Date of Award

January 2023

Document Type


Degree Name

Master of Public Health (MPH)


School of Public Health

First Advisor

Sten H. Vermund


Background & Aims: China contributed to 49% of all liver cancer deaths worldwide in 2020. We sought to investigate the relationship between clinical characteristics, antiviral therapy (ART), and multiple risk factors that affect the prognosis of primary liver cancer (PLC) patients over time to highlight proper chronic liver disease management.Methods: We identified 1322 PLC patients diagnosed between 2000 to 2020 in a major academic teaching hospital in Shanghai, China. We used descriptive epidemiology to characterize the evolution of liver cancer in China, and Cox proportional hazard models and Kaplan-Meier survival analysis to assess the relationship between evolving ART and survival outcomes. Results: Chronic hepatitis B (CHB) infection remains the predominant etiology of PLC in this hospital, accounting for 83.3% of cases. The use of ART among PLC patients increased from 23.9% in 2000-2004 to 62.1% in 2017-2020. The proportion of patients treated with entecavir (ETV) increased from less than 20% in 2010 to 80% in 2020, while the number of patients treated with tenofovir fumarate (TDF) increased significantly since 2017. Much better survival was noted for PLC patients who received first-line treatments with ETV and TDF. Among patients with HBV DNA <500 IU/mL, the median survival times for patients with hypertriglyceridemia, hypercholesterolemia, high low-density lipoprotein cholesterol level (LDL-C), and high Apolipoprotein B (ApoB) level were significantly worse than for patients with normal levels (P=0.01; P=0.03; P=0.01; P=0.02, respectively). Conclusions: Early diagnosis of PLC is vital for middle to older-aged men and women in China, given high incidence rates. Our hospital data suggest that early screening, accurate diagnosis, and improved therapies have improved chronic liver cancer management and survivorship.


This thesis is restricted to Yale network users only. It will be made publicly available on 05/10/2025