Hepatocellular cancer (HCC) is among the top 10 causes of cancer death in Australia, with ~80% of cases attributable to chronic viral hepatitis. Although 60-80% of HCCs are preventable by antiviral therapies, multiple barriers exist in the diagnostic and treatment continuum. Chronic hepatitis B (CHB) is the main cause for rising HCC rates in Western Sydney, where the greatest burden of disease is among people born in hepatitis B endemic countries.

1. Implementing a shared care model to
prevent liver cancer and improve chronic
hepatitis B outcomes in a high disease
prevalence area.
Kristen Stone
Storr Liver Centre, Westmead Hospital

2. Acknowledgements
Professor Jacob George
Storr Liver Centre, Westmead Hospital
Dr Monica Robotin
Cancer Council NSW
Mamta Porwal
Cancer Council NSW

3. Background

4. Figure 14a Liver cancer, ASR*, NSW, 1973−2009¹ Figure 14b Liver cancer, new cases by age group, NSW, 2009¹
¹ Excludes death certificate only (DCO) cases in 2009. DCO cases are incident cases identified during death certificate processing. For further information refer to Appendix 3.
Age-standardised rate, standardised to the Australian 2001 population.
** APC is the average annual percent change in ASR* calculated from a log linear model, fitted to rates over the years 2000 to 2009. For further information refer to Appendix 4.
CANCER IN NSW: INCIDENCE REPORT 2009
HCC incidence

5. Trends in overall Cancer Mortality:
NSW (1999-2008)
• HCC amongst top 10 causes of
cancer death
• Increasing incidence of HCC means
mortality rates are also increasing
• >85% 5 year mortality
SOURCE: Cancer in New South Wales – Incidence and Mortality
report 2008

6. HCC and Hepatitis B- our local problem
Incidence of liver cancer, in NSW males, 1998-2002

7. HCC and Hepatitis B
State or Territory Population, 2011
Number of
people living with
CHB, 2011
Number
receiving care,
2013
Proportion of
people in care (%)
Number still
requiring care,
2013
ACT 357,219 3,603 493 13.7% 3,110
NSW 6,917,655 77,076 14,237 18.5% 62,839
NT 211,943 3,556 568 16.0% 2,988
QLD 4,332,737 37,427 2580 6.9% 34,847
SA 1,596,570 14,442 630 4.4% 13,812
TAS 495,352 3,513 95 2.7% 3,418
VIC 5,354,042 56,836 10,819 19.0% 46,017
WA 2,239,170 22,055 1278 5.8% 20,777
AUSTRALIA 21,507,719 218,567 30,700 14.0% 187,808
Totals may not add up due to inclusion of those without a State or Territory of residence
Source: HEPATITIS B MAPPING PROJECT NATIONAL REPORT 2012/13
Table 7: Number and proportion of people receiving guideline-based care for CHB, 2013

8. Gap: medical awareness
• National Hepatitis B Needs Assessment 2008
– Survey of ~90 GPs in northern suburbs of Melbourne
– 70% of GPs highlighted need for more knowledge
– Nearly 1/3 could not interpret HBV serology
• Guirgis 2011
– Survey of ~120 GPs in SW Sydney
– 20% lacked confidence in interpreting HBV serology
– 22% did not recognise HCC as a complication of HBV
– 20% were unaware of any treatment for HBV
– 89% identified language difficulties as the main barrier to treatment

9. Key challenge in HCC prevention
How do we get more people living with
CHB informed, and treated appropriately
to decrease and prevent the increasing
mortality?

10. Aims

11. What are we trying to achieve?
• Provide high quality, supportive service to
local GP’s
• Increase knowledge to increase effective care
• Increase support to patients
• Increase antiviral therapy uptake
• Decrease burden of liver disease and
liver cancer

12. Method

13. Shared Care Model
HOTTeR West Clinical Interactions

14. Related patient investigations (pathology, ultrasound, family history) discussed
by CNS with Professor George. Triage to either GP care or for review in Liver
clinic
Patient’s with CHB enrolled into the program by GP using the program specific referral form
(HBsAg +ve & anti-HBc +ve)
Non Complex CHB
Recommended care
discussed with GP.
CNS will support the
ongoing GP based CHB
monitoring.
(HBV DNA <2000 IU/ml,
ALT <30IU/ml Male
<19IU/ml Female
Nurse Specialist
Fibroscan
Community based clinic
(ALT >40IU/ml, liver
ultrasound suggestive of
fibrosis)
If
Results indicate
need for specialist
review
Complex CHB
Patient reviewed by
Specialist in Liver clinic.
Once results are stable
patient is sent back to
GP care.
(HBV DNA >2000 IU/ml,
ALT >30IU/ml Male
>19IU/ml Female)
Specialist
Nurse Specialist

15. Results

16. The numbers
• Following ethics approval the program commenced
receiving patient enrolments in March 2015.
• 120 patients enrolled and triaged appropriately
• 2 large medical practices (10+ GP’s) engaged
• 70 patients assessed in community fibroscan clinic
• 10 patients commenced on antiviral therapy with
successful ongoing GP management

17. Increasing knowledge
• Hepatitis B and HCC educational session: 90
local GP’s attended, 3 local specialist guest
speakers
• Patient group education sessions: 20
participants in each. Topics covering CHB,
treatment, taking charge of your care, HCC,
healthy living

18. In-language resources
Resources for patients available in English
and Chinese

19. In-language resources
Fibroscan patient information :
available in English and Chinese

20. On going support
• Development of a website: Patient section and health
professional section, access to relevant program information,
CHB and HCC resources. Multiple languages.

21. Implications

22. Implications
• Shared care model has improved the
management of these 120 patients
• Timely referrals for more complex cases
• Tracking of results
• Appropriate HCC surveillance
• Successful initiation and ongoing management of
antiviral therapy
• Increased general knowledge and confidence
amongst GP’s involved

23. And finally…
• Further growth of the program
• Expanding community engagement
• Evaluation of impact on timely diagnosis and
treatment of HCC

24. Would you like to know more?
Kristen Stone- Nurse Specialist
Storr Liver Centre, Westmead Hospital
kristen.stone@health.nsw.gov.au
0407141139