tag:theconversation.com,2011:/id/topics/liver-cancer-8322/articlesliver cancer – The Conversation2019-04-02T10:41:42Ztag:theconversation.com,2011:article/1123462019-04-02T10:41:42Z2019-04-02T10:41:42ZKids exposed to flame retardant PBDE are at risk for lifelong liver or cardiovascular problems<figure><img src="https://images.theconversation.com/files/266586/original/file-20190329-70986-1q75yi3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Most baby clothes, toys, bedding and furniture are treated with flame-retardant chemicals.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/baby-clothes-newborn-pastel-colors-326694860">vkuslandia/SHutterstock.com</a></span></figcaption></figure><p>What factors determine if you will experience healthy and cheerful aging or if it will turn into an endless chain of suffering from numerous health conditions? </p>
<p>Many factors shape our health, including genetics, diet, physical activity, smoking and stress. Some other factors may be as powerful but may not yet be recognized. </p>
<p>I am an environmental toxicologist studying how man-made chemicals affect our health. I was always interested in understanding how our current health is shaped by chemical exposures during the embryonic and early postnatal period – life stages that are particularly sensitive to environmental stressors. </p>
<p>To address these questions, I focused on the analysis of long-term health effects induced by a family of chemicals used as flame retardants called <a href="https://www.epa.gov/sites/production/files/2014-03/documents/ffrrofactsheet_contaminant_perchlorate_january2014_final_0.pdf">polybrominated diphenyl ethers (PBDEs)</a>. The first patent for PBDE use as a flame retardant was issued in 1960, and manufacturing of commercial products containing PBDEs, such as building materials, electronics, furnishings, motor vehicles, plastics, polyurethane foams, baby pajamas and others, <a href="https://doi.org/10.1016/j.scitotenv.2008.05.003">began in 1965</a>. PBDEs were first detected by scientists in <a href="https://doi.org/10.1016/0045-6535(87)90291-8">animal tissues in the 1980s</a>. </p>
<p>Later studies showed that concentrations of these chemicals in human blood, milk and tissues were <a href="http://doi.org/10.1021/es035082g">increasing exponentially over the past 30 years, doubling every five years</a>, while their health effects were poorly understood.</p>
<h2>Early exposures trigger lifelong changes in blood lipids</h2>
<p>In one of my experiments, I fed mice one of the PBDEs most often found in human blood and milk – BDE-47. The <a href="http://doi.org/10.1210/js.2016-1011">female mice received it</a> from day 8 of their pregnancy until the end of nursing (postpartum day 21). </p>
<p>We exposed mice to 0.2 milligrams of this chemical per kilogram of body weight. This caused BDE-47 concentrations in the fat of experimental animals to reach similar levels to concentrations found in humans living in big American cities. This comparison is used in toxicology to ensure that laboratory experiments use doses relevant for human exposures. </p>
<p>We were surprised to find that triglyceride levels were significantly altered in the offspring of exposed mothers, even though exposure to BDE-47 ceased three months earlier. Triglycerides are main constituents of body fat and cell membranes in humans and other animals.</p>
<p>To understand how BDE-47 changes blood triglycerides and other lipids, <a href="http://doi.org/10.3389/fendo.2018.00548">my laboratory conducted another experiment</a> with mice. Lipids are insoluble molecules that are used to store energy and as structural components of cell membranes. </p>
<p>We hypothesized that changes in blood lipids result from changes in liver function. It is well-known that the liver regulates composition of lipids in blood. The liver can synthesize new lipids, destroy them, secrete lipids to blood and absorb them from blood. </p>
<p>To test our hypothesis, we exposed female mice to BDE-47 daily during pregnancy or during the period of lactation and analyzed health outcomes in offspring when they reached one year old – roughly equivalent to 50 years in humans. </p>
<p>This experiment again demonstrated that short-term exposure to BDE-47 during early steps of development results in long-lasting effects on blood lipids in mice. These effects were very similar in animals that were exposed during the embryonic period or during nursing. </p>
<h2>Reprogramming the balance of lipid in blood and liver</h2>
<p>In exposed animals, levels of blood triglycerides fell by half, and <a href="http://doi.org/10.3389/fendo.2018.00548">livers accumulated 20 percent to 40 percent more lipids than in mice that were never exposed to the chemical</a>. Activity of many liver genes encoding enzymes important for lipid metabolism was altered in exposed mice. </p>
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<a href="https://images.theconversation.com/files/266845/original/file-20190401-177196-xgnkmm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/266845/original/file-20190401-177196-xgnkmm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/266845/original/file-20190401-177196-xgnkmm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/266845/original/file-20190401-177196-xgnkmm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/266845/original/file-20190401-177196-xgnkmm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/266845/original/file-20190401-177196-xgnkmm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/266845/original/file-20190401-177196-xgnkmm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/266845/original/file-20190401-177196-xgnkmm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Stages of liver damage. In severe cases, high levels of fat in the liver can lead to liver cancer.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/stages-liver-damage-disease-healthy-fatty-1071451652">wowow/Shutterstock.com</a></span>
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<p>Among key proteins involved in lipid metabolism, one was particularly high. This protein – CD36 – is responsible for pumping lipids from blood to the liver. Increased amount of CD36 in exposed animals is likely responsible for lowering lipids in blood and raising them in the liver, resulting in increased accumulation of these fats in the liver. </p>
<p>We observed that lower-exposure dose (0.2 mg/kg) and higher-exposure dose (1.0 mg/kg) regulated CD36 in opposite directions. Lower dose resulted in decreased CD36 and elevated blood triglycerides, while higher dose raised CD36 and decreased blood triglycerides. We think it is important to note that both tested doses were in the range of human exposures. </p>
<h2>Do changes in CD36 pose health risks?</h2>
<p>Our findings demonstrate that exposure to BDE-47 during early development can alter the levels of CD36 in either direction in mice and that both increase and decrease in CD36 may be deleterious. </p>
<p>When we exposed mice to high doses of BDE-47, this increased levels of the CD36 protein, which causes excessive accumulation of fat in liver cells. This condition is called nonalcoholic fatty liver disease. It is the <a href="http://doi.org/10.1002/hep.20701">most common form of chronic</a> <a href="http://doi.org/10.1097/01.mpg.0000239995.58388.56">liver disease among adults and children</a>. </p>
<p>Around <a href="https://doi.org/10.1002/hep.20466">one-third of the American population has</a> nonalcoholic fatty liver disease, and it is a risk factor for <a href="https://doi.org/10.1038/nrgastro.2013.41">Type 2 diabetes, hypertension, cardiovascular and kidney disease</a>, <a href="https://doi.org/10.1016/j.jhep.2011.10.027">liver cirrhosis and liver cancer</a>.</p>
<p>On the other hand, decreased activity of CD36 will lead to higher lipid levels in the blood and result in <a href="https://medlineplus.gov/atherosclerosis.html">atherosclerosis</a> – a disease in which plaques of lipids build on the walls of vessels. Atherosclerosis is the primary risk factors for <a href="https://healthmetrics.heart.org/wp-content/uploads/2017/06/Heart-Disease-and-Stroke-Statistics-2017-ucm_491265.pdf">heart attack, which causes around 800,000 deaths annually</a> in the U.S. alone. Thus, early life exposure to this environmental chemical may completely reprogram lifelong health trajectory.</p>
<p>Studies published by other laboratories confirm that <a href="https://doi.org/10.1007/s00204-018-2292-y">PBDEs disrupt lipid metabolism in rats</a> and <a href="https://doi.org/10.1007/s00204-018-2177-0">increase risk of nonalcoholic fatty liver disease</a> in mice exposed during early steps of development.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/266843/original/file-20190401-177163-1eavddz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/266843/original/file-20190401-177163-1eavddz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=280&fit=crop&dpr=1 600w, https://images.theconversation.com/files/266843/original/file-20190401-177163-1eavddz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=280&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/266843/original/file-20190401-177163-1eavddz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=280&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/266843/original/file-20190401-177163-1eavddz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=352&fit=crop&dpr=1 754w, https://images.theconversation.com/files/266843/original/file-20190401-177163-1eavddz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=352&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/266843/original/file-20190401-177163-1eavddz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=352&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">High levels of blood triglycerides can cause the buildup of fatty plaques that eventually block blood flow.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/closeup-atherosclerosis-3d-rendering-1036109620">Crevis/Shutterstock.com</a></span>
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<h2>Still at risk?</h2>
<p><a href="https://doi.org/10.1021/es303879n">PBDEs were banned in Europe by 2008</a> and <a href="https://www.epa.gov/sites/production/files/2014-03/documents/ffrrofactsheet_contaminant_perchlorate_january2014_final_0.pdf">voluntarily withdrawn by industry in North America by 2013</a>. It is likely that PBDEs’ production ceased all over the world, although data are missing for many regions. However these chemicals are still present in products used in U.S. households and cars. PBDEs are very stable compounds. Once released into the environment, they accumulate in sediments and in fatty tissues of wildlife and humans and stay there for many years. For example, the <a href="https://doi.org/10.1021/es1035046">half-life of different PBDEs</a> in the human body is between one and seven years. In the environment they found their way to fatty tissues of animals, many of which represent important sources of food for us.</p>
<p>Although production of PBDEs has ceased in developed countries, some studies report that concentrations of PBDEs in human tissues in the U.S. <a href="http://doi.org/10.1021/acs.est.7b00565">continue to grow</a>. </p>
<p>People born in the U.S. and Canada during the last 15 to 20 years were exposed during their early life to environmental concentrations of PBDE, comparable to those that reprogrammed lipid metabolism in our experiments with mice. Thus, we believe that about 20 percent of the North American population may be at risk of conditions associated with altered lipid concentrations in blood and liver. </p>
<p>Will these people develop aging-related conditions more readily than previous generations? The answer is yet to come. It is likely that PBDEs are not the only culprit. Many other ubiquitous pollutants, such as <a href="https://doi.org/10.1016/j.tox.2012.07.007">polychlorinated biphenyls (PCBs)</a>, <a href="https://www.toxicology.org/pubs/docs/Tox/2018Tox.pdf">dioxin (TCDD) and perfluorinated compounds (PFOS, PFNA)</a>, are known today to affect CD36 in mice. </p>
<p>It is not yet clear if effects of these other chemicals are as long-lasting as effects of PBDE. It is also not yet clear if effects of chemical exposures observed in mice are the same in humans. Mice are the most widely used animal model for testing the toxicity of pharmaceuticals and industrial chemicals, and animal toxicology studies generally are applicable to humans, <a href="https://www.ncbi.nlm.nih.gov/books/NBK215893/">although responses of laboratory animals</a> and humans to chemicals may differ in type and severity.</p><img src="https://counter.theconversation.com/content/112346/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alexander Suvorov receives funding from:
1. University of Massachusetts - Amherst (startup funding), expired
2. Institute of general Genetics of the Russian Academy of Sciences (research contract), expired
3. USA Department of State (research grant), expired
4. USA National Institutes of Health (research grant), current</span></em></p>Brief exposure to a family of chemicals used as flame retardants early in life can permanently alter fat levels in the blood and liver, raising the risk of liver cancer and heart disease.Alexander Suvorov, Assistant Professor, UMass AmherstLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/992732018-07-09T20:38:23Z2018-07-09T20:38:23ZA rare instance when preventative screening is worth the dollar cost<figure><img src="https://images.theconversation.com/files/226394/original/file-20180705-122265-10g7n91.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A technician holds a blood sample that tested positive for the hepatitis B virus.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/blood-sample-positive-hepatitis-b-virus-592666922?src=Q3nbsrnWqB7AmXl2mo2f6Q-1-11">Jarun Ontakrai/shutterstock.com</a></span></figcaption></figure><p>Very few people know about hepatitis B, the so-called <a href="http://www.who.int/mediacentre/commentaries/viral-hepatitis/en/">silent killer</a>, and the <a href="https://doi.org/10.1002/hep.22975">billions of dollars</a> it costs the U.S. health care system. The hepatitis B virus can cause chronic infection that is usually asymptomatic for decades until it leads to costly, debilitating <a href="https://liverfoundation.org/for-patients/about-the-liver/the-progression-of-liver-disease/">liver cirrhosis</a> or liver cancer. </p>
