Samuel So, MBBS, FACSLui Hac Minh Professor

Professor of SurgeryDirector, Asian Liver Center

Stanford University School of Medicine

Manila, February 2014

Liver Cancer 7th most common cancer in the

worldRanks 2nd in causing the most

cancer deaths each year (746,000 deaths in 2012)

Among the most deadly cancers with a mortality to incidence ratio of 0.95

Western Pacific Region has the Greatest Burden of Liver Cancer in the World

WPRO accounts for 66% of new liver cancercases and deaths each year

Top 5 Causes of Cancer Deaths in the Philippines

Men Women Both Sexes

1 Lung Breast Lung

2 Liver Cervix Breast

3 Prostate Lung Liver4 Colorectal Colorectal Colorectal

5 Leukemia Liver Leukemia

Source: GLOBOCAN 2012, (IARC)

GLOBOCAN 2012 (IARC)

Liver cancer deaths will double in 20 yrs

Liver Cancer is A Leading Cause of Cancer Death in Countries where Chronic Hepatitis B is Prevalent

Source: WHO International Agency for Research on Cancer, GLOBOCAN 2008 http:// http://globocan.iarc.fr/ US CDC, <http://www.cdc.gov/mmwr/PDF/rr/rr5708.pdf>

Chronic hepatitis B prevalence

Liver cancer ranking as cause of cancer death in

men Thailand ≥ 7% 1Vietnam ≥ 7% 1China ≥ 7% 2Korea ≥ 7% 2Philippines ≥ 7% 2Indonesia ≥ 7% 3Singapore ≥ 7% 3Malaysia ≥ 7% 4India ~ 3% 7Australia < 2% 11New Zealand < 2% 12

Transmission of HBVTransmission of HBVBirth: From an infected mother to

newborn at birth (about 40% of chronic HBV infection in Asia)

Blood: Direct contact with infected bloodUnsafe injections or transfusions in the

Healthcare setting cause up to 20 million infections a year

Open wound contact, sharing contaminated toothbrush or razors

Sharing or reusing needles for tattoos, piercing and drug use

Sex: Unprotected sex

CDC. Available at: www.cdc.gov/ncidod/diseases/hepatitis/b/faqb.htm

Global Elimination of Hepatitis B Global Elimination of Hepatitis B Transmission is FeasibleTransmission is Feasible1981, the first

hepatitis B vaccine was FDA approved. World Health Organization calls “The First Anti-Cancer Vaccine”

3 Shots given over 6 monthscan ProtectYou for Life

1~ 5~ 10~ 15~ 20~ 30~ 40~ 50~0

2

4

6

8

10

12

HB

sAg

Pre

vale

nce

(%

)

1992

9.710.2

11.3

9.

6

11.5

Age (Yrs)

1.0 1.4

3.2

5.4

2006

8.2 8.1 8.38.0

9.99.3

7.6

Liang X, et al. Vaccine 2013 (in press)Liang X, et al. J Infect Dis 2009; 200: 39-47Courtesy of Prof Zhuang Hui, PKU

Hepatitis B Immunization would Reduce the Future Burden of Chronic Hepatitis B infection and Liver Cancer

in China

Impact of infant immunization after 14 years:Prevented up to 20 million chronic infectionPrevented up to 3.5 million future deaths from liver cancer and liver disease

WHO Western Pacific Region Hepatitis B Control Goal

In 2005, all member states adopted the goal to reduce prevalence of chronic hepatitis B to < 2% among children 5 years of age by 2012.Hepatitis B birth dose coverage (given within 24

hours) over 65%Hepatitis B complete 3 dose coverage over 85%

In 2013, all member states adopted a new goal to reduce prevalence of chronic hepatitis B to < 1% among children 5 years of age by 2017.

Founded in 1996 to address the disproportionately high prevalence of chronic hepatitis B and liver cancer in Asians and Asian Americans (funded by donations, foundations and federal grants)

Goal: eliminate HBV transmission, stigma and complications, and reduce the incidence and mortality of HCC worldwide

Focus on addressing the gaps in education, prevention, treatment and country policies by a four-pronged approach C - collaboration (public and private)A - evidence-based advocacy (guide country policies)R - research (liver cancer and health policy)E - education (public, healthcare providers, policy

makers) Liver.stanford.edu

ALC: Spearheads efforts leading to Changes in U.S. Policies to Address the Gaps in HBV Prevention and Control

2008, Office of Minority Health recognized chronic HBV infection in Asians and Pacific Islanders as a serious and frequently neglected national health disparity

2008, CDC updated hepatitis B screening guidelines2010, Institute of Medicine report on a national

strategy on prevention and control of hepatitis calls for the nation to act now

Partner with legislators: Hepatitis and Liver Cancer Bills introduced in Congress

