Impact and Scope of HBV and Liver Cancer in the API Community Samuel So, MD, FACS Lui Hac Minh Professor Director, Asian Liver Center Director, Liver Cancer.

Impact and Scope of HBV and Liver Cancer in the API Community

Samuel So, MD, FACSLui Hac Minh Professor

Director, Asian Liver Center Director, Liver Cancer Program

Stanford University School of Medicine

Hepatitis B is the Most Common Serious Liver Infection in the World

350-400 million people worldwide have chronic HBV infection (compare with 40 million living with HIV)1,2

Without appropriate treatment or monitoring, 1 in 4 person with chronic HBV infection will die of liver cancer, cirrhosis or liver failure

HBV takes a 700,000- a million lives a year1,2

Preventable with a vaccine available for over 25 years

Millions worldwide are infected every year without vaccination

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

2.WHO. Available at: www.who.int/csr/disease/hepatitis/en/

Hepatocellular Carcinoma (HCC)from a Global Perspective Ranks 4th in cancer incidence and 3rd in cancer mortality Takes about 600,000 lives a year HCC is largely preventable (80% caused by chronic HBV,

15% chronic HCV) Other risk factors:

cirrhosis of any etiology (risk of HCC increases to 1-6% per year with cirrhosis

Alcohol Viral hepatitis Metabolic diseases (hemochromatosis, tyrosinemia)

aflatoxins

HBV is Transmitted the Same Way as HIV 1

Birth: From an infected mother to newborn at birth (accounts for 40-50% of the cases in Asia)

Blood: Direct contact with infected blood Unsafe injections and transfusions Sharing or reusing needles or syringes Open wound contact

Sex: Unprotected sex

US Incidence of chronic HBV: same as HIV

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

HBV is up to 100x moreInfectious than HIV

HBV is not transmitted by food or casual contact

Sharing foodor drinks

Kissing

ShakingHands

Sneezing

HBsAg PrevalenceHigh >8%

Intermediate 2-7%

Low <2%

Geographic Distribution of Chronic HBV Infection

1 Goldstein ST, et al. J Infedct Dis. 2002;185:713-7192 Kim WR, et al. Hepatology. 2004;39:811-816.3 WHO. Available at: www.who.int/csr/disease/hepatitis/en/

Connecting the Dots between HBV and Liver Cancer

At a time when the world thought chemicals like aflatoxins is the cause of liver cancer

Dr. Beasley, his co-investigator Dr. Lu-yu Huang and Taiwan team of investigators conducted a study of over 22,000 government workers found Risk of liver cancer is 60 times higher in

chronic HBV infected persons (which is higher than the association between lung cancer and smoking …20-25 times)

Life time risk of dying from liver cancer is 40% in men and 15% in women

R. Palmer Beasley, MD

Hepatitis B is the Most Common Cause of Liver Cancer in the World

Chronic hepatitis B infection is the cause of about 80% of primary liver cancer in the world1

Risk of HCC in persons with chronic HBV (HBsAg positive) is as high as 0.5% per year

Second only to tobacco in causing the most cancer deaths worldwide1

The World Health Organization named the hepatitis B vaccine “The First Anti-Cancer Vaccine”

1. WHO. Available at: www.who.int/csr/disease/hepatitis/en/

There is now Irrefutable Evidence that Chronic Hepatitis B Causes Liver Cancer

In 1997, Taiwan reported a significant drop in liver cancer rates in children under 15 years of age after the adoption of a national universal newborn vaccination program

In 2005, HBV was officially recognized as one of 58 known agents that cause human cancer (11th Report on Carcinogens, U.S. Dept of Health and Human Services, National Toxicology Program)

Source: Chang MH et al. N Engl J Med. 336(26):1855-9,1997

Comparing HBV and HIV in China

HIV1 HBV2

650,000 with HIV

in 2005 0.05% of

population

130 million with chronic HBV

10% population

1 Z Sun et. al., J Med Virol 2002, 67:447-4502 UNAIDS/WHO Epidemiological Fact Sheet accessed at www.who.int /3by5/support/efs2004_chn.pdf

China has the Greatest Burden of Hepatitis B and Liver Cancer in the World

1/3 of the world’s chronic HBV patients live in China1

130 million Chinese (1 in 10) have chronic hepatitis B1

China accounts for about 55% of the 600,000 worldwide deaths from liver cancer each year

HBV kills an estimated half a million mainland Chinese each Year2

1 WHO. Available at: www.who.int/csr/disease/hepatitis/en/

2 Z Sun et. al., J Med Virol 2002, 67:447-450

No HBVAwarenessPosters in China!

Discrimination of those with HBV is widespread

Only adopted National newborn vaccination program in 2002

China reported 14 deaths from avianflu between 2003-9/14/2006Preparing to vaccinate every bird against avian flu

Vaccinate every person against HBV is more urgent!