<p>The World Health Organization is appealing to countries to significantly <a href="http://www.who.int/hepatitis/strategy2016-2021/ghss-hep/en/">increase screening and treatment of hepatitis B</a> to reduce hepatitis deaths by 65 percent. But this is costly and the U.S. has other competing health priorities. Is it worth our time and effort to try to achieve the goals set by WHO? <a href="https://profiles.stanford.edu/mehlika-toy">My colleagues</a> and I <a href="https://doi.org/10.1377/hlthaff.2018.0035">recently addressed the question</a> in the journal Health Affairs and concluded it is a valuable public health initiative that could potentially save almost half a billion dollars in the long run.</p>
<p>I am a <a href="https://sph.umich.edu/faculty-profiles/hutton-david.html">public health researcher</a> interested in how we can spend our health care dollars wisely to boost the health of the population. I was inspired to focus on hepatitis B health policy through <a href="https://profiles.stanford.edu/samuel-so">Dr. Sam So</a>, a hepatitis B advocate at Stanford University who is trying to raise awareness of this serious, under-recognized disease. We teamed up with my co-author <a href="https://scholar.google.com/citations?user=4Sh35EkAAAAJ&hl=en&oi=ao">Dr. Mehlika Toy</a> to examine hepatitis B policy.</p>
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<a href="https://images.theconversation.com/files/226397/original/file-20180705-122253-htur6b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/226397/original/file-20180705-122253-htur6b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/226397/original/file-20180705-122253-htur6b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/226397/original/file-20180705-122253-htur6b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/226397/original/file-20180705-122253-htur6b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/226397/original/file-20180705-122253-htur6b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/226397/original/file-20180705-122253-htur6b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/226397/original/file-20180705-122253-htur6b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Liver with hepatitis B infection highlighted inside human body and an close-up view of hepatitis B viruses.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1103225849?size=huge_jpg">Kateryna Kon/shutterstock.com</a></span>
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<p>The goal of our <a href="http://med.stanford.edu/liver.html">research team</a> was to calculate whether it would be cost-effective for U.S. health practitioners to take up and execute WHO’s challenge.</p>
<h2>A stealthy virus</h2>
<p>Over <a href="https://doi.org/10.17226/24731">a million people</a> in the U.S. are estimated to be living with chronic hepatitis B infection, but <a href="https://doi.org/10.1002/hep.21784">only about a third</a> <a href="http://doi.org/10.1002/hep.26286">know they have the disease</a> and <a href="http://doi.org/10.1007/s10620-014-3283-3">only about 15 percent</a> of those are receiving treatment. </p>
<p>Hepatitis B is caused by a virus that leads to liver disease and is transmitted during childbirth or by blood, semen or other body fluid. Fortunately, most Americans born in the last 30 years have been <a href="https://www.cdc.gov/nchs/fastats/immunize.htm">vaccinated</a> and are protected. But, for those born in other countries, particularly in Asia or Africa, the risk of having a chronic infection is high. </p>
<p>A majority of those in the U.S. with <a href="https://doi.org/10.17226/24731">chronic hepatitis B are immigrants</a>. The good news is this disease can be treated with long-term antiviral drug therapy, dramatically reducing risks of cirrhosis and liver cancer, which are much more expensive to treat. </p>
<p>Since hepatitis B progression takes decades, my group built a mathematical model of immigration and hepatitis B disease progression to simulate what will happen when Asian and African immigrants to the U.S. wait until they became ill before seeking treatment. We then compared what their health and costs would look like if we met WHO’s specific goals and diagnosed 90 percent and treated 80 percent of immigrants.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/226757/original/file-20180709-122277-1p0ye55.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/226757/original/file-20180709-122277-1p0ye55.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/226757/original/file-20180709-122277-1p0ye55.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=375&fit=crop&dpr=1 600w, https://images.theconversation.com/files/226757/original/file-20180709-122277-1p0ye55.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=375&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/226757/original/file-20180709-122277-1p0ye55.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=375&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/226757/original/file-20180709-122277-1p0ye55.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=471&fit=crop&dpr=1 754w, https://images.theconversation.com/files/226757/original/file-20180709-122277-1p0ye55.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=471&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/226757/original/file-20180709-122277-1p0ye55.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=471&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Seven symptoms of hepatitis.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/hepatitis-icon-design-infographic-health-medical-1007619907?src=Q3nbsrnWqB7AmXl2mo2f6Q-1-22">By iLoveCoffeeDesign/Shutterstock.com</a></span>
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<h2>Herculean effort to screen</h2>
<p>In order to reach these targets, the U.S. would have to give a blood test to 14 million foreign-born individuals from Asia and Africa over the next seven to 12 years.</p>
<p><a href="https://doi.org/10.17226/24731">We included</a> the additional costs required for outreach to these marginalized populations that are poorly integrated into the U.S. health care system. We estimate that insurers and patients in the U.S. would spend between US$700 and $800 million over the next 50 years screening people for hepatitis B. Although that sounds like a lot of money, dramatic increases in screening and treatment would prevent between about 80,000 and 100,000 cases of cirrhosis, 50,000 and 60,000 cases of liver cancer, and 80,000 to 100,000 hepatitis B-related deaths over the next 50 years.</p>
<p>The savings from preventing cirrhosis and liver cancer could pay for the costs of screening and treatment if they were achieved by 2025. If the U.S. could achieve those goals by 2025, we estimate the U.S. health care system would save $1.2 billion in hepatitis B treatment costs. When we account for the screening costs to achieve this, we would see net savings of about $400 million to patients and insurance companies.</p>
<h2>Public health value of screening and treatment</h2>
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<a href="https://images.theconversation.com/files/226759/original/file-20180709-122280-j76lw1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/226759/original/file-20180709-122280-j76lw1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/226759/original/file-20180709-122280-j76lw1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/226759/original/file-20180709-122280-j76lw1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/226759/original/file-20180709-122280-j76lw1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/226759/original/file-20180709-122280-j76lw1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/226759/original/file-20180709-122280-j76lw1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/226759/original/file-20180709-122280-j76lw1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">July 28 is World Hepatitis Day. The date honors the birthday of Nobel laureate Baruch Samuel Blumberg, who discovered the hepatitis B virus.</span>
<span class="attribution"><a class="source" href="https://upload.wikimedia.org/wikipedia/commons/6/6b/WHD_Globe.jpg">FF2011/Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
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<p>In contrast, when my colleagues and I examined this policy a decade ago, we determined that screening and treating adult Asian and Pacific Islanders <a href="http://doi.org/10.7326/0003-4819-147-7-200710020-00004">would not save money</a>, but would instead cost between $30,000 and $40,000 per year of healthy life gained.</p>
<p>So, why is hepatitis B screening and treatment so much more valuable now? In the last year, there have been dramatic reductions in the price of antiviral treatment because <a href="http://www.tevapharm.com/news/teva_announces_exclusive_launch_of_generic_viread_in_the_united_states_12_17.aspx">highly effective generics have reached the market</a>. Treatments that used to cost many hundreds or even thousands of dollars a month are now only $115 per month. So now the analysis tips heavily in favor of screening and treatment.</p>
<p>These findings are unique and significant because many prevention interventions do not save money. A <a href="http://doi.org/10.1056/NEJMp0708558">2008 study</a> of the academic literature on cost-effectiveness found that fewer than 20 percent of the prevention interventions led to cost savings.</p>
<p>Of course, our health care system does not exist solely to save costs. Improving quality and length of life are important, but the fact that most studies are not cost-saving illustrates how uncommon our results are. It also highlights that increasing screening and treatment of hepatitis B ought to be prioritized.</p><img src="https://counter.theconversation.com/content/99273/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Hutton receives funding from the World Health Organization. </span></em></p>A new analysis shows that the US health care system will save money in the long run by screening people born in Asia and Africa for the hepatitis B virus, which causes liver cancer and cirrhosis.David Hutton, Associate Professor of Health Management and Policy , University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/980612018-06-15T03:08:09Z2018-06-15T03:08:09ZDoctors are drowning in a tsunami of liver disease and cancer<figure><img src="https://images.theconversation.com/files/223082/original/file-20180613-32342-ty2dm8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Hepatitis B, hepatitis C and obesity all play a part in the rising incidence of liver cancer -- in Canada and globally.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Deaths from liver cancer in Canada have doubled over the past 25 years. And to make matters worse, there’s an epidemic of liver cancer on the horizon if action isn’t taken soon.</p>
<p>While less people are dying from most major cancers — such as breast cancer and lung cancer — liver cancer (hepatocellular carcinoma or HCC) is bucking the trend and heading in the wrong direction. </p>
<p>In 1993, <a href="http://www.cancer.ca/en/cancer-information/cancer-type/liver/statistics/?region=on">liver cancer rates in Canadian men</a> were five cases per 100,000 population. By 2017 this had risen to 9.9 cases. </p>
<p>For women, rates are much lower, but the trend is the same. In 1993, 1.6 Canadian women per 100,000 were diagnosed with liver cancer; by 2017 this had almost doubled. In hard numbers this means that last year 1,900 men in Canada were diagnosed with liver cancer and 580 women. A total of 950 men died from liver cancer and 270 women.</p>
<p>This is not unique to Canada; a <a href="http://globocan.iarc.fr/Pages/fact_sheets_cancer.aspx">similar pattern is seen in the United States, the United Kingdom, Australia and most other developed countries</a>.</p>
<p>At this week’s <a href="http://www.globalhepatitissummit2018.com/">Global Hepatitis Summit</a> in Toronto (June 14-17), I will be among a group of liver cancer experts exploring these trends. </p>
<h2>The role of hepatitis and obesity</h2>
<p>What are the reasons for this increase, and why are they being discussed at the Global Hepatitis Summit? It is because both <a href="https://www.liver.ca/patients-caregivers/liver-diseases/hepatitis-b/">hepatitis B</a> and <a href="https://www.liver.ca/patients-caregivers/liver-diseases/hepatitis-c/">hepatitis C</a> are serious liver infections that cause inflammation. </p>
<p>When left untreated, both infections can progress to liver scarring, cirrhosis, liver cancer and, ultimately, an early death.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/223081/original/file-20180613-32307-12y84lc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/223081/original/file-20180613-32307-12y84lc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/223081/original/file-20180613-32307-12y84lc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/223081/original/file-20180613-32307-12y84lc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/223081/original/file-20180613-32307-12y84lc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=565&fit=crop&dpr=1 754w, https://images.theconversation.com/files/223081/original/file-20180613-32307-12y84lc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=565&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/223081/original/file-20180613-32307-12y84lc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=565&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">3D image of cirrhosis of the liver.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>Today, there are an estimated 230,000 Canadians with hepatitis B and 250,000 with hepatitis C. Almost half of each group do not know they are infected, which hugely increases their risk of progression to serious liver disease and cancer. </p>
