Thurmond K, et al (2003).
Overweight, obesity, and mortality from cancer in a
prospectively studied cohort of U.S. adults. N Engl J Med,
Chen ZM, Liu BQ, Boreham J, et al (2003). Smoking and liver
cancer in China: case-control comparison of 36, 000 liver
cancer deaths vs. 17, 000 cirrhosis deaths. Int J Cancer,
Chen WQ (2009). Estimation of cancer incidence and mortality
in China in 2004-2005. Chin J Oncol, 31, 664-8.
Chen JG, Zhang SW, Chen WQ (2010). Analysis of liver cancer
mortality in the national retrospective sampling survey of
death causes in China, 2004-2005. Zhonghua Yu Fang Yi
Xue Za Zhi, 44, 383-9.
Chuang SC, La Vecchia C, Boffetta P (2009). Liver cancer:
descriptive epidemiology and risk factors other than HBV
and HCV infection. Cancer Lett, 286, 9-14.
Danaei G, Vander Hoorn S, Lopez AD, et al (2005). Causes of
cancer in the world: comparative risk assessment of nine
behavioural and environmental risk factors. Lancet, 366,
Darrow LA, Steenland NK (2011). Confounding and bias in the
attributable fraction. Epidemiology, 22, 53-8.
de Martel C, Ferlay J, Franceschi S, et al (2012). Global burden
of cancers attributable to infections in 2008: a review and
synthetic analysis. Lancet Oncol, 13, 607-15.
Ezzati M, Hoorn SV, Rodgers A, et al (2003). Estimates of global
and regional potential health gains from reducing multiple
major risk factors. Lancet, 362, 271-80.
Ferlay J, Shin HR, Bray F, et al (2010). Estimates of worldwide
burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer,
Ge KY (1997). Body mass index of young Chinese adults. Asia
nPacific J Clin Nutr, 6, 175-9.
Gu D, Kelly TN, Wu X, et al (2009). Mortality attributable to
smoking in China. N Engl J Med, 360, 150-9.
Inoue M, Sawada N, Matsuda T, et al (2012). Attributable
causes of cancer in Japan in 2005--systematic assessment
to estimate current burden of cancer attributable to known
Jin-Hu Fan et al Download full-text
Asian Pacific Journal of Cancer Prevention, Vol 14, 2013
preventable risk factors in Japan. Ann Oncol, 23, 1362-9.
International Agency for Research on Cancer, Académie des
Sciences-Institut de France, Académie de Médecine,
Fédération Nationale des Centres de Lutte contre le Cancer
(2007). IARC Working Group Reports, Vol 3, Attributable
Causes of Cancer in France in the Year 2000. Lyon: IARC
Lai SW, Chen PC, Liao KF, et al (2012). Risk of hepatocellular
carcinoma in diabetic patients and risk reduction associated
with anti-diabetic therapy: a population-based cohort study.
Am J Gastroenterol, 107, 46-52.
Levin ML (1953). The occurrence of lung cancer in man. Acta
Unio Int Contra Cancrum, 9, 531-41.
Liang X, Bi S, Yang W, et al (2009). Epidemiological serosurvey
of hepatitis B in China--declining HBV prevalence due to
hepatitis B vaccination. Vaccine, 27, 6550-7.
Liang H, Wang J, Xiao H, et al (2010). Estimation of cancer
incidence and mortality attributable to alcohol drinking in
China. BMC Public Health, 10, 730.
Liu BQ, Peto R, Chen ZM, et al (1998). Emerging tobacco
hazards in China: 1. Retrospective proportional mortality
study of one million deaths. BMJ, 317. 1411-22.
Liu Y, Chang CC, Marsh GM, et al (2012). Population
attributable risk of aflatoxin-related liver cancer: systematic
review and meta-analysis. Eur J Cancer, 48, 2125-36.
Lu PX, Wang JB, Zhang QN, et al (2010). Longitudinal study
of aflatoxin exposure in the development of primary liver
cancer in patients with chronic hepatitis. Zhonghua Yi Xue
Za Zhi, 90, 1665-9.
Ministry of Health of the People’s Republic of China (2008).