HCC in the US

Estimated incidence for 2006: 18,510 new cases 16,200 deaths (44 deaths/day)

Source: Cancer Facts & Figures 2006, American Cancer Society

Chronic HBV and HCC is the Chronic HBV and HCC is the Greatest Health Disparity Greatest Health Disparity between Asian and Caucasian between Asian and Caucasian AmericansAmericans Chronic hepatitis B (1 in 10 Asians)

10% of Asian-Americans vs. 0.1% of Caucasian Americans

1.4 million people chronically infected in U.S. Over 60% are Asian-American

HCC incidence (up to 9x higher for Asians compare with white Americans)

HCC is the second leading cause of cancer death in Asian men living in the US

Many Asians in the US are foreign born and came from countries with high incidence of chronic HBV infection

HBV and Liver Cancer is the Greatest Health Disparity Between Asian and White Americans1,2

Maternal race/ethnicity 2002 Births

Estimated maternal HBsAg Prevalence

Estimated Births to HBsAg positive women

White, non-Hispanic 2,298,156 0.13% 2,988

Hispanic 876,642 0.09% 789

African American 593,691 0.5% 2,968

Asian Pacific Islander

Foreign born

US born

175,264

35,643

8.9%

1.4%

15,598

499

Other 42,330 0.5% 212

Total 4,021,726 23,054

1. Asian Liver center http://liver.stanford.edu2. Draft ACIP hepatitis B recommendations, CDC 2005

Prevalence of Adult (mostly foreign born) API positive for HBsAg in the US

# Screened

Mean Age(yr)

Ethnicity Location HBsAg (+)

HBsAg(-) HBsAb(-)

5341 43 Chinese Korean Vietnamese

Chicago, New York, Philadelphia

10.4%

37.5%

California: Bay Area

12.3%

NA

Los Angeles

12.5%

NA

1311

46.6 Chinese

Orange County

9.3%

NA

925 newly screened

45 Chinese Korean

NYC 14.8% 31.6%

1. Guan R et al. Hepatology 40 (S4): 716A, 20042. Chao S. et al. Hepatology 40 (S4): 717A 20043. MMWR 55(18): 505-509, 2006

Source: California Cancer Facts & Figures 2005, American Cancer Society

Five Most Common Cancers in Males by Race/EthnicityCalifornia, 1997-2001

  Rank

  1 2 3 4 5

Asian

Laotian liver lung stomach colorectal oral

Cambodian

lung liver colorectal lymphoma oral

Vietnamese

lung liver prostate colorectal stomach

Chinese prostate colorectal lung liver stomach

Korean lung stomach colorectal prostate liver liver

Filipino prostate lung colorectal lymphoma liver

Non-Asian

White prostate lung colorectal bladder melanoma

Hispanic prostate colorectal lung lymphoma leukemia

Black prostate lung colorectal lymphoma oral

Trends in 5-Year Survival by Year of Diagnosis in the U.S.

Site 1974-76 1983-85 1992-99

Breast cancer

75% 78% 87%

Colon cancer

51% 58% 62%

Prostate cancer

67% 75% 98%

Liver cancer

4% 6% 7%

In the U.S.:

Liver Cancer Mortality

Asians vs. All Races

Source: National Cancer Institute – Surveillance Epidemiology and End Results 2006. http://seer.cancer.gov/resources/

Chronic Hepatitis B is a Silent Killer in the Asian American community1

Many people don’t know they have been infected

Many feel perfectly healthy Routine liver function blood

test are often normal Doctors and patients are then

fooled that everything is OK If you wait for symptoms

(jaundice, pain or swollen belly), it is often too late

1. Asian Liver Center. Available at: http://liver.stanford.edu

Many hepatitis B carrier don’t know that you could have developed a large liver cancer without any symptoms

35 years old Asian American Engineer, Hepatitis B carrier with no symptoms: 14 cm Liver Cancer

Liver Cancer Often Strikes at the Prime of Life (35-65 years of age)

Brothers in their 30s found to haveliver cancer at the same time

Dr. Mark LimInternist“Healthy hepatitis B carrier”

Diagnosed with advanced liver cancer at 31years of age

Died before 32nd birthday

Engardio. San Francisco Chronicle, 2003

Many Doctors do not know about the Importance of Regular Screening for Liver Cancer

Many doctors we are training are not aware of the prevalence and risks of chronic HBV(including liver cancer)

Survey of Knowledge and Screening Practices of Incoming Housestaff to Stanford Medical Center in 2003 Only 53.5% of incoming PGY-1 were aware Asian

Americans has the highest incidence of HBV Only 27.4% knew about the 1 in 4 risk of dying from liver

cancer or cirrhosis Only 40% recognized perinatal transmission is the major

mode of transmission in Asians 27.1% will order an HBV screening test for Asians

It is important to promote awareness and testing of all Asian Americans for HBV

Screen for the 1 in 10 API who don’t even know they have been chronically infected

Vaccinate those who are not protected “First anti-cancer vaccine”

For those who test positive for HBsAg, even though there is no cure Appropriate HBV treatment can reduce risk of liver

cancer and cirrhosis regular screening for liver cancer can lead to early

detection and successful removal of the cancer

Early detection by regular screening is the only way to improve HCC survival1

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

1 Yang B et al. J Cancer Res and Clin Oncol, 123:375, 1997

California Initiative

First California Liver Cancer Control Plan (partners include ACS & Dept of Health), that by 2010 all Asians in California

should be tested for HBV Aim to have 99% of Asians

vaccinated if they are not protected

Improve liver cancer survival by 20%

First National Hepatitis B Bills (H.R. 4550, S. 3558)

(Introduced with bipartisan sponsorship on Dec 2005 in Congress, and June 2006 in Senate) Partners include Congressmen Honda and Charlie Dent,

Senators Feinstein and Santorum, AAPCHO, ALF, NYU, Hepatitis International, Hepatitis B Foundation

Establish and implement a comprehensive HBV prevention, education, research and medical treatment program

Reduce liver cirrhosis and cancer incidence, and improve liver cancer survival caused by chronic HBV infection

Write to your RepresentativesIn Congress and Senate!

Goals of Healthy People 2010

Increase quality and years of healthy life Eliminate health disparities

It’s time to UNITE and ACT NOW to eliminate HBV and liver cancer in the API communities!