Hepatocellular carcinoma has a lower prevalence and presents at a later age in urban Blacks than in rural Blacks. These differences have previously been shown not to be attributable to differences in serum hepatitis B virus markers. In the present study, the average age of patients with hepatocellular carcinoma in a developing urban Black population is shown to have risen from 38.9 to 56.5 years (p < 0.0001) over a 20-year interval, while the prevalence of co-existing cirrhosis has declined from 66 to 44% (p < 0.05) and tissue HBsAg positivity has fallen from 44 to 17.7% (p = 0.002). The lower prevalence of tissue HBsAg in the recent patients may be explained by their older age. Macronodular cirrhosis was present in 56% of cases in the earlier period but declined to 18.9% in the later period, with micronodular cirrhosis becoming the dominant nontumor pathology (p = 0.002). Liver damage attributable to the abuse of alcohol is now found in more than half of the cases (48/90) of hepatocellular carcinoma occurring in this population. The remainder show no changes (12 cases) or show macronodular or incomplete septal cirrhosis (30 cases), presumed to be of viral origin. The latter cases are more likely to have serum markers of current hepatitis B virus infection than those with evidence of alcohol abuse. We conclude that alcohol is increasing in importance as an etiologic association of hepatocellular carcinoma in urban South African Blacks. At the same time, the prevalence of macronodular cirrhosis (and of cirrhosis as a whole) in urban patients with this tumor has declined. The reason for this decline is not known.