Report of the Third National Retrospective Survey of Death
Causes in China. Beijing: Chinese Academy of Medical
Sciences & Peking Union Medical College Press.
Olsen JH, Andersen A, Dreyer L, et al (1997). Summary of
avoidable cancers in the Nordic countries. APMIS Suppl,
Omer RE, Kuijsten A, Kadaru AM, et al (2004). Population-
attributable risk of dietary aflatoxins and hepatitis B virus
infection with respect to hepatocellular carcinoma. Nutr
Cancer, 48, 15-21.
Pan XR, Yang WY, Li GW, et al (1997). Prevalence of diabetes
and its risk factors in China, 1994. National Diabetes
Prevention and Control Cooperative Group. Diabetes Care,
Parkin DM, Boyd L, Walker LC (2011). 16. The fraction of
cancer attributable to lifestyle and environmental factors in
the UK in 2010. Br J Cancer, 105, S77-81.
Pei GJ, Fu L, Cui YL (2008). Meta-analysis on the association
of hepatocellular carcinoma with alcohol drinking among
Chinese people. Xian Dai Yu Fang Yi Xue, 35, 2626-7.
Polesel J, Zucchetto A, Montella M, et al (2009). The impact of
obesity and diabetes mellitus on the risk of hepatocellular
carcinoma. Ann Oncol, 20, 353-7.
PRC National Blood Pressure Survey Cooperative Group (1995).
Alcohol Consumption and Blood Pressure: A Nation-wide
Survey of in 1991 in China. Chin J Hypert, 3, 50-4.
Rothman KJ (2012). Epidemiology: An introduction. 2nd edition.
New York: Oxford University Press.
Shin A, Park S, Shin HR, et al (2011). Population attributable
fraction of infection-related cancers in Korea. Ann Oncol,
Wang JB, Jiang Y, Wei WQ, et al (2010). Estimation of cancer
incidence and mortality attributable to smoking in China.
Cancer Causes Control, 21, 959-65.
Wang JB, Jiang Y, Liang H, et al (2012a). Attributable causes
of cancer in China. Ann Oncol, 23, 2983-9.
Wang C, Wang X, Gong G, et al (2012b). Increased risk of
hepatocellular carcinoma in patients with diabetes mellitus:
a systematic review and meta-analysis of cohort studies. Int
J Cancer, 130, 1639-48.
Weng XZ, Hong ZG, Chen DY (1987). Smoking prevalence
in Chinese aged 15 and above. Chin Med J, 100, 886-92.
Wu HC, Wang Q, Yang HI, et al (2009). Aflatoxin B1 exposure,
hepatitis B virus infection, and hepatocellular carcinoma in
Taiwan. Cancer Epidemiol Biomarkers Prev, 18, 846-53.
Xia GL, Liu CB, Cao HL, et al (1996). Prevalence of hepatitis
B and C virus infections in the general Chinese population.
Results from a nationwide cross-sectional seroepidemiologic
study of hepatitis A, B, C, D, and E virus infections in China,
1992. Int Hepatol Commun, 5, 62-73.
Xiang W, Shi JF, Li P, et al (2011). Estimation of cancer cases
and deaths attributable to infection in China. Cancer Causes
Control, 22, 1153-61.
Yang G, Fan L, Tan J, et al (1999). Smoking in China: findings of
the 1996 National Prevalence Survey. JAMA, 282, 1247-53.
Yang WS, Va P, Bray F, et al (2011). The role of pre-existing
diabetes mellitus on hepatocellular carcinoma occurrence
and prognosis: a meta-analysis of prospective cohort studies.
PLoS One, 6, e27326.
Yao HY, Yang NN, Fang Y, et al (2002). A comprehensive
analysis on the risk factors of lung cancer, liver cancer and
breast cancer. Zhongguo Zhong Liu, 11, 695-6.
Yu MC, Yuan JM (2004). Environmental factors and risk for
hepatocellular carcinoma. Gastroenterology, 127, S72-8.
Zhou XY, Fang JQ (2002). The application of Gibbs sampling in
meta-analysis for case-control studies of HBV, HCV and dual
infection in primary hepatocelluar carcinoma. Zhongshan Yi
Ke Da Xue Xue Bao, 23, 165-7.