Liver cancer is the sixth most common cancer diagnosis and fourth most common cause of cancer death in the world [1], [2]. In the United States (US), cancer of the liver and bile duct will be responsible for over 41,000 new cases and over 30,000 deaths in 2022 [2]. Hepatocellular carcinoma (HCC) is the most common primary cancer of the liver, representing 75–85% of cases and making HCC one of the major causes of cancer and cancer-related deaths [3]. It is the fourth leading cause of cancer death worldwide (782,000 deaths each year) and the ninth leading cause of cancer death in the US [4]. The incidence and mortality rates of HCC have been increasing for decades and have been predicted to continue to increase through 2030, according to novel age-period-cohort models classifying by sex, race, and age [5], [6]. Chronic inflammation due to hepatitis B virus (HBV) or hepatitis C virus (HCV) infection is the leading risk factor for HCC. Other risk factors that increase HCC risk in infected individuals include chronic alcohol consumption, obesity, non-alcoholic steatohepatitis, and non-alcoholic fatty liver disease. In addition to the concern regarding the increasing incidence, HCC disproportionally affects US racial minority populations. In particular, the incidence of HCC is more than two times higher among Asians (7.8 per 100,000 persons) and African Americans (4.2 per 100,000), as compared with Caucasians (2.6 per 100,000) [7]. The underlying explanation for the higher HCC incidence in racial minorities remains unknown. However, social, biological, and financial factors may account for these disparities. For example, socioeconomic status may limit access to appropriate preventive measures resulting in a higher incidence among minority patients [8].

Treatment recommendations for HCC depend on disease stage and patient characteristics. For patients with early-stage disease, curative treatment strategies include liver transplant and surgical resection. For patients with inoperable disease, guideline-recommended locoregional options include radiotherapy or liver-directed treatments. Systemic treatment options are also recommended for patients with advanced and metastatic disease [9]. A recent study demonstrated that although 40% of patients with HCC received surgical treatment, racial minorities had lower rates of surgery [10]. Possible explanations for this apparent difference may be related to disease biology and stage at presentation amongst different racial groups. In addition, cultural beliefs and attitudes, as well as patient-physician communication, may play a role in treatment decision-making among minorities [11].

HCC is an aggressive tumor since it is typically diagnosed at an advanced stage in its course, and the median overall survival following diagnosis ranges from approximately 6 to 20 months [4], [12]. If patients are untreated, the median survival is 3.4 months for advanced stage patients and 1.6 months for end stage or terminal stage patients [13]. Strikingly, nearly half of HCC patients in the US do not undergo any treatment in their disease course. Factors commonly associated with not receiving treatment include older age, poor baseline liver function, African American race, and being enrolled in Medicaid, or having no insurance [14]. Previous studies also have found that African American HCC patients have more advanced tumor stages at diagnosis and lower rates of survival than Caucasian HCC patients in the US [15], [16]. Given the known disparities that exist for HCC patients, the main objective of this study was to use a large national database to identify significant differences in pre-treatment clinical presentation, surgical procedure allocation, and post-treatment hospital outcomes for patients with HCC based on race and ethnicity.