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Ann Epidemiol. 2014 Feb;24(2):104-10. doi: 10.1016/j.annepidem.2013.11.006. Epub 2013 Nov 21.

Local geographic variation in chronic liver disease and hepatocellular carcinoma: contributions of socioeconomic deprivation, alcohol retail outlets, and lifestyle.

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Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD; Office of Surveillance and Epidemiology, US Food and Drug Administration, Silver Spring, MD. Electronic address:
Cancer Control Research Program, Norris Cotton Cancer Center, Dartmouth College, Lebanon, NH.
Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD.
AARP, Washington, DC.
Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD.



Hepatocellular carcinoma (HCC) incidence rates continue to increase in the United States. Geographic variation in rates suggests a potential contribution of area-based factors, such as neighborhood socioeconomic deprivation, retail alcohol availability, and access to health care.


Using the National Institutes of Health-American Association of Retired Persons Diet and Health Study, we prospectively examined area socioeconomic variations in HCC incidence (n = 434 cases) and chronic liver disease (CLD) mortality (n = 805 deaths) and assessed contribution of alcohol outlet density, health care infrastructure, diabetes, obesity, and health behaviors. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated from hierarchical Cox regression models.


Area socioeconomic deprivation was associated with increased risk of HCC incidence and CLD mortality (HR, 1.48; 95% CI, 1.03-2.14 and HR, 2.36; 95% CI, 1.79-3.11, respectively) after accounting for age, sex, and race. After additionally accounting for educational attainment and health risk factors, associations for HCC incidence were no longer significant; associations for CLD mortality remained significant (HR, 1.78; 95% CI, 1.34-2.36). Socioeconomic status differences in alcohol outlet density and health behaviors explained the largest proportion of socioeconomic status-CLD mortality association, 10% and 29%, respectively. No associations with health care infrastructure were observed.


Our results suggest a greater effect of area-based factors for CLD than HCC. Personal risk factors accounted for the largest proportion of variance for HCC but not for CLD mortality.


Census; Cohort; Health care; Kernel density estimation; Liver cancer; Liver disease; Multilevel; Neighborhood; Socioeconomic disparities

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