(2009, HR 3974) and Senate (2010) 2010 Resolution passed by state of California to recognize

Hepatitis Awareness Week in May2012, CDC updated guidelines for HBV infected

healthcare workers

Recognized as the universal symbol to raise awareness about HBV and liver cancer

and support those living with hepatitis B

Bringing the CommunitiesTogether to Fight Hepatitis B and Liver Cancer:

Jade Ribbon

Jade = Good health and longevity

Advocacy: Increase WPRO and Country Level Capacity in Viral Hepatitis Prevention and Treatment

Partner with US CDC and advocate to policy leaders

& donors (including Zeshan Foundation)to support & strengthen WPRO viral hepatitis B initiatives:FT Hepatitis staff in ChinaP5 Hepatitis medical officer

and admin in WPROALC/APAVH provide partial

funding to create WPRO Hepatitis B website and funding/messaging for annual WHD activities

Vietnam, Hanoi, 2012 Phu Tho field visit & Hanoi,2013

Mongolia, 2013

Lao PDR, 2011

Partner withUS CDC toSupport theNational Workshop onHepatitis Prevention and Control to develop 2013-2017 national action plan

Invited by MOH to assist indevelopingcommunicationsand training toolsand strategies

Developed bannersto improve infant immunization

Partner withMOH in Lao PDRand WHO

Invited by vice Minister of Healthto identify nationalpriorities beyond infant immunization

Partner with WHO country office and FIRE (NGO)

Sept 2004: ALC and ACS invited to Manila to Examine Ways to Improve Liver Cancer Prevention and Control by Philippine Cancer Society, DOH and Philippine Gastroenterology Society

Recommendations Made at Interactive Panel Discussion on Liver Cancer, Manila, Sept. 2004

Include Hep B vaccination in the national free infant immunization program

Give the first dose within 24 hours of birth

Two recommendations

Senator Pia Cayetano led the fightin making these changes into Law.

Cancer screening

Cancer screening

* Wong SN et al. WJH 2013

Early detection of HCC by ultrasound and AFP Screening of HBsAg positive Persons to Improve Survival

Small 1.2 cm HCC detected on routine screening in “healthy” 53 year old Asian HBV carrier with normal AFP and ALT

Arterial phase CT Venous phase CT

Challenges and Limitations in HCC TreatmentGlobal mortality to incidence ratio of liver cancer is 0.95More complicated than other cancers because most

patients have 2 diseases:Liver cancer Cirrhosis (often from underlying chronic viral hepatitis)

Both can be fatal. The severity of the underlying cirrhosis limits cancer treatment option and outcome.

<30% are resectable at presentationSystemic chemotherapy is not very effectiveTransplantation and TACE treatments are expensiveRecurrence rate after initial treatment is high, so costly

longterm surveillance with CT/MRI scans and repeat treatments for recurrence are necessary to improve survival

* Wong SN et al. WJH 2013

Antiviral Rx

Antiviral Rx

New oral suppressive antiviral therapies are highly effective with low drug resistanceOne of them (tenofovir) is the same drug

that the health system in the Philippines is using to treat HIV/AIDS.

Putting patients with liver damage on antiviral therapyCan prevent disease progression and

reduce risk of death and costly complications associated with liver cirrhosis and liver cancer

Without appropriate chronic disease management, 15-25% of chronically infected persons will die from liver cancer or liver disease

Lok,McMahon. AASLD practice guideline:chronic HBV: Update 2009. Hepatology 2009; 50(3):1-362012 Physician’s guide to hepatitis B. A silent killer. Asian Liver Center, 2011

85% reduction in deaths from cirrhosis

Toy, M et al. Hepatology 2014, in press

VaccinationEliminate mother to child transmissionSafe injection and blood banking Protected sex

monitoring

Cancer screening

Cancer screening

Antiviral RxAntiviral Rx

2010 Institute of Medicine Report on Hepatitis 2010 Institute of Medicine Report on Hepatitis and Liver Cancer: Major Hurdle in Chronic Viral and Liver Cancer: Major Hurdle in Chronic Viral Hepatitis Prevention and ControlHepatitis Prevention and Control

Lack of Public Awareness Lack of Provider Awareness

Lack of Public Resource Allocation

Morbidity and Mortality related to hepatitis B and hepatitis C

JRC: Uniting the Community to Prevent and Treat Hepatitis B

San Francisco: First City in the US to test, vaccinate or treat all Asians and Pacific Islanders for hepatitis BMake routine hepatitis B testing by PCP the standard of careSee a doctor who will test you

Meredith et al. J Community Health, 2011

Hepatitis B Infant Vaccination Coverage

Source: WHO