title: Hepatocellular carcinoma in a low-endemic area:  rising incidence and improved survival.
abstract: OBJECTIVE
  To examine recent trends in incidence and outcome among patients with hepatocellular carcinoma (HCC) in an unselected population in Western Europe.
  
  
  METHODS
  Data from the nationwide Netherlands Cancer Registry were used to estimate trends in incidence for all 6514 patients newly diagnosed with primary liver cancer between 1989 and 2009. Trends in incidence, treatment, and relative survival according to sex and age were estimated in 5143 patients with HCC, also using the European Standardized Rates (ESR).
  
  
  RESULTS
  The ESR for all primary liver cancers combined increased significantly between 1989 and 2009 as did the ESR for HCC among men (estimated annual percentage change: 2.2%, 95% confidence interval: 1.6-2.7) and for women aged below 60 years, suggesting etiological influences in these groups. Especially, the nonhistologically confirmed HCC incidence increased. More patients underwent surgery for HCC, from 9% in 1989-1994 to 23% in 2005-2009, as well as chemotherapy and/or irradiation, from 6 to 11% in the same period. At the end of the study period, only 66% of patients received noncancer-related HCC therapy, that is, best supportive care, compared with 85% in 1989-1994. The 1 and 5-year relative survival for patients with HCC increased significantly (P<0.001 and P<0.001).
  
  
  CONCLUSIONS
  In as much as the modest increase in the incidence of HCC was a matter of better detection, due to improved imaging techniques, which may have affected the overall relative survival for HCC patients, the increasing trend in survival is likely to be, in the absence of other explanations, due to better treatment of the underlying liver cirrhosis.
authors.affiliation: Department of Hepatobiliary and Transplantation Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands. c.witjes@erasmusmc.nl
authors.forename: Caroline D M
authors.initials: CD
authors.lastname: Witjes
authors.forename: Henrike E
authors.initials: HE
authors.lastname: Karim-Kos
authors.forename: Otto
authors.initials: O
authors.lastname: Visser
authors.forename: Sanne A W
authors.initials: SA
authors.lastname: van den Akker
authors.forename: Esther
authors.initials: E
authors.lastname: de Vries
authors.forename: Jan N M
authors.initials: JN
authors.lastname: Ijzermans
authors.forename: Robert A
authors.initials: RA
authors.lastname: de Man
authors.forename: Jan Willem W
authors.initials: JW
authors.lastname: Coebergh
authors.forename: Cornelis
authors.initials: C
authors.lastname: Verhoef
mesh_terms: D000293:Adolescent; D000328:Adult; D017677:Age Distribution; D000368:Aged; D000369:Aged, 80 and over; D001650:Bile Duct Neoplasms / Q000453:epidemiology; D001653:Bile Ducts, Intrahepatic; D006528:Carcinoma, Hepatocellular / Q000453:epidemiology* / Q000628:therapy; D018278:Carcinoma, Neuroendocrine / Q000453:epidemiology; D018281:Cholangiocarcinoma / Q000453:epidemiology; D019353:Endemic Diseases; D005260:Female; D006801:Humans; D015994:Incidence; D008113:Liver Neoplasms / Q000453:epidemiology* / Q000628:therapy; D008297:Male; D008875:Middle Aged; D009426:Netherlands / Q000453:epidemiology; D012509:Sarcoma / Q000453:epidemiology; D017678:Sex Distribution; D016019:Survival Analysis; D016896:Treatment Outcome; D055815:Young Adult