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Adam Barsouk,1 Krishna Chaitanya Thandra,2 Kalyan Saginala,3 Prashanth Rawla,4 Alexander Barsouk5 1Sidney Kimmel Cancer Center, Jefferson University, Philadelphia, PA 19107, USA; 2Department of Pulmonary and Critical Care Medicine, Sentara Virginia Beach General Hospital, Virginia Beach, VA, USA; 3Plains Regional Medical Group Internal Medicine, Clovis, NM 88101, USA; 4Department of Medicine, Sovah Health, Martinsville, VA 24112, USA; 5Hematologist-Oncologist, Allegheny Health Network, Pittsburgh, PA 15212, USACorrespondence: Prashanth RawlaDepartment of Internal Medicine/Hospitalist, SOVAH Health, 320 Hospital Dr, Martinsville, VA 24115, USATel +1 336-701-2285Email rawlap@gmail.comAbstract: Primary liver cancer has the sixth highest incidence and fourth highest cancer mortality worldwide. Hepatitis B is the leading cause of liver cancer, though its incidence is decreasing with vaccination. Alcohol is the leading cause of liver transplant, cirrhosis, and cancer in the developed world, and is projected to surpass hepatitis B as the leading hepatic cancer etiology worldwide. Tobacco smoking has shown a positive association with liver cancer in a majority of studies, though not all. Aflatoxin, a mycotoxin produced by Aspergillus, is estimated to account for 3– 20% of global liver cancer cases, 40% of which occur in sub-Saharan Africa. These statistics are confounded by the prevalence of hepatitis B, which may have a synergistic effect on hepatic carcinogenesis. Aflatoxin is ingested and likely inhaled from agricultural products, placing farmers, food processors, and textile workers in developing nations at risk. Vinyl-chloride is used in the production of PVC plastics and causes rare liver angiosarcoma, hepatocellular carcinoma, and other neoplasms. Arsenic and cadmium are naturally-occurring, hepatocarcinogenic metals with high occupational exposure in industries involving coal, metals, plastics, and batteries. Millions of laborers in waste-disposal and manufacturing are exposed to organic solvents and N-nitrosamines, which vary from carcinogenic (group 1) to possibly carcinogenic (group 2B) in their IARC designation. Insecticide DDT is possibly hepatocarcinogenic (group 2B), though continues to be used for malaria control in the developing world. While suggested by case reports, anabolic steroids and oral contraceptives have not been shown to increase liver cancer risk in large studies.Keywords: chemical agents, hepatocellular carcinoma, occupational exposure, aflatoxin, pesticides