<p>An enormous effort will be needed from provincial and territorial governments —with federal government support — to find, diagnose and treat these missing patients and to link them to care.</p>
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Read more:
<a href="https://theconversation.com/why-all-canadian-infants-need-a-hepatitis-b-vaccination-98060">Why all Canadian infants need a hepatitis B vaccination</a>
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<p>Also contributing to Canada’s liver cancer problem is the <a href="https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1310009620">obesity epidemic</a>: about two thirds of Canadian men and half of women are thought to be overweight or obese. </p>
<p>Some one in five Canadians have some degree of <a href="https://www.liver.ca/patients-caregivers/liver-diseases/fatty-liver-disease/">non-alcoholic fatty liver disease</a> (NAFLD), which causes inflammation and can progress to cirrhosis and liver cancer.</p>
<h2>A lack of liver cancer specialists</h2>
<p>Canada’s limited number of liver specialists (less than 100 nationwide) and a few oncologists dealt with around 5,000 cases of liver cancer during 2017. </p>
<p>However, the hepatitis B and C epidemics, combined with Canada’s continuously increasing obesity problem, threaten to drown liver cancer specialists with new cases in the coming decades — with numbers reaching tens of thousands annually over the next 20 years.</p>
<p>We are completely unprepared to deal with such an epidemic of liver cancer. Not only would we be submerged in the sheer number of cases, the financial considerations for provinces and territories and the federal government would be phenomenal. </p>
<p>And many of these liver cancers strike people in their 50s, when they are still of working age. So families are not only in danger of losing a loved one, but possibly the main breadwinner in their family unit.</p>
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<img alt="" src="https://images.theconversation.com/files/223080/original/file-20180613-32342-1rbu8w9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/223080/original/file-20180613-32342-1rbu8w9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/223080/original/file-20180613-32342-1rbu8w9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/223080/original/file-20180613-32342-1rbu8w9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/223080/original/file-20180613-32342-1rbu8w9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/223080/original/file-20180613-32342-1rbu8w9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/223080/original/file-20180613-32342-1rbu8w9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">As obesity in Canada shows no signs of retreating, new treatments for fatty liver disease could play a part in helping to reduce future incidences of liver cancer.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>Not only is Canada’s system of liver specialists being gradually overwhelmed, but there is also a shortage of new liver specialists interested in HCC being trained.</p>
<p>Graduating liver specialists (hepatologists) tend not to specialise in liver cancer. Nor is it a popular speciality in oncology. However, this area is a growing field and there are plenty of opportunities for young physicians to do both practice and research. </p>
<p>Provinces and territories must also take a fresh look at remuneration for liver specialists, who are generally not as well paid as those in other specialities such as gastroenterology.</p>
<p>It may be necessary to develop some special programs to address this issue and boost recruitment in order to deal with the tsunami of liver disease and cancer that Canada is facing.</p>
<h2>How to reverse the trend</h2>
<p>However, the news is not all bad. Even though Canada’s incidence and mortality rates for liver cancer have doubled over the last 25 years, the actual numbers are much better for Canada than other developed nations. With six new cases per 100,000 population per year, Canada’s liver cancer incidence is lower than <a href="https://www.aihw.gov.au/reports/cancer/acim-books/contents/acim-books">Australia</a> (7.4) the <a href="https://seer.cancer.gov/csr/1975_2015/results_merged/sect_14_liver_bile.pdf">U.S.</a> (9.2) and the <a href="http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/liver-cancer">U.K.</a> (9.6).</p>
<p>A similar pattern is seen with mortality: Canada’s death rate for liver cancer (three per 100,000 population) is less than half that of the U.S. and Australia (both 6.6) and the U.K. (8.7). </p>
<p>I believe this is due to our excellent record in finding cases of liver cancer very early, when they can still be successfully operated and treated. The U.S. obviously lacks universal health coverage and the U.K. has a high level of alcoholic liver disease contributing to the epidemic there.</p>
<p>To reverse the increasing trend in liver cancer in Canada and elsewhere, a combination of things will need to occur. First, more patients with hepatitis B and hepatitis C must be diagnosed and treated or cured. Second, new therapies within the next decade should also greatly improve care and prognosis for hepatitis B. </p>
<p>Finally, because obesity in Canada shows no signs of retreating, we will be dependent on new treatments in the pipeline for fatty liver disease. It is unclear at this point how many cases of cirrhosis and liver cancer this will prevent.</p><img src="https://counter.theconversation.com/content/98061/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Morris Sherman sits on safety committees for Merck, Celsion, Sirtex and Adaptimmune, all of which have products currently under test for the treatment of hepatocellular carcinoma</span></em></p>To prevent the epidemic of liver cancer that looms on the horizon, we need to tackle hepatitis B, hepatitis C and obesity.Morris Sherman, Affiliate Scientist, Toronto General Hospital Research Institute (TGHRI) and Emeritus Professor, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/909792018-02-05T09:49:37Z2018-02-05T09:49:37ZCan England really eliminate hepatitis C by 2025?<figure><img src="https://images.theconversation.com/files/204735/original/file-20180204-19921-3pnw69.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/559630771?src=EcfCLqUhuXJOLzuTvXA3zw-1-40&size=medium_jpg">nokwalai/Shutterstock</a></span></figcaption></figure><p>The World Health Organisation set a goal to eliminate hepatitis C by 2030. The NHS recently announced that it will go one better than that: it will eliminate the disease in England by <a href="http://www.pharmatimes.com/news/nhs_plans_to_be_first_to_eliminate_hepatitis_c_1219469">2025</a>. In theory, the goal is achievable, but there are still significant challenges to overcome. </p>
<p><a href="https://www.nhs.uk/conditions/hepatitis-c/">Hepatitis C</a> is a viral infection that causes chronic liver disease, which can lead to life-threatening complications. Thankfully, a new class of drugs, known as direct-acting antivirals (DAAs) has revolutionised hepatitis C treatment. A three month course of DAAs can clear hepatitis C from the blood. </p>
<p>The drugs aren’t perfect, though. They have a failure rate of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4970473/">around 10-15%</a>. However, the real problem with eliminating the disease lies in the hidden nature of the hepatitis C epidemic in the UK.</p>
<p>For many years it was known that some blood donations, or products made from blood, such as factor VIII used to treat haemophilia, contained an unknown virus that inflammed the liver (hepatitis) in patients who received a transfusion. The identity of this virus remained unknown until the mid-1980s when the development of new technologies allowed the virus to be identified by its gene sequence. </p>
<p>Tests on blood donations soon followed, designed to help prevent the transmission of the virus by transfusion or during surgery. As these tests were applied more widely, though, the real extent of the problem with hepatitis C virus began to emerge. </p>
<p>By the early 1990s, it became clear that many more people were infected than previously thought. Two groups were particularly affected: those who had been infected through medical treatment (including some children who had been infected by their mother either in the womb or during the process of birth), and a second much larger group who had used illegal drugs (injecting or inhaling drugs through the nose). Many of the infected people had not used drugs for years.</p>
<p>Hepatitis C doesn’t usually cause symptoms in the early stages of infection, but the virus remains in the liver, causing a hidden and silent infection in at least 80% of cases. (In 20% of cases, the patient’s immune system manages to clear the virus on its own.) Over decades, the infection causes progressive liver damage. By the time the patient begins to suffer from fatigue as a result of the infection, liver failure and liver cirrhosis has usually set in. This can progress to liver cancer (hepatoma) and premature death. Globally, hepatitis C virus infection is now a leading cause of liver transplantation.</p>
<p>As with many viral infections, at first there were few treatment options. The antiviral drug interferon was tried with limited success. Treatment was improved when interferon was combined with a second antiviral drug, ribavirin. However, some strains of the virus proved very difficult to treat, requiring 12 months of continuous therapy, and even then the infection sometimes returned <a href="https://link.springer.com/content/pdf/10.1007/s11901-006-0014-z.pdf">once treatment stopped</a>. </p>
<p>The development of DAAs has revolutionised treatment of hepatitis C virus infection. Now, short treatment courses effectively cure the infection in a high percentage of cases. Because of this, transmission of the infection between people can be stopped, leading to the enticing prospect that hepatitis C virus infection could be eliminated. </p>
<p>Elimination should not of course be confused with eradication. So far, only one human virus infection, smallpox, has been eradicated. Others, <a href="http://www.who.int/features/factfiles/polio/en/">such as polio virus</a>, are close to global eradication.</p>
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<img alt="" src="https://images.theconversation.com/files/204612/original/file-20180202-162087-11w6jl8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/204612/original/file-20180202-162087-11w6jl8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/204612/original/file-20180202-162087-11w6jl8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/204612/original/file-20180202-162087-11w6jl8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/204612/original/file-20180202-162087-11w6jl8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/204612/original/file-20180202-162087-11w6jl8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/204612/original/file-20180202-162087-11w6jl8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Hepatitis C virus.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/484370686?src=-nUn9GHvj9eSGHQy4l81cg-1-3&size=medium_jpg">fotovapl/Shutterstock</a></span>
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<h2>A hidden disease</h2>
<p>The current problem with hepatitis C infection is not how we should treat it, it is rather how do we identify those who are infected so that they can be guided into treatment and cure. For those who contracted infection through medical interventions and do not know they are infected, they may not yet be suffering the symptoms of long-term infection that would cause them to seek medical help. The biggest problem, however, lies with drug users – a social group that tends to actively avoid the health system for fear of being challenged or stigmatised because of current or former drug use. </p>
<p>In order to reach these two groups of infected people, new approaches to diagnosis outside of conventional healthcare facilities need to be much more widely applied. Simple rapid tests on blood or saliva specimens that can be used anywhere, or even self-collection of blood dried onto filter paper spots (known as “<a href="https://en.wikipedia.org/wiki/Dried_blood_spot">DBS testing</a>”), offer ways to greatly extend the numbers of people who come forward for diagnosis. The wider application of these tests will be an essential step in persuading people who may be in denial about their risk of infection into a programme that offers a cure. </p>
<p>Hepatitis C virus could be eliminated. The treatment to do this is available, it appears to be <a href="https://www.ncbi.nlm.nih.gov/pubmed/28836278">cost effective</a> and the technology to provide quick and easy diagnosis is available. However, a concerted and coordinated effort to reach the infected, but untested public, will be necessary if the NHS is to achieve its worthwhile goal of eliminating hepatitis C in England by 2025.</p><img src="https://counter.theconversation.com/content/90979/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Klapper received funding from the Greater Manchester Hepatitis C Strategy. He is affiliated with The Labour Party. </span></em></p><p class="fine-print"><em><span>Pam Vallely is affiliated with The Liberal Democrats Party. </span></em></p>If England eliminates hepatitis C, it will be the first country to do so. But how feasible is it?Paul Edward Klapper, Chair Professor, University of ManchesterPam Vallely, Chair in Graduate Education, University of ManchesterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/816722017-08-02T20:19:44Z2017-08-02T20:19:44ZDr G. Yunupingu’s legacy: it’s time to get rid of chronic hepatitis B in Indigenous Australia<p>News of the tragic death of Dr G. Yunupingu last week in Darwin at only 46 years of age has again highlighted the unacceptable gap in life expectancy between Aboriginal and Torres Strait Islanders and other Australians. Yunupingu had been <a href="http://www.abc.net.au/news/2017-07-27/dr-g-yunupingu-death-we-need-to-close-the-gap/8748562">living with chronic hepatitis B</a> since early in life, and experienced complications of this condition including liver and kidney disease.</p>
