23 October 2023
How to put the brakes on liver cancer deaths
More Australians are getting and dying from liver cancer, but keeping close watch on the most vulnerable will save lives.
Tackling liver cancer means switching from a focus on individuals’ behaviour, to addressing demographic and social disadvantage instead, according to new Australian research.
A study of six million adults, analysed through the NSW Cancer Registry and Australian Bureau of Statistics datasets from 2016 to 2018, found that the 1185 cases of primary hepatocellular carcinoma were more likely to be found in disadvantaged groups.
Men born in China had more than twice the odds of getting liver cancer as those born in Australia, while those from the Philippines, Vietnam and New Zealand had 80% higher odds.
The odds were twice as high in men who had no formal education and under-70s with long-term disability, 78% higher among labourers, 72% higher among drivers and people who lived in public housing, and 73% higher among those with more than four medicated comorbidities.
Those who were not proficient in English had a 40% higher chance than the proficient, men who didn‘t reach year 12 in high school had a 25% higher chance and those with a low income had a 20% higher chance of liver cancer.
Interestingly, the odds of liver cancer were 10-20% lower in men living in regional and remote areas compared with those in large cities, but the cancer was more likely to have spread for those living in regional and remote areas.
The results were similar in women.
“These data will inform service planning and targeting. Repeating the process on a periodic basis, potentially in relation to future censuses, will indicate changes in risk profiles that may inform adjustments to service plans and priorities,” Sydney hepatologist Professor Jacob George and colleagues authors wrote in BMC Public Health.
As in other economically advantaged countries, the rates of Australians being diagnosed with and dying from liver cancer are rising.
The incidence has tripled over the last three decades, and deaths have almost doubled. Prognosis is poor for this disease, with only 22% of those diagnosed living beyond five years. Around 2800 adults were diagnosed in 2021, and three in four were men. That year, 2,424 adults died, with men accounting for two in three.
Professor George said the strong role social determinants of health played in liver cancer had been seen anecdotally and in individual studies, however the use of “big data” provided concrete, representative and robust numbers.
“But then we need to have the ability to respond, which comes down to political will, funding, resourcing – all of those things,” the liver specialist at Westmead Hospital and Sydney West Local Health District told Oncology Republic.
“As a clinician in Western Sydney, I live through this data every day. Every patient that I see is from one of these groups,” he said.
Obesity, diabetes, alcohol dependency, hepatitis B and C and other risk factors of liver cancer were common in people from disadvantaged groups, Professor George said. Additionally, while well off patients were likely to undertake “a whole cascade of care”, those from lower socio-economic groups had lower health literacy and health seeking behaviour. Liver cancer, being largely asymptomatic, was not high on the list of priorities for these patients, he said.
“When you combine all of that, it’s a perfect recipe to get cancers diagnosed at a very late stage.”
In their article, Professor George and colleagues said that targeting high-risk groups was an opportunity for prevention.
“Notably around half the burden of liver cancer in Australia have been attributed to hepatitis B and C infections, such that treating and curing HCV and suppressing HBV infection with drugs would markedly reduce the risk if hepatocellular carcinoma,” they wrote.
Clinical practice guidelines for hepatocellular carcinoma surveillance for people at high risk were launched in June this year. The aim was to increase awareness and testing for risk factors (such as hepatitis B and C, obesity, alcohol, smoking and drug intake) and then to treat those factors and continue to monitor at-risk people.
“If you diagnose early, one or two centimetres, it’s curable. If you’re going to get liver cancer, we want to be able to diagnose it early,” said Professor George, who chaired the group that developed the guidelines.
But increasing health literacy and engaging patients in care was a challenge, said Professor George.
“We’ve got a van. We actually go to communities which are at high risk of hep C. We offer to test them and to treat them. In the old days, we wanted patients to come to us. This group of patients do not come to us. So we go to homeless shelters, Aboriginal health clinics, needle exchanges, community events and church group events. We test and we treat.”
Early diagnosis was more likely when a patient with an existing risk factor (such as hepatitis B or C) was referred for specialist treatment, Professor George said, because it was more difficult to get patients to prioritise surveillance in a primary care setting.
The hope is that Australia will eventually have a national surveillance program, said Professor George. And he said there were cost-effective ways to do it.
“All we’re looking for is a lump in a liver. You could have a van like the breast cancer van. Expert nurses could be trained. It’s efficient and doesn’t require the resources of a private practice.”
“People get tested and treated for hep B or C, they get reminders, they’re linked to expert GPs – all of those things are possible if money is made available,” he said.