Background: In China, liver cancer imposes a substantial burden on public health. Elucidating epidemiological characteristics and major risk factor attribution of the major histological subtypes of hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (iCCA) is key to formulating precise prevention and control strategies.
 
Methods: Data from 157 cancer registries in China in Volume XII of Cancer Incidence in Five Continents (CI5) were abstracted to estimate the proportion of liver cancer histological subtypes. Based on those proportions and data from 700 cancer registrations, the distribution of different pathological subtypes of liver cancer in China in 2022 was estimated. Population attributable fractions (PAFs) for hepatitis B virus (HBV), hepatitis C virus (HCV), Clonorchis sinensis, smoking, drinking, and body mass index (BMI) were calculated for different histological subtypes. In addition, the study modeled the temporal impact of liver cancer prevention efforts. The numbers of cases prevented between 2005 and 2022 was estimated by comparing the actual annual incidence of liver cancer to a hypothetical scenario in which incidence rates had remained constant at 2005 levels, thereby quantifying the net benefit of public health interventions over time.
 
Results: In 2022, it was estimated that 367,657 new liver cancer cases occurred in China. Among these, HCC accounted for the majority (78.5%), while iCCA comprised 17.4%. The distribution of histological subtypes varied by sex. In males, HCC represented 81.7% of liver cancer cases, corresponding to an age-standardized incidence rate (ASIR) of 18.7 per 100,000, whereas iCCA accounted for 14.2% (ASIR: 3.1 per 100,000). Among females, HCC accounted for 69.9% of cases (ASIR: 5.2 per 100,000), and iCCA contributed to 25.9% (ASIR: 1.9 per 100,000), indicating a relatively higher burden of iCCA in women. The overall PAF for all liver cancer cases was 70.0%, underscoring the substantial role of modifiable risk factors in liver cancer development. For HCC specifically, the PAF reached 78.2%, with HBV being the dominant contributor, followed by smoking and BMI. In contrast, the PAF for iCCA was 36.4%, reflecting its more heterogeneous etiology, with BMI, Clonorchis sinensis infection, and smoking emerging as the top three contributors. Over the period from 2005 to 2022, it was estimated that approximately 1.3 million liver cancer cases were prevented in China due to public health interventions and risk factor control measures. Among these averted cases, 1,001,966 occurred in men and 301,129 in women.
 
Conclusion: China has made substantial progress in the prevention and control of liver cancer over the past two decades. Nevertheless, liver cancer remains a major health threat, with ongoing challenges posed by persistent HBV infection, rising obesity rates, and regional variations in risk factor distribution, such as Clonorchis sinensis endemicity. These findings underscore the need for continued investment in precision prevention strategies, stratified by histological subtype and tailored to specific population risk profiles. Future efforts should also prioritize enhanced screening, early detection, and access to curative treatment, particularly in high-burden regions and vulnerable populations.