<p>Hepatitis B infections, which can lead to liver disease and cancer, are unacceptably high in Indigenous Australians. In Northern Australia, 10-20% of the Indigenous population is <a href="http://www.abc.net.au/news/2017-08-02/aboriginal-health-workers-hosted-in-alaska/8765916">infected with the virus</a>. Eliminating the impact of this infection in Indigenous Australians would make a substantial contribution to closing the gap in life expectancy.</p>
<h2>Hepatitis B in Indigenous Australia</h2>
<p>Hepatitis B is the most prevalent form of viral hepatitis worldwide. It’s also the leading cause of liver cancer. Interestingly, hepatitis B used to be known as <a href="http://jamanetwork.com/journals/jama/article-abstract/654843">the “Australia Antigen”</a> as it was first discovered in Australian Aboriginal people in the 1960s.</p>
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Read more:
<a href="https://theconversation.com/explainer-the-a-b-c-d-and-e-of-hepatitis-54739">Explainer: the A, B, C, D and E of hepatitis</a>
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<p>Hepatitis B is around ten times more prevalent in Indigenous communities than in the rest of Australia. Of the nearly <a href="http://onlinelibrary.wiley.com/doi/10.1111/1753-6405.12693/full">240,000 Australians</a> estimated to be living with chronic hepatitis B, over 20,000 are thought to be Indigenous people. New infections with hepatitis B remain <a href="http://www.who.int/bulletin/volumes/94/11/16-169524/en/">three times as common</a> in Indigenous people as in non-Indigenous Australians. </p>
<p>The chance of developing chronic hepatitis B depends on an individual’s age at the time of infection. Around 90% of those who were exposed as infants develop chronic hepatitis B, but only 5% of those who were exposed as adults will develop chronic infection. Most people living with chronic hepatitis B were infected as young children – often, through mother-to-child transmission at the time of birth. This is why vaccination during infancy is particularly important.</p>
<p>The <a href="https://bmcinfectdis.biomedcentral.com/articles/10.1186/1471-2334-13-403">prevalence of chronic (long-term) hepatitis B</a> in Indigenous Australians varies significantly between regions. It is most prevalent in remote areas of Australia, with the Northern Territory having the highest prevalence of any Australian jurisdiction. Around <a href="http://onlinelibrary.wiley.com/doi/10.1111/1753-6405.12693/full">1.8% of the NT population</a> live with the disease. </p>
<p>The prevalence of hepatitis B and other communicable diseases such as skin infections and influenza in Indigenous communities is intensified by the social, economic, environmental and political situation in which Indigenous Australians find themselves.</p>
<h2>Liver disease</h2>
<p>In some people, chronic hepatitis B can cause severe liver scarring (cirrhosis) or liver cancer. Less commonly, hepatitis B can damage other parts of the body, including the kidneys and blood vessels. </p>
<p>Chronic liver disease contributes significantly to the Indigenous life expectancy gap. Liver cancer is the fastest-increasing cause of cancer deaths in Australia. In 2016, it was the <a href="http://onlinelibrary.wiley.com/wol1/doi/10.1111/imj.13393/full">sixth-most-common</a> cause of cancer deaths. However, for Indigenous people it is the <a href="http://www.aihw.gov.au/publication-detail/?id=60129558547">second-most-common cause</a> of cancer-related death after lung cancer. </p>
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Read more:
<a href="https://theconversation.com/three-charts-on-cancer-rates-in-australia-where-liver-cancer-is-on-the-rise-while-other-types-fall-79572">Three charts on: cancer rates in Australia, where liver cancer is on the rise while other types fall</a>
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<p>Compared to non-Indigenous Australians living in the NT, the rate of death due to liver cancer is <a href="https://www.mja.com.au/journal/2014/201/8/hepatocellular-carcinoma-australias-northern-territory-high-incidence-and-poor">six times greater</a> in Indigenous Australians.</p>
<p>Cure is rare with liver cancer, and most Indigenous Australians die within a few months of being diagnosed. In the NT, a range of factors contribute to the unequal burden of liver cancer in Indigenous Australians, but <a href="https://www.mja.com.au/journal/2014/201/8/hepatocellular-carcinoma-australias-northern-territory-high-incidence-and-poor">hepatitis B is the most important</a> cause.</p>
<h2>Hepatitis B vaccine is one way</h2>
<p>A safe, effective vaccine for hepatitis B has been provided for all infants in Australia since 2000 – and in the Northern Territory since 1990. As a result, new hepatitis B infections in children born since 2000, as well as those who received adolescent catch-up vaccination from 1998 onwards, <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home%7Ehandbook10part4%7Ehandbook10-4-5">have fallen markedly</a>.</p>
<p>However, funded hepatitis B vaccine for Indigenous adults is available <a href="http://onlinelibrary.wiley.com/doi/10.1111/1753-6405.12316/full">only in some states and territories</a>. This limits access for Indigenous people who remain at much higher risk of infection. A <a href="http://www.who.int/bulletin/volumes/94/11/16-169524/en/">recent study</a> suggested a funded catch-up vaccination program for Indigenous adults could rapidly eliminate disparity in hepatitis B incidence.</p>
<p>Vaccination has no effect for those who already have chronic hepatitis B. It is believed over 90,000 Australians living with hepatitis B have never been diagnosed and are unaware of their infection. <a href="http://onlinelibrary.wiley.com/doi/10.1111/1753-6405.12693/full">Only 15% of those infected</a> are receiving treatment or monitoring for their condition. </p>
<p><a href="https://theconversation.com/explainer-the-a-b-c-d-and-e-of-hepatitis-54739">Unlike hepatitis C</a>, hepatitis B is not yet curable, but current treatments are very well tolerated and effective at preventing liver disease and liver cancer. The profound <a href="http://onlinelibrary.wiley.com/doi/10.1111/1753-6405.12693/full">lack of access to treatment and care</a> among Indigenous people contributes to the disproportionate impact of hepatitis B on this population.</p>
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Read more:
<a href="https://theconversation.com/australia-leads-the-world-in-hepatitis-c-treatment-whats-behind-its-success-81760">Australia leads the world in hepatitis C treatment – what's behind its success?</a>
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<h2>Other ways to reduce infections</h2>
<p>An example of innovative care has been operating in Dr G. Yunupingu’s home community of Galiwin’ku for over five years. Under the management of <a href="http://miwatj.com.au/">Miwatj Health</a>, an Aboriginal community-controlled health organisation, a hepatitis specialist visits regularly three to four times per year. </p>
<p>The specialist brings necessary diagnostic equipment and effectively provides a “one-stop shop” for individuals living with hepatitis B in Galiwin’ku. Just as importantly, a local healthcare practitioner <a href="http://miwatj.com.au/what-we-do/clinical-services/at-galiwinku/">champions the cause of hepatitis B</a> treatment and elimination. Those infected are contacted and encouraged to see the specialist team.</p>
<p>Several other regions in the world with large Indigenous populations and high hepatitis B prevalence, such as <a href="http://anthctoday.org/community/hep/about/">Alaska</a> and <a href="http://www.hepatitisfoundation.org.nz/hepatitis-b/the-hepatitis-b-follow-up-programme/">New Zealand</a>, have developed programs to test most of the population and identify those with hepatitis B infections. Affected individuals are offered regular follow-up and care to prevent cirrhosis and liver cancer. </p>
<p>When delivering such care to Indigenous communities, it’s essential to develop trust and ensure <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-14-1233">culturally appropriate approaches</a>. Also important is partnering with communities and their health workers to develop <a href="https://www.menzies.edu.au/page/Resources/Hep_B_Story/">new ways of building awareness</a> of hepatitis B as an important health issue.</p>
<p>With comprehensive public health initiatives, long-term commitment to funding and policy – including significant workforce development to ensure as many people as possible are tested and appropriately followed up – the impact of hepatitis B on Indigenous communities can be eliminated.</p><img src="https://counter.theconversation.com/content/81672/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Benjamin Cowie receives funding from the Australian Government Department of Health, the Victorian Government Department of Health and Human Services, the Royal Melbourne Hospital Office for Research, and the Cooperative Research Centre for Spatial Information.</span></em></p><p class="fine-print"><em><span>Steven Tong receives funding from the National Health and Medical Research Council and has received funding from Gilead for Hepatitis B related research projects.</span></em></p><p class="fine-print"><em><span>James Ward does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Hepatitis B rates in Indigenous communities are ten times higher than the rest of Australia. Eliminating the infection from Indigenous Australia can make a significant contribution to closing the gap.Benjamin Cowie, Director, WHO Collaborating Centre for Viral Hepatitis, The Peter Doherty Institute for Infection and ImmunityJames Ward, Associate Professor, Infectious Diseases Research Aboriginal and Torres Strait Islander Health, South Australian Health & Medical Research InstituteSteven Tong, Associate Professor, The Peter Doherty Institute for Infection and ImmunityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/817602017-07-31T06:05:17Z2017-07-31T06:05:17ZAustralia leads the world in hepatitis C treatment – what’s behind its success?<figure><img src="https://images.theconversation.com/files/180287/original/file-20170731-15340-1wjpi3b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Tens of thousands of Australians have been cured of Hepatitis C since March 2016.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>The Australian government has <a href="http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2017-hunt072.htm">listed yet another drug</a> to cure hepatitis C on the Pharmaceutical Benefits Scheme (PBS). The drug Epclusa® – a combination of sofosbuvir 400mg and velpatasvir 100mg – is the first of the <a href="https://theconversation.com/weekly-dose-sofosbuvir-whats-the-price-of-a-hepatitis-c-cure-63208">direct-acting antiviral treatments</a> effective for all types of the disease. It will cost most patients A$38.80, and A$6.30 for concession card holders. Before the PBS listing, the cost exceeded A$20,000.</p>
<p>A number of <a href="http://www.pbs.gov.au/info/healthpro/explanatory-notes/general-statement-hep-c">hepatitis C treatments</a> have been listed on the PBS since March 2016. The government has committed to investing A$1 billion over five years to treat the <a href="http://www.hepatitisaustralia.com/inquiry-facts/">230,000 Australians</a> living with the disease. </p>
<p>Australia is a leading country in the global response to hep C. Since March 2016, around 40,000 people with hep C have <a href="https://kirby.unsw.edu.au/news/chronic-cured-could-australia-be-first-country-world-eliminate-hep-c">had treatment</a>. An estimated 95% of them have been cured.</p>
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Read more:
<a href="https://theconversation.com/weekly-dose-sofosbuvir-whats-the-price-of-a-hepatitis-c-cure-63208">Weekly Dose: sofosbuvir – what's the price of a hepatitis C cure?</a>
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<p>The <a href="http://www.who.int/mediacentre/factsheets/fs164/en/">World Health Organisation</a> recently set ambitious goals for the “elimination of hepatitis C as a major public health threat”. These included having 80% of people treated and an 80% reduction in the spread of the virus by 2030. Given there are around 70 million people infected with hep C worldwide, only 20% diagnosed, and no effective vaccine, the task ahead is enormous. </p>
<p>But Australia is impressively heading towards these targets and may present a model for other countries to adopt. A recent <a href="https://kirby.unsw.edu.au/news/chronic-cured-could-australia-be-first-country-world-eliminate-hep-c">report by the Kirby Institute</a> estimated Australia was on track to eliminate hepatitis C by 2026 – four years earlier than the WHO goal.</p>
<h2>Why are we doing this?</h2>
<p>The government has taken such a proactive approach to treating hepatitis C for several reasons. </p>
<p>The first is the large burden of serious liver disease, such as liver cancer and liver failure. A recent report from the <a href="http://www.aihw.gov.au/publication-detail/?id=60129559785">Australian Institute for Health and Welfare</a> showed rates of liver cancer increased five-fold from 1982 to 2013, with hep C the major cause. Nearly <a href="https://liver-cancer.canceraustralia.gov.au/statistics">1,500 Australians died from liver </a> cancer in 2011-2012 and that number could more than double over the coming decade. </p>
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Read more:
<a href="https://theconversation.com/three-charts-on-cancer-rates-in-australia-where-liver-cancer-is-on-the-rise-while-other-types-fall-79572">Three charts on: cancer rates in Australia, where liver cancer is on the rise while other types fall</a>
