While mortality rates from all other cancers are falling or remain static, liver cancer deaths have increased at a higher rate than those of any other cancer in Australia since figures were first published from 1968. Hepatitis B and C infection are the main cause for the unprecedented increase, compounded by other risk factors such as smoking, alcohol and obesity.
With one of the lowest survival rates of any cancer in Australia, Professor Jacob George has dedicated his career to improving outcomes for people with liver cancer. We sat down with Professor George recently to hear about the impact a major project, funded by Cancer Council back in 2008, has made to reducing the impact of liver cancer in NSW and his ongoing work to curb the threat of this devastating cancer.
Professor Jacob George knew the survival rate for liver cancer was poor and there was a high rate of prevalence in some migrant communities. He also knew liver cancer was one of the fastest growing cancers in Australia and, unless detected early or intercepted in precancerous stages, had one of the worst outcomes:
“The five-year survival rate of liver cancer was around 10% back in 2007. This was a problem we were not tackling – we needed to do something about it”.
Hepatitis B and C were known to be major risk factors associated with liver cancer and the team recognised that if they implemented strategies to identify at-risk populations, they could monitor and manage these patients to prevent the infection developing into cancer.
“If we identified at-risk patients and treated them, we could reduce liver cancer by 60-70% in hepatitis B patients and 90% in hepatitis C patients”.
The first task was to identify which population groups the patients with hepatitis B and C were in and which local health districts in NSW the patients were located. Bringing together epidemiologists and statisticians, the team pinpointed by postcode which areas needed to be targeted to treat the most hepatitis B and C patients.
Once the team identified where the at-risk populations were located, the next stage was to implement surveillance systems. One pilot surveillance program – the ‘B Positive’ program, offered screening for at-risk hepatitis B patients and then enrolled them on to a tailored follow-up and treatment program. GPs within the communities were informed and educated to make sure they were actively screening at-risk patients and treating them if required. Two hospitals – Westmead and the Royal Prince Alfred, each recruited over 600 patients.
“If you detect hepatitis B through a targeted screening program, your survival is much better as opposed to presenting with a symptomatic cancer”.
The next stage was making sure each patient received appropriate best treatment if they developed liver cancer. A key component the team recognised was that in order to successfully treat patients, a high-quality multi-disciplinary team would ensure that each individual patient received the best treatment approach. This has now been established at Westmead and many other hospitals in NSW
The funding from Cancer Council NSW allowed Jacob George and his team to implement different strategic measures to prevent and manage liver cancer in NSW. They have created a ‘Liver Wellness’ website to provide patients and health professionals with information about liver cancer and liver disease and nutrition and exercise advice. The website is available in four different languages and receives over 5000 hits per month.
In 2015, new retroviral drugs for hepatitis C became available, efforts to target at-risk communities have been stepped up and rates of hepatitis C related liver cancer are plateauing – and even declining in some communities.
Moving forward with this research
Preventing liver cancer at a national level
Professor Jacob George now wants to tackle the bigger picture. While rates of hepatitis C related liver cancer have declined, much more needs to be done at the national level. He wants to focus on detecting hepatitis B and C in every patient early enough to prevent liver disease advancing and becoming harder to treat.
“We need to focus on prevention of the disease. If we can systematically identify patients with hepatitis B and C and link them to care then this would have a big impact on liver cancer control”.
Liver cancer affects the marginalised populations and unfortunately most don’t have a strong advocacy voice. Many are in marginalised migrant and Indigenous communities, are practicing high risk behaviours or are from socially disadvantaged groups who have poor access to health services. Changing how the public perceives the causes of liver cancer is something Jacob wants to achieve.
“Like lung and other cancers that are common but have relatively poor survival, liver cancer lacks a strong advocacy voice – because there are not enough survivors to provide a platform and the survivors we work with are marginalised. If we can do more to prevent liver cancer and raise awareness working with Cancer Council, we can build a stronger advocacy voice, from prevention through to research investment in treating established disease. We have the epidemiologists, the clinicians, and the Cancer Council, but the fourth pillar we are missing is the public advocacy.”
Roadmap to improved liver cancer outcomes
In 2019, the Australian Government commissioned Cancer Council Australia to develop the nation’s first ever “Roadmap to improved liver cancer outcomes”.
The focus will be on preventing liver cancer by exploring systematic approaches to identifying and treating populations at high risk. An independent expert advisory group was formed and, in recognition of his leadership, Professor George was appointed co-chair, with GP and hepatitis researcher, Dr Nicole Allard. Cancer Council NSW will support the work, as part of the Pathways to a cancer-free future.
New treatment approaches
In addition to preventing and managing the disease, Professor George is investigating the different types of liver cancer and developing alternative treatment approaches. Liver cancer is highly diverse among patients. If the tumours are sub-classified better, then personalised medicine can be developed improving each patient’s outcome.
One approach he is taking is to target a select set of cells known as cancer stem cells. Liver cancer stem cells are a small population of cells that are resistant to treatment and responsible for the cancer returning. Unfortunately, it is difficult to target stem cells using standard treatment. Therefore, Jacob and his team are developing aptamer molecules, also known as chemical antibodies, to target and kill the stem cells.
“Investigating how to target the liver cancer stem cells will allow us to get much better cure rates”.
This exciting new approach could revolutionise the way liver cancer patients are treated. Understanding what causes the cancer to return and being able to prevent this from happening would significantly improve the outcome for liver cancer patients.
Jacob George AM, MBBS, FRACP, PhD, FAASLD, is Professor of Gastroenterology and Hepatic Medicine, Faculty of Medicine, University of Sydney and currently holds the Robert W Storr Chair of Hepatic Medicine at the University. He is Head, Department of Gastroenterology and Hepatology at Westmead Hospital and Director of Gastroenterology and Hepatology Services, Sydney West Area Health Service and Director of the Storr Liver Centre, The Westmead Institute for Medical Research, Westmead
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