Dr. Samuel So Director, Asian Liver Center Stanford University

1. Samuel So, MBBS, FACS
Lui Hac Minh Professor
Professor of Surgery
Director, Asian Liver Center
Stanford University School of Medicine
Manila, February 2014

2. Liver Cancer
7th most common cancer in the world
Ranks 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

3. Western Pacific Region has the Greatest
Burden of Liver Cancer in the World
WPRO accounts for
66% of new liver cancer
cases and deaths each year

4. Top 5 Causes of Cancer Deaths
in the Philippines
Men
Women
Both Sexes
1
2
Lung
Liver
Breast
Cervix
Lung
Breast
3
Prostate
Lung
Liver
4
5
Colorectal
Leukemia
Colorectal
Colorectal
Leukemia
Liver
Source: GLOBOCAN 2012, (IARC)

5. Liver cancer deaths
will double in 20 yrs
GLOBOCAN 2012 (IARC)

6. Liver Cancer is A Leading Cause of Cancer Death in
Countries where Chronic Hepatitis B is Prevalent
Thailand
Vietnam
China
Korea
Philippines
Indonesia
Singapore
Malaysia
India
Australia
New Zealand
Chronic hepatitis B
prevalence
≥ 7%
≥ 7%
≥ 7%
≥ 7%
≥ 7%
≥ 7%
≥ 7%
≥ 7%
~ 3%
< 2%
< 2%
Liver cancer ranking
as cause of cancer
death in men
1
1
2
2
2
3
3
4
7
11
12
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>

7. Transmission of HBV
Birth: From an infected
mother to newborn at birth
(about 40% of chronic HBV infection
in Asia)
Blood: Direct contact with
infected blood
 Unsafe 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

8. Global Elimination of Hepatitis B
Transmission is Feasible
1981, the first hepatitis B
vaccine was FDA
approved. World Health
Organization calls “The
First Anti-Cancer
Vaccine”
3 Shots given
over 6 months
can Protect
You for Life

9. Hepatitis B Immunization would Reduce the Future
Burden of Chronic Hepatitis B infection and Liver Cancer
in China
12
HBsAg Prevalence (%)
10
11.3
9.7
1992
2006
11.5
10.2
9.
6
9.9
9.3
8.0
8
8.2
8.1
8.3
7.6
6
5.4
4
3.2
2
0
1.0
1~
Impact of infant immunization after 14 years:
Prevented up to 20 million chronic infection
Prevented up to 3.5 million future deaths
from liver cancer and liver disease
1.4
5~
10~
Liang X, et al. Vaccine 2013 (in press)
Liang X, et al. J Infect Dis 2009; 200: 39-47
Courtesy of Prof Zhuang Hui, PKU
15~
20~
30~
40~
50~
Age (Yrs)

10. 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.

11. 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

12. 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 guidelines
 2010, 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 May
 2012, CDC updated guidelines for HBV infected
healthcare workers

13. Bringing the Communities
Together to Fight Hepatitis B and Liver Cancer:
Jade Ribbon
Jade = Good health and longevity
Recognized as the universal symbol to
raise awareness about HBV and liver cancer
and support those living with hepatitis B

14. 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 China
 P5 Hepatitis medical officer
and admin in WPRO
 ALC/APAVH provide partial
funding to create WPRO
Hepatitis B website and
funding/messaging for annual

15. Vietnam, Hanoi, 2012
Partner with
US CDC to
Support the
National
Workshop on
Hepatitis
Prevention and Control to
develop 2013-2017 national action
plan
Phu Tho field visit & Hanoi,2013
Invited by MOH to
assist in
developing
communications
and training tools
and strategies
Lao PDR, 2011
Developed banners
to improve infant
immunization
Partner with
MOH in Lao PDR
and WHO
Mongolia, 2013
Invited by vice
Minister of Health
to identify national
priorities beyond
infant immunization
Partner with WHO
country office
and FIRE (NGO)

16. 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

17. Recommendations Made at Interactive Panel
Discussion on Liver Cancer, Manila, Sept. 2004
Two recommendations
 Include Hep B vaccination in the
national free infant immunization
program
 Give the first dose within 24 hours
of birth
Senator Pia Cayetano led the fight
in making these changes into Law.

19. Cancer screening
Cancer screening
* Wong SN et al. WJH 2013

20. 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

21. Challenges and Limitations in HCC
Treatment
Global mortality to incidence ratio of liver cancer is 0.95
More 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 presentation
Systemic chemotherapy is not very effective
Transplantation and TACE treatments are expensive
Recurrence rate after initial treatment is high, so costly
longterm surveillance with CT/MRI scans and repeat
treatments for recurrence are necessary to improve
survival

22. Antiviral Rx
Antiviral Rx
* Wong SN et al. WJH 2013

23. New oral suppressive antiviral therapies are
highly effective with low drug resistance
 One 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 therapy
 Can 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):1-36
2012 Physician’s guide to hepatitis B. A silent killer. Asian Liver Center, 2011

24. 85% reduction in
deaths from
cirrhosis
Toy, M et al. Hepatology 2014, in press

25. Vaccination
Eliminate mother to child transmission
Safe injection and blood banking
Protected sex
monitoring
Antiviral Rx
Cancer screening
Antiviral Rx
Cancer screening

26. 2010 Institute of Medicine Report on Hepatitis
and Liver Cancer: Major Hurdle in Chronic Viral
Hepatitis Prevention and Control
Morbidity and Mortality related to hepatitis B and hepatitis C
Lack of Public Awareness
Lack of Provider Awareness
Lack of Public Resource Allocation

27. 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 B
Make routine hepatitis B testing by PCP the standard of care
See a doctor who will test you
Meredith et al. J Community Health, 2011

28. Hepatitis B Infant Vaccination Coverage
Source: WHO