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<p>Secondly, most people affected with hepatitis C are injecting drug users. Although Australia has led harm-reduction strategies, such as needle syringe programs and access to methadone for people who inject drugs, several thousand <a href="https://kirby.unsw.edu.au/report/annual-surveillance-report-hiv-viral-hepatitis-stis-2016">new infections continue</a> to occur each year.</p>
<p>A third reason is the appeal of the new direct-acting antiviral treatments themselves, which can cure 95% of people treated and have the capacity to prevent serious liver disease and spread of hep C. By contrast, treatments such as Harvoni (sofosbuvir plus ledipasvir) and Zepatier (grazoprevir plus elbasvir), which were added to the PBS in March 2016 and January 2017 respectively, are highly effective, but only active against one or two of the hep C strains. </p>
<p>The latest treatment, <a href="http://www.pbs.gov.au/info/industry/listing/elements/pbac-meetings/psd/2016-11/sofosbuvir-plus-velpatasvir-psd-november-2016">Epclusa</a>, is one tablet, to be taken daily, which combines two existing drugs – sofosbuvir and velpatasvir. It is highly effective against all six hep C strains, has a treatment duration of around three months and minimal side effects. </p>
<p>Another treatment effective for all the strains – which combines glecaprevir and pibrentasvir – is <a href="https://www.pbs.gov.au/industry/listing/elements/pbac-meetings/agenda/pdf/pbac-meeting-agenda-july-2017.doc">expected to be available</a> in Australia in 2018. Treatment duration will be only two months for patients without advanced liver disease.</p>
<h2>What’s behind Australia’s success?</h2>
<p>Australia has managed to develop a program of unrestricted access to treat people with hepatitis C – all adults with hep C are eligible. Most countries have restricted access to those with more advanced disease. <a href="http://www.journal-of-hepatology.eu/article/S0168-8278(17)30450-6/abstract">Many have denied access</a> to people with ongoing drug and alcohol use.</p>
<p>The key to this universal access was the Australian government’s capacity to negotiate much lower drug prices than in other high-income countries, following strong advocacy from the hepatitis C sector. For instance, Australia paid an estimated <a href="http://www.sciencedirect.com/science/article/pii/S0168827817302064?via%3Dihub">ten-fold lower price per patient</a> treated in 2016 than did Germany.</p>
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<a href="https://images.theconversation.com/files/180289/original/file-20170731-16184-k7iz2h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/180289/original/file-20170731-16184-k7iz2h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/180289/original/file-20170731-16184-k7iz2h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/180289/original/file-20170731-16184-k7iz2h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/180289/original/file-20170731-16184-k7iz2h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/180289/original/file-20170731-16184-k7iz2h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/180289/original/file-20170731-16184-k7iz2h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/180289/original/file-20170731-16184-k7iz2h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Many countries restrict access to hep C treatment for injecting drug users.</span>
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<p>In December 2015, the government <a href="http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2015-ley154.htm">committed to providing sizeable funding</a> for tackling hepatitis C for five years with a cap in expenditure and no cap in the treatment number. Australia also managed to involve non-specialists in hep C treatment, who from March 2016 were able to prescribe the new treatments. </p>
<p>General practitioners and other non-specialists now write at least <a href="https://kirby.unsw.edu.au/sites/default/files/kirby/report/Monitoring-hep-C-treatment-uptake-in-Australia_Iss7-JUL17.pdf">half of prescriptions</a> for the new antivirals, with around 80% of treatments dispensed in community pharmacies.</p>
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<a href="https://theconversation.com/how-new-hepatitis-c-drugs-could-tackle-liver-cancer-too-73455">How new hepatitis C drugs could tackle liver cancer, too</a>
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<p>In <a href="http://www.journal-of-hepatology.eu/article/S0168-8278(17)30450-6/abstract">almost all other countries</a>, treatment of hep C is largely through specialist hospital-based clinics. In many countries only specialists can prescribe. Australia’s history of GP involvement in HIV antiviral treatment and drug dependency treatment was an important foundation to build a concerted hep C education and training program on.</p>
<p>Australia has also reached highly marginalised populations in large numbers. An estimated 20% of <a href="https://kirby.unsw.edu.au/report/australian-nsp-survey-national-data-report-2012-2016">people who inject drugs</a> have access to the new treatments, and numbers treated through the prison system are expanding rapidly. As mentioned, Australia has been a world leader in harm reduction for people who inject drugs (resulting in <a href="https://kirby.unsw.edu.au/report/annual-surveillance-report-hiv-viral-hepatitis-stis-2016">only 1% being HIV-infected</a>), and has also led the world in evaluating the new treatments in this key population group. </p>
<p>Most Australian jurisdictions are developing programs for new treatment access in drug and alcohol services and prisons. All these measures have provided the optimal framework for taking advantage of the incredible curative potential of the hep C treatments and their capacity to improve quality of life, prevent advanced liver disease, and limit the spread of hep C. </p>
<h2>How to sustain momentum</h2>
<p>A key to ensuring momentum of the initial surge of hep C treatment will be ongoing screening of high-risk populations. These include people with current or past injecting drug use and immigrants from high-prevalence countries, such as Egypt and Pakistan, where unsafe medical procedures have been responsible for most infections. In Australia, around 20% of people with hepatitis C <a href="https://kirby.unsw.edu.au/report/annual-surveillance-report-hiv-viral-hepatitis-stis-2016">remain undiagnosed</a>.</p>
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<a href="https://theconversation.com/eliminating-hepatitis-c-an-ambitious-but-achievable-goal-24485">Eliminating hepatitis C – an ambitious but achievable goal</a>
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<p>Finally, raising awareness through days like World Hepatitis Day and overcoming the stigma many people with hep C carry will be fundamental to success. The potential of revolutionary hep C treatments to empower the whole sector, together with continued advocacy and government support, should see Australia head towards elimination of the disease over the next decade.</p><img src="https://counter.theconversation.com/content/81760/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Greg Dore consults to Gilead, Merck, Abbvie, and Bristol-Myers Squibb. He receives research funding from NHMRC, National Institutes of Health, Australian Government Department of Health, and NSW Health; Gilead, Merck, Abbvie, and Bristol-Myers Squibb. He is affiliated with Kirby Institute, UNSW Sydney. </span></em></p>Australia has been subsidising drugs to cure hepatitis C since March 2016. Unlike in many other countries, these are available to everyone with the disease and are much cheaper for our government.Gregory Dore, Professor of Medicine, Clinical Researcher and Epidemiologist, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/795722017-06-25T20:11:43Z2017-06-25T20:11:43ZThree charts on: cancer rates in Australia, where liver cancer is on the rise while other types fall<figure><img src="https://images.theconversation.com/files/175094/original/file-20170622-30227-39gmf0.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C3994%2C2658&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The incidence of liver cancer is increasing and has the potential to become a national health crisis.</span> <span class="attribution"><span class="source">from shutterstock.com </span></span></figcaption></figure><p>Liver cancer is a looming health threat in Australia, recent findings from the Australian Institute of Health and Welfare’s (AIHW) <a href="http://www.aihw.gov.au/publication-detail/?id=60129559785">Burden of Cancer report</a> suggest. </p>
<p>While rates of other cancers are falling or remaining static, liver cancer is the only “top ten” cancer for which rates increased between 2003 and 2011.</p>
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<p>The “burden” of cancer is a measure also called “Disability Adjusted Life Years” (or DALYs), capturing quality and quantity of life. It combines the impact of the number of deaths (and how young people die) and number of people ill from a disease, accounting for how sick or disabled they are and for how long. This allows comparisons across different diseases. </p>
<p>Using “rates” allows comparisons across time, taking account of differences in population numbers and age profiles.</p>
<h2>Liver cancer crisis?</h2>
<p>While still not a common cancer, making up less than 1.5% of the 125,000 cancer cases diagnosed in 2013, liver cancer rates have <a href="http://www.aihw.gov.au/acim-books/">increased fivefold</a> since 1982. Action is required due to the <a href="http://ww2.health.wa.gov.au/%7E/media/Files/Corporate/general%20documents/WA%20Cancer%20Registry/The-Cancer-Effect-All-Cancers-Survival-2010-2014.ashx">poor five-year-survival rate</a> of less than 20%.</p>
<p>But why are diagnosis rates going up?</p>
<p>Unpublished work in progress, which builds on a <a href="http://onlinelibrary.wiley.com/doi/10.1111/azph.2015.39.issue-5/issuetoc">series of studies</a> by the Cancer Control Group at QIMR Berghofer Medical Research Institute in Brisbane, suggests liver cancer is caused by five main factors.</p>
<p>Tobacco smoking caused 365 liver cancer cases, or about 21% in 2013 in Australia. Hepatitis C virus contributed to 330 cases (19%) of liver cancer. Hepatitis B virus accounted for 281 cases (16%), alcohol 266 cases (15%) and obesity 451 (25%).</p>
<h2>What’s to blame?</h2>
<p><a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129556763">Falling smoking rates</a> suggest liver cancer figures should have been have been higher in the past. Due to the lag time between when people smoked and cancer diagnosis, tobacco is still a leading driver of liver cancer. Current smoking trends leave us optimistic these rates may drop in the future. </p>
<p>Similarly, alcohol consumption is on a <a href="http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/4364.0.55.001%7E2014-15%7EMain%20Features%7EAlcohol%20consumption%7E25">modest decline</a> and is unlikely to explain the increase in liver cancer. </p>
<p>Obesity is a different story. Well-documented <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129556760">increases in overweight and obesity</a> will likely be a driver of liver cancer through the pathways of diabetes and non-alcoholic fatty liver disease, a condition where fat accumulates in liver cells. </p>
<p>But the major engine driving increased liver cancer is likely to be the rising prevalence of people infected with hepatitis B and hepatitis C viruses. Chronic hepatitis causes infection and inflammation of the liver, which can lead to scarring called cirrhosis. In some, this leads to cancer.</p>
<p>Around <a href="http://wiki.cancer.org.au/policy/Liver_cancer/Causes">450,000 Australians</a> live with either hepatitis B or hepatitis C. The two viruses are passed on in quite different ways. </p>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/24090323">More than 90%</a> of people with hepatitis B virus were born overseas in countries where the virus is common, such as the Asia Pacific or sub-Saharan Africa. </p>
<p>Meanwhile, <a href="https://kirby.unsw.edu.au/sites/default/files/kirby/report/SERP_HepBandC-Annual-Surveillance-Report-Supp-2016.pdf">injecting drug users</a> dominate the 227,000 people with chronic hepatitis C virus in Australia, making up 57% of those affected. </p>
<h2>Liver cancer in Indigenous Australians</h2>
<p>Aboriginal people are another major group among which hepatitis B virus is endemic and hepatitis C is disproportionately common. High rates of viral infection in these communities (as in any community) are often untreated and tend to persist. This is especially the case when high rates of incarceration, needle sharing and other infection transmission behaviours occur. </p>
<p>While other causes of the disease are also at play, hepatitis rates are likely to be the main culprit to explain disturbing liver cancer rates in Australia’s First Nations people. It has become the third-most-common cancer in that group. </p>
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<h2>Other cancer deaths expected to rise</h2>
<p>Liver cancer is predicted to grow to become the fifth-most-common cause of cancer death in 2020 in Australian men and the sixth-biggest killer in women. This will eclipse melanoma as a cause of death.</p>
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<p>Higher death rates from pancreatic and brain cancers may be linked to a lack of successful treatment for these cancers. Increased pancreatic cancer mortality is also linked to smoking. Increased lung cancer mortality in women is linked to the higher uptake of smoking by women in the 1970s and ’80s. The elevated bowel cancer death rates expected in women do not take into consideration the effect of the government’s <a href="http://www.health.gov.au/internet/screening/publishing.nsf/Content/bowel-screening-1">National Bowel Cancer Screening Program</a>, which should soon start to show benefits in reduced mortality from that cancer.</p>
<h2>Averting the ‘crisis’</h2>
<p>Improved efforts to identify and treat people with hepatitis B and C viruses are required to combat liver cancer. </p>
<p>Infant vaccination for hepatitis B virus is making great strides, with <a href="https://kirby.unsw.edu.au/sites/default/files/kirby/report/SERP_HepBandC-Annual-Surveillance-Report-Supp-2016.pdf">participation rates exceeding 90%</a> in general and Indigenous populations. While this is good news, the challenge of reaching inbound migrant communities remains.</p>
<p>Needle exchange programs in prisons and outside are vital strategies to reduce needle sharing – the vehicle for much of the transmission of hepatitis C virus.</p>
<p>Efforts to reduce smoking, obesity and alcohol consumption are under way, but persistence is vital, especially in Indigenous communities. Tools are available to avert the “liver cancer crisis”, but we need to use them.</p><img src="https://counter.theconversation.com/content/79572/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Terry Slevin is employed by Cancer Council Western Australia and is affiliated with Cancer Council Australia and Curtin University. He is a Fellow of the Public Health Association of Australia (PHAA) and a Board member of the WA Health Promotion Foundation. He has been involved in funded cancer research programs on various topics over more than two decades. </span></em></p>While other cancer rates fall or remain static, liver cancer is on the rise. Here’s why we need to start paying attention.Terry Slevin, Adjunct Professor, School of Psychology and Speech Pathology, Curtin University; Education and Research Director, Cancer Council WA; Chair, Occupational and Environmental Cancer Committee, Cancer Council AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/734552017-03-06T01:52:46Z2017-03-06T01:52:46ZHow new hepatitis C drugs could tackle liver cancer, too<figure><img src="https://images.theconversation.com/files/159473/original/image-20170306-893-1bo07y9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">How to cut rates of liver cancer? Reducing hepatitis C rates would be a good start.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/472256644?size=huge_jpg">from www.shutterstock.com</a></span></figcaption></figure><p>Wider availability of newer <a href="https://theconversation.com/explainer-the-a-b-c-d-and-e-of-hepatitis-54739">hepatitis C</a> drugs may not only lead to fewer cases of this blood-borne disease, but may also slow the rise in related liver cancer.</p>
<p>But these so-called <a href="https://www.hep.org.au/hep-c-direct-acting-antiviral-treatment/">direct acting antiviral drugs</a> have not been widely available in Australia or overseas for long enough for us to confirm this long-term trend.</p>
<p>So, we need to see if their increased use is linked with a downturn in new cases of liver cancer, the focus of our research.</p>
<h2>Liver cancer rates rising</h2>
<p><a href="https://www.cancercouncil.com.au/liver-cancer/">Primary liver cancer</a> (liver cancer that starts in the liver rather than spreading from elsewhere) is the <a href="http://globocan.iarc.fr/old/FactSheets/cancers/liver-new.asp">fifth most common cancer in men and the ninth in women</a> globally. In 2012, it was responsible for 746,000 deaths around the world.</p>
<p>On average, people only live for a year once diagnosed. This is partly because most people are only diagnosed when the cancer is advanced and available treatments do not always prolong life.</p>
<p>In Australia, about 1,500 people a year are diagnosed with the most common type of primary liver cancer, hepatocellular carcinoma, and a similar number die from it each year. Both numbers have <a href="http://www.aihw.gov.au/publication-detail/?id=60129550047">doubled over the past two decades</a>.</p>
<p>A major driver of the rise in the number of new cases of primary liver cancer and people dying from it has been infection with the <a href="https://theconversation.com/explainer-the-a-b-c-d-and-e-of-hepatitis-54739">hepatitis C virus</a>. Over time, infection leads to <a href="https://www.thieme-connect.com/products/ejournals/abstract/10.1055/s-0031-1297922">cirrhosis of the liver</a>, where scar tissue replaces normal, healthy tissue. This damage makes the <a href="https://www.ncbi.nlm.nih.gov/pubmed/17570226">liver prone to cancer</a>.</p>
<h2>Older drugs made a start</h2>
<p>Until recently, we’ve seen an ageing population of people with chronic hepatitis C but few were treated. Between the early 2000s and mid-2010s, only <a href="http://onlinelibrary.wiley.com/doi/10.1111/jgh.13453/suppinfo">1-2% a year</a> of the estimated 230,000 people living with chronic hepatitis C in Australia were treated each year with interferon-based therapy.</p>
<p>This injectable medication mimics a protein the body naturally produces to fight off infections. <a href="http://www.nejm.org/doi/full/10.1056/NEJMp1202608">But few people were treated</a> with it as the drugs weren’t always effective, had side-effects ranging from fatigue to depression and had to be taken for 24–48 weeks.</p>
<p>The natural history of chronic hepatitis C (cirrhosis, liver failure and primary liver cancer) and an ageing population means without major improvements in hepatitis C treatment uptake and outcomes there would be a poor outlook. We would expect to see a <a href="http://onlinelibrary.wiley.com/doi/10.1111/jgh.12677/full">large burden of advanced liver disease</a> in Australia over the next decade.</p>
<h2>Direct-acting antivirals make a difference</h2>
<p>Fortunately, <a href="https://www.hep.org.au/hep-c-direct-acting-antiviral-treatment/">direct-acting antiviral therapies</a> and the move towards interferon-free oral treatments have revolutionised how we treat hepatitis C.</p>
<p>Direct-acting antiviral drugs work by blocking the action of specific proteins or enzymes in the hepatitis C virus, which are essential for the virus to replicate and infect liver cells.</p>
<p>With these drugs, hepatitis C treatment has minimal side effects, is short (8-24 weeks), and <a href="https://academic.oup.com/cid/article/60/12/1829/2462789/Hepatitis-C-Virus-Therapeutic-Development-In">95% of people</a> who take the drugs are effectively cleared of the virus.</p>
<p>Although direct-acting antivirals have been available since 2014, they have been listed in Australia on the Pharmaceutical Benefits Scheme since March 2016 for any adult with hepatitis C. General practitioners as well as specialists can prescribe the drugs, with no cap on numbers of people treated a year, no restrictions based on the stage of liver disease, or ongoing drug and alcohol use.</p>
<p>This <a href="http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2015-ley154.htm">A$1 billion hepatitis C treatment investment</a> for the period 2016-2020 has been <a href="http://www.hepatitisaustralia.com/newsarticles/australia-shows-an-alternative-to-rationing-hepatitis-c-treatment/8/6/2016">championed</a> <a href="http://apps.who.int/iris/bitstream/10665/250625/1/WHO-HIV-2016.20-eng.pdf?ua=1">internationally</a> as a major public health initiative.</p>
<p>In 2016, between March and December, <a href="http://kirby.unsw.edu.au/sites/default/files/hiv/attachment/Kirby_HepC_Newsletter_Issue6_2.pdf">more than 30,000 people in Australia started treatment</a>, equating to 13% of the population living with chronic hepatitis C, and more than were treated in the previous decade.</p>
<p>Importantly, an estimated 60% of people with hepatitis C-related cirrhosis (those at highest risk of liver cancer) <a href="http://kirby.unsw.edu.au/sites/default/files/hiv/attachment/Kirby_HepC_Newsletter_Issue5_2.pdf">have received</a> direct-acting antivirals.</p>
<p>This provides an opportunity to confront the rising disease burden of liver cancer in Australia.</p>
<h2>Spotting trends</h2>
<p>Ongoing surveillance of trends in new cases of liver cancer and deaths from it will be crucial in evaluating how close we are to ending hepatitis C-related liver cancer, and in particular hepatocellular carcinoma.</p>
<p>If we show treating hepatitis C reduces a person’s risk of getting liver cancer, and prolongs survival for people already with it, it would change cancer prevention and treatment policy and practice around the world. </p>
<p>Strategies would be developed to ensure people with hepatitis C get access to treatment, including people living with liver cancer. These potential findings would also increase efforts to ensure people with hepatitis C and serious liver disease have regular liver ultrasounds to detect early liver cancers. Increased screening would lead to a higher number of patients having their liver cancer treated.</p><img src="https://counter.theconversation.com/content/73455/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Maryam Alavi receives funding from CASCADE International Fellowship; the People Programme (Marie Curie Actions) of the European Union’s Seventh Framework Programme (FP7/2007-2013) under REA grant agreement No PCOFUND-GA-2012-600181.</span></em></p><p class="fine-print"><em><span>Greg Dore is supported through a National Health and Medical Research Council of Australia Practitioner Fellowship. He was received research support and is a consultant for Gilead Sciences, Merck, and Janssen; has received research support from Bristol-Myers Squibb, Abbvie, and Roche; is on the speaker’s bureau for Gilead Sciences, Merck, Janssen, and Roche; is a member of the advisory board for Gilead Sciences, Merck, Janssen, Bristol-Myers Squibb, Abbvie, Roche, GlaxoSmithKline, and Abbott Diagnostics; and has received travel support from Gilead Sciences, Merck, Bristol-Myers Squibb, Abbvie, and Roche. The authors have just been granted a Cancer Council NSW Research Award to evaluate the impact of improving hepatitis C treatment on rates of liver cancer.</span></em></p>The newer drugs for hepatitis C might mean fewer people are diagnosed with liver cancer.Maryam Alavi, Research Associate, The Kirby Institute, UNSW SydneyGregory Dore, Professor, Head of the Viral Hepatitis Clinical Research Program, Kirby Institute, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/687822016-11-16T09:46:20Z2016-11-16T09:46:20ZA common virus could help fight liver cancer and hepatitis C<figure><img src="https://images.theconversation.com/files/146100/original/image-20161115-31144-1gfovk4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">CT scan of liver cancer.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/278700260?src=qNdpGDLrjuLfebxNgoXnGA-1-30&id=278700260&size=medium_jpg">Puwadol Jaturawutthichai/Shutterstock.com</a></span></figcaption></figure><p>Reovirus, a common virus that causes mild cases of respiratory infection, mainly in children, could be harnessed as an immunotherapy to fight primary liver cancer and hepatitis C.</p>
<p>Viruses cause around <a href="http://www.cancer.org/cancer/cancercauses/othercarcinogens/infectiousagents/infectiousagentsandcancer/infectious-agents-and-cancer-viruses">20% of all human cancer</a>. While only a handful are known to be tumour-promoting, this is a particular problem for liver cancer, where around three-quarters of cases are caused by either hepatitis C virus (HCV) or hepatitis B virus (HBV). These cause long-lived infections within the liver that in some people eventually give rise to tumours. But in our <a href="http://gut.bmj.com/content/early/2016/11/15/gutjnl-2016-312009.short?g=w_gut_ahead_tab">latest study</a>, we show that our immune systems can be coerced into targeting both the tumour and the underlying HCV infection that is driving it to grow. </p>
<p>We persuaded the immune system to target both the tumour and the underlying HCV infection by administering a benign virus – reovirus – as an immunotherapy. Mice with liver cancer caused by hepatitis C responded well to this therapy. The therapy could also be extended to other virus-driven malignancies, including Epstein Barr virus blood cancers.</p>
<p>Liver cancer is the third highest cause of cancer-associated death worldwide, killing about <a href="http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/liver-cancer">745,000 people in 2012</a>, despite being only around the tenth most common cancer. This reflects the difficulty in treating this tumour at advanced stages, where it has progressed too far to be removed by surgery. In around 90% of cases where surgery is not an option, most other forms of treatment tend to prolong life, rather than cure the tumour. HCV and HBV cause about <a href="http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/liver-cancer">30 and 50% of these tumours, respectively</a>. HCV is the leading cause for liver transplant surgery in developed countries and infects around <a href="http://www.who.int/mediacentre/factsheets/fs164/en/">170m people across the planet</a>. </p>
<h2>Cancer-killing viruses</h2>
<p>It is becoming clear that one of the most powerful weapons to combat cancer is our own immune response. However, as cancers essentially grow as extensions of our own bodies, we usually need to manipulate this response using immunotherapy. This approach can take several forms, including disabling immune “checkpoints”, whereby we take the brakes off immune responses. Alternatively, we can put our foot on the accelerator by using strategies that hyper-stimulate immunity, allowing it to recognise and respond to targets that may otherwise be ignored. </p>
<p>One such strategy is to use viruses themselves, but only those that don’t cause human disease. These cancer-killing or “oncolytic” viruses are increasingly used in clinical trials. One example was recently licensed as a medicine for the <a href="http://www.amgen.com/media/news-releases/2015/10/fda-approves-imlygic-talimogene-laherparepvec-as-first-oncolytic-viral-therapy-in-the-us/">treatment of skin cancer</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/146102/original/image-20161115-31148-1lhg067.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/146102/original/image-20161115-31148-1lhg067.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/146102/original/image-20161115-31148-1lhg067.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/146102/original/image-20161115-31148-1lhg067.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/146102/original/image-20161115-31148-1lhg067.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/146102/original/image-20161115-31148-1lhg067.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/146102/original/image-20161115-31148-1lhg067.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A reovirus.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-314784767/stock-photo-reovirus-on-colorful-background-a-virus-causes-infection-of-gastrointestinal-and-respiratory-system-a-model-is-built-using-data-of-viral-molecular-structure-from-protein-data-bank-pdb-2.html?src=mdOy7nwfZLqFmXlYieF6zg-1-3">Kateryna Kon/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Our study focused on a particular oncolytic virus, reovirus, as we knew that it could reach tumours within the liver following injection into the bloodstream. Reovirus is a very safe agent to use in cancer patients. Importantly, it safely pressed the immune accelerator pedal throughout the liver, as well as within cancers. This was important, as the underlying HCV infection affects the whole organ, not just the tumour. </p>
<p>The lynchpin of this accelerator response was a substance called interferon, which is released by the body when mounting aggressive responses to both infections and cancers alike. Using both primary human liver tissue and mice, we were able to show that the reovirus-stimulated interferon acted in two ways: first, it directly eliminated HCV within liver or tumour cells, and second, it hyper-activated specific immune cells known as natural killer cells, causing them to kill both virus-infected and cancerous cells.</p>
<p>The outcome of reovirus therapy was the simultaneous elimination of HCV as well as the direct destruction of liver cancer cells, culminating in reduced tumour growth within mouse models of this devastating human disease. The same approach also worked in models of HBV liver cancers and Epstein Barr virus blood cancers. </p>
<p>As reovirus is already available in a clinically usable form, our next step is to secure support for early clinical trials assessing how this therapy might act alongside current liver cancer drugs. In the future, we envisage that this or similar strategies might be useful for treating multiple tumours caused by virus infection. Effectively, by pitting curative against causative viruses, we hope to improve outcomes for cancer patients in the future.</p><img src="https://counter.theconversation.com/content/68782/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr Stephen Griffin currently receives funding from the MRC, ERC and the Leeds Teaching Hospitals Charitable Foundation. He has previously received funding from CRUK, the Wellcome Trust and Oncolytics Biotech. He is affiliated with the UK Microbiology Society.</span></em></p>A promising new immunotherapy to treat liver cancer has been discovered.Stephen Griffin, Associate Professor, University of LeedsLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/677492016-10-27T15:07:14Z2016-10-27T15:07:14ZScotland’s alcoholic fallout: new findings lay bare what country is up against<figure><img src="https://images.theconversation.com/files/143497/original/image-20161027-11271-lqlrxi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Wha's like us?</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/gertcha/4212196886/in/photolist-5VYne3-2qBAA-7J8dEU-6LqW63-9VTbFx-6i8wZo-4rbhbU-6G9EdD-afMEou-aggTYn-4pXiPo-2PD6yE-K41BE-8HTQ7q-axeJW7-ciNrLW-aoeikz-9UbgSK-4r7dBP-c79Jij-bDbw1R-9SMWd4-f9r2Do-7qdBof-axcg2x-9WowtC-7mba4e-QpFr1-4rbiPL-bu6ah3-9WkH14-7XoJmt-2J55kh-9WkH1n-cwfGw7-c2jnJo-9PMxk1-axrDyo-zAa3aX-axrtaC-eDdQkW-4KpZP-8eZqgA-rrfLP3-nD2vPn-9VWDtq-6Eu9hR-dLdquZ-fsqZUD-4r7cpR">Stuart Chalmers</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>Alcoholic liver disease is a major cause of illness, death and economic burden across the world. A catch-all for conditions including cirrhosis, alcoholic hepatitis and liver fibrosis, it <a href="https://www.ncbi.nlm.nih.gov/pubmed/23511777">results in</a> around a half a million deaths each year. </p>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/18385413">While</a> other liver diseases like hepatitis B and C are expected to become less prevalent in years to come, people drink so much that alcoholic liver disease (ALD) is unlikely to move in the same direction. The <a href="https://www.ncbi.nlm.nih.gov/pubmed/26592352">UK has</a> one of the highest rates in western Europe (albeit lower than much of eastern Europe), and <a href="http://www.healthscotland.com/scotlands-health/evaluation/planning/MESAS.aspx">Scotland</a> drinks more and suffers more alcohol-related harms than the rest of the country. Worse, it is the poorest in society <a href="http://www.ias.org.uk/Alcohol-knowledge-centre/Socioeconomic-groups/Factsheets/Socioeconomic-groups-relationship-with-alcohol.aspx">who suffer</a> the most alcohol-related harm. </p>
<p>There has been some cause for optimism in recent years in Scotland – but only at first glance. The incidence of ALD hospitalisations for new patients <a href="http://www.isdscotland.org/Health-Topics/Drugs-and-Alcohol-Misuse/Publications/data-tables.asp">fell between</a> 2008/09 and 2012/13 – or may have started to drop a couple of years earlier, according to <a href="http://www.healthscotland.com/documents/26884.aspx">different figures</a>. It has since been <a href="http://www.isdscotland.org/Health-Topics/Drugs-and-Alcohol-Misuse/Publications/data-tables.asp">rising again</a>, however – and still is, according to the new figures. </p>
<p><strong>Total ALD patients admitted over time</strong></p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/143472/original/image-20161027-32322-1r62scu.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/143472/original/image-20161027-32322-1r62scu.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/143472/original/image-20161027-32322-1r62scu.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=301&fit=crop&dpr=1 600w, https://images.theconversation.com/files/143472/original/image-20161027-32322-1r62scu.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=301&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/143472/original/image-20161027-32322-1r62scu.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=301&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/143472/original/image-20161027-32322-1r62scu.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=378&fit=crop&dpr=1 754w, https://images.theconversation.com/files/143472/original/image-20161027-32322-1r62scu.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=378&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/143472/original/image-20161027-32322-1r62scu.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=378&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">ISD Scotland</span></span>
</figcaption>
</figure>
<p>And even at their lowest recent level in 2012/13, the rates were still high compared to the rest of the UK and western Europe. The most recent figure for 2015/16 of 3,788 hospitalisations is higher than all years except 2006-09 and the figures also mask the fact that chronic ALD rates caused by heavy alcohol consumption – cirrhosis, fatty liver and hepatic failure – have been rising all along. </p>
<p><strong>Chronic ALD patients admitted over time</strong></p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/143473/original/image-20161027-11260-iamduj.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/143473/original/image-20161027-11260-iamduj.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/143473/original/image-20161027-11260-iamduj.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=299&fit=crop&dpr=1 600w, https://images.theconversation.com/files/143473/original/image-20161027-11260-iamduj.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=299&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/143473/original/image-20161027-11260-iamduj.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=299&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/143473/original/image-20161027-11260-iamduj.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=376&fit=crop&dpr=1 754w, https://images.theconversation.com/files/143473/original/image-20161027-11260-iamduj.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=376&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/143473/original/image-20161027-11260-iamduj.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=376&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">ISD Scotland</span></span>
</figcaption>
</figure>
<p>Explaining why Scots drink more than those in many countries is not easy. But the reason for the sharp rise and then the slight fall in the ALD rates is arguably because excessive drinking got worse in the 1970s and 1980s. These people continued to drink large amounts over time and were then dying in the 2000s in greater numbers for the first time. </p>
<p><strong>Cirrhosis incidence by country</strong></p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/143477/original/image-20161027-11268-1fynk2f.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/143477/original/image-20161027-11268-1fynk2f.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/143477/original/image-20161027-11268-1fynk2f.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=312&fit=crop&dpr=1 600w, https://images.theconversation.com/files/143477/original/image-20161027-11268-1fynk2f.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=312&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/143477/original/image-20161027-11268-1fynk2f.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=312&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/143477/original/image-20161027-11268-1fynk2f.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=393&fit=crop&dpr=1 754w, https://images.theconversation.com/files/143477/original/image-20161027-11268-1fynk2f.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=393&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/143477/original/image-20161027-11268-1fynk2f.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=393&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Male = red (W Eur), green (E Eur); Female = blue (W Eur), yellow (E Eur). (All 2012, except Scot 2014)</span>
<span class="attribution"><span class="source">WHO/Scottish PHO</span></span>
</figcaption>
</figure>
<h2>Effects</h2>
<p>We have published <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0162980">a new study</a> into the prevalence and costs of alcoholic liver disease in Scotland between 1991 and 2011. We found that almost one in five of these patients died during their first hospitalisation. Of the people discharged alive, more than 50% died within five years. These risks are markedly increased if patients present with severe symptoms such as liver or heart failure. </p>
<p>When we compared with a group from the general population who had healthy livers but were similar in terms of sex, age and where they came from, the ALD patients are much more likely to spend time in hospital (for any reason) both before and after their first ALD diagnosis. </p>
<p>The average annual hospital cost per person was meanwhile over twice as high for ALD patients than the other group before diagnosis (approximately £1,400 vs £570). After diagnosis it went up to ten times as high (approximately £14,000 vs £1,200). </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/143475/original/image-20161027-11252-y3g67f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/143475/original/image-20161027-11252-y3g67f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/143475/original/image-20161027-11252-y3g67f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=857&fit=crop&dpr=1 600w, https://images.theconversation.com/files/143475/original/image-20161027-11252-y3g67f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=857&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/143475/original/image-20161027-11252-y3g67f.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=857&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/143475/original/image-20161027-11252-y3g67f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1077&fit=crop&dpr=1 754w, https://images.theconversation.com/files/143475/original/image-20161027-11252-y3g67f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1077&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/143475/original/image-20161027-11252-y3g67f.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1077&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">In one.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-58486459/stock-photo-figure-alcoholic-drinking-from-bottle.html?src=okYFpdQX1CtLzuYklK8Wrg-1-28">Komvell</a></span>
</figcaption>
</figure>
<p>A first admission to hospital with ALD often indicates a very poor outcome with a high risk of dying during that hospitalisation or afterwards. Those discharged alive are often readmitted, frequently multiple times, which helps explain the high costs to the NHS. (Patients with alcoholic liver disease are also regular health service users before the disease develops.) </p>
<p>We also found that the rate of readmission for these patients has been increasing over the past 20 years. This makes the recent rise in incidence of chronic ALD in Scotland particularly concerning. And it’s not just the ALD figures that are concerning when it comes to alcohol-related diseases – the <a href="http://www.isdscotland.org/Health-Topics/Cancer/Cancer-Statistics/">latest national figures</a> show that death rates from liver cancer have increased by 52% in the last ten years. It is all a reminder of the seriousness of Scotland’s problem. </p>
<h2>Answers</h2>
<p>In short, preventative strategies need to be a focus for further research. For example, the Scottish government is rolling out what are known as <a href="http://www.nhsggc.org.uk/your-health/health-services/alcohol-brief-intervention/what-is-brief-intervention/">alcohol brief interventions</a>, which involve the person keeping an alcohol diary then being offered support and advice. (While the evidence is generally supportive for this approach, it should be said there are a lot of <a href="http://alcalc.oxfordjournals.org/content/49/1/66">unanswered questions</a> surrounding their effectiveness). <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3036962/">Other possibilities</a> are abstinence and lifestyle motivation programmes, educational programmes in schools over dangers of alcohol, social support and nutritional support and drug treatments combined with <a href="https://www.bps.org.uk/system/files/user-files/DCP%20Faculty%20for%20the%20Psychology%20of%20Older%20People%20(FPoP)/public/a_guide_to_psychosocial_interventions_in_dementia.pdf">different kinds of support</a>. </p>
<p>And given the high cost of hospital care, it is highly likely that <a href="http://www.gov.scot/Topics/Health/Services/Alcohol/minimum-pricing">minimum unit pricing</a> of alcohol will be cost-effective as well. We welcome the <a href="http://www.bbc.co.uk/news/uk-scotland-37725251">recent ruling</a> by the Scottish courts to reject a challenge by Scotland’s drinks industry which claimed minimum unit pricing was in breach of European law. </p>
<p>Although not perfect, it has <a href="https://theconversation.com/why-im-fighting-alcohol-industry-obstruction-of-minimum-pricing-25126">made a difference</a> in the likes of Canada and will directly target the cheap alcohol that is consumed by most dependent drinkers. This should tackle the problem among the poorest drinkers, which is an added attraction.</p><img src="https://counter.theconversation.com/content/67749/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jim Lewsey was PI on a grant application awarded by the CSO to carry out this work on the epidemiology and costs of alcoholic liver disease in Scotland.</span></em></p><p class="fine-print"><em><span>Mathis Heydtmann does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>New Scottish alcoholic liver disease figures show how far country’s problem is from being under control.Jim Lewsey, Reader in Medical Statistics, University of GlasgowMathis Heydtmann, Honorary Clinical Senior Lecturer, University of GlasgowLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/616662016-07-31T20:07:33Z2016-07-31T20:07:33ZChildhood cancer deaths have fallen in Australia, but some types remain more of a challenge<figure><img src="https://images.theconversation.com/files/132133/original/image-20160727-5663-143ky4o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Death rates from childhood cancer in Australia have fallen sharply.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>Childhood deaths from cancer have decreased by nearly 40% in the past 15 years in Australia, our <a href="http://www.anr2016.org/anzchog/full-program/">latest figures show</a>. While overall cancer rates have increased during the past 30 years, mortality rates have dropped, both overall and for particular types of childhood cancer.</p>
<p>According to unpublished data from the <a href="https://cancerqld.org.au/research/cancer-registries/australian-paediatric-cancer-registry/">Australian Paediatric Cancer Registry</a>, childhood cancer death rates decreased by about 3% per year between 1998 and 2013. There have been significant improvements in survival for childhood leukaemias, lymphomas, neuroblastoma and malignant bone tumours.</p>
<p>Today, tumours of the central nervous system (mainly brain tumours) account for 40% of all childhood cancer deaths, the single largest cause of cancer deaths for children in Australia. These are followed by leukaemias (23%) and <a href="http://www.neuroblastoma.org.au/about-neuroblastoma/overview/">neuroblastoma</a> (12%), which is the most common solid tumour in childhood, usually found in the abdomen.</p>
<p>Death rates from leukaemia – the most common form of childhood cancer – have dropped from 16.6 deaths per million children in 1998 to 4.4 in 2013. This equates to an overall decrease of 68% over that period. </p>
<iframe src="https://datawrapper.dwcdn.net/25agA/1/" frameborder="0" allowtransparency="true" allowfullscreen="allowfullscreen" webkitallowfullscreen="webkitallowfullscreen" mozallowfullscreen="mozallowfullscreen" oallowfullscreen="oallowfullscreen" msallowfullscreen="msallowfullscreen" width="100%" height="400"></iframe>
<p>Five-year survival for all childhood cancers increased from 77% for the period 1994-2003 to 84% for 2004-2013. We know 98% of children who survive the first five years after diagnosis will survive a further five years.</p>
<p>However, there was little or no survival change for several types of childhood cancers over recent years. These included brain, kidney and liver cancers. </p>
<h2>Childhood cancer in Australia</h2>
<p>Australia has the <a href="https://cancerqld.org.au/news/australian-childhood-cancer-deaths-drop-sharply/">lowest childhood cancer death</a> rate of all G20 countries. And Australia’s five-year survival rates for childhood cancer are among the best in the world. </p>
<p>The key reason for the downward trends of death rates is improved treatment, particularly the introduction of more effective chemotherapy protocols and adjunct therapies such as radiotherapy. Cancer research, especially clinical trials, has contributed to improved treatments and better survival rates.</p>
<p>However, our figures also show Australia has one of the highest childhood cancer rates in the world. Incidence of childhood cancer increased significantly from 1983 until the mid-1990s, but has remained fairly constant since. </p>
<iframe src="https://datawrapper.dwcdn.net/tQJdA/4/" frameborder="0" allowtransparency="true" allowfullscreen="allowfullscreen" webkitallowfullscreen="webkitallowfullscreen" mozallowfullscreen="mozallowfullscreen" oallowfullscreen="oallowfullscreen" msallowfullscreen="msallowfullscreen" width="100%" height="400"></iframe>
<p>Cancer is the second leading cause of death in Australian children, behind injury and poisoning. Around 710 children aged under 15 are diagnosed with cancer each year and about 100 die from the disease. </p>
<p>The causes of most childhood cancers and factors driving changes in incidence over time are largely unknown. Unlike cancer in adults, where <a href="https://theconversation.com/interactive-body-map-what-really-gives-you-cancer-52427">behavioural factors</a> such as smoking, alcohol consumption, diet and exercise play an important role, almost nothing is known about what may increase cancer risk in children. </p>
<p>A possible exception to this is melanoma. Our figures show a 38% decrease in the incidence of melanoma among children in Australia between 1993 and 2013.
This is most likely the result of long-running public health campaigns such as Slip, Slop, Slap that promote improved sun protection, particularly among children.</p>
<h2>Tough cancers in children</h2>
<p>In the most recent period, almost all children (98%) diagnosed with the rare eye-cancer <a href="https://childrenscancer.canceraustralia.gov.au/types-childrens-cancers/retinoblastoma">retinoblastoma</a> survived for at least five years. Five-year survival rates also exceeded 90% for lymphomas (cancers of the lymphatic system), germ cell tumours (most of which are occur in the ovaries and testes) and the group of cancers that includes melanoma. </p>
<p>In contrast, five-year survival was more moderate (between 70% to 75%) for children with tumours of the liver, the central nervous system (mainly brain tumours) and neuroblastoma. Five-year survival for tumours of the central nervous system has only slightly improved from 71% in 1994-2003 to 74% in 2004-2013.</p>
<p>The incidence of liver cancer in children is increasing by 2.5% per year, compared to a stable trend of 0.2% per year increase in the rate for all childhood cancers combined.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/132143/original/image-20160727-5638-2qgiki.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/132143/original/image-20160727-5638-2qgiki.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=411&fit=crop&dpr=1 600w, https://images.theconversation.com/files/132143/original/image-20160727-5638-2qgiki.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=411&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/132143/original/image-20160727-5638-2qgiki.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=411&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/132143/original/image-20160727-5638-2qgiki.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=517&fit=crop&dpr=1 754w, https://images.theconversation.com/files/132143/original/image-20160727-5638-2qgiki.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=517&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/132143/original/image-20160727-5638-2qgiki.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=517&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Long-running public health campaigns such as Slip Slop Slap likely contributed to decreased incidence of melanoma in Australian children.</span>
<span class="attribution"><a class="source" href="http://robotzo.blogspot.com.au/2011/10/boc-slip-slap-slop.html">Screenshot Robotzo Blogspot</a></span>
</figcaption>
</figure>
<p>The causes of liver cancer in children are largely unknown. Hepatoblastoma, a type of liver cancer that occurs in children aged under four, can occur in association with certain genetic syndromes such as <a href="https://ghr.nlm.nih.gov/condition/familial-adenomatous-polyposis">familial adenomatous polyposis</a> and <a href="https://ghr.nlm.nih.gov/condition/beckwith-wiedemann-syndrome">Beckwith-Wiedemann syndrome</a>, also known as overgrown syndrome. It has also <a href="http://www.so-online.net/article/S0960-7404(07)00068-0/abstract">occurred more frequently among infants</a> delivered prematurely.</p>
<p>The risk of hepatic carcinoma, a type of liver cancer mainly affecting children aged over ten, appears to increase among those who have had other liver diseases such as cirrhosis, metabolic diseases or chronic hepatitis. </p>
<p>The reasons for the apparent increase in the incidence of liver cancer are unknown and an international study involving the Australia Paediatric Cancer Registry is being planned to examine issues around childhood liver cancer.</p>
<p>Children who survive cancer can suffer serious long-term consequences resulting from their treatment. These <a href="http://www.cancer.org/treatment/childrenandcancer/whenyourchildhascancer/children-diagnosed-with-cancer-late-effects-of-cancer-treatment">late effects are many and varied</a> and depend on factors such as the type of cancer and the treatment the child received.</p>
<p>Some examples include <a href="https://theconversation.com/many-survivors-of-childhood-brain-cancer-have-cognitive-difficulties-but-these-can-be-treated-57566">learning and behavioural problems</a>, vision and hearing deficiencies, stunted growth, heart disease, reduced lung capacity, dental issues, impaired sexual development and a higher risk of second cancers.</p>
<p>As well as improving survival, it’s important to find better therapies that do not impact on long-term health and quality of life.</p><img src="https://counter.theconversation.com/content/61666/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Joanne Aitken receives funding from Cancer Council Queensland and Cancer Australia. </span></em></p>Childhood deaths from cancer have decreased by nearly 40% in the past 15 years in Australia. But some types of childhood cancer have shown little improvement.Joanne Aitken, Professor and Head of Research, Cancer Council QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/631342016-07-31T17:23:37Z2016-07-31T17:23:37ZThe risk of early liver cancer is spurred by a combo of hepatitis B and HIV<figure><img src="https://images.theconversation.com/files/132206/original/image-20160727-21569-jllwyc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A model of the hepatitis B virus in a blood vessel with red blood cells.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>People who have both hepatitis B and HIV may have a greater chance of developing liver cancer at a young age, <a href="http://www.sun.ac.za/english/Lists/news/DispForm.aspx?ID=4113">according to our new study</a>. </p>
<p>The study, to be published shortly, involved patients from cancer units. The results showed that the age profile of liver cancer patients was affected by HIV. Liver cancer in Africans occurs <a href="https://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-031574.pdf">at a young age</a>: between the ages of 30 and 40 years. But we found that it occurs at a significantly younger age in those who are infected with HIV and hepatitis B. </p>
<p>Liver cancer is the third most common cause of death among the seven million people who die from cancer annually across the globe. </p>
<p>Early death from liver cancer could be reduced if HIV-positive people were more rigorously screened for hepatitis B. </p>
<p>Diagnosing hepatitis B in HIV-infected people is important because it is treatable. But it often goes undiagnosed. Second, hepatitis B appears to be more aggressive in HIV as viral loads are higher and it is more difficult to clear. The rates of liver cancer may be higher and the risk of onward transmission is greater. </p>
<p>Our study is significant because it highlights the need for early diagnosis of hepatitis B. Screening for the infection is not currently taking place and, as a result, patients are presenting with cancer at a young age, with a late-stage malignancy that could be prevented.</p>
<h2>Tackling hepatitis B</h2>
<p>There have been dramatic improvements in the <a href="https://theconversation.com/the-scientific-journey-of-aids-from-despair-to-cautious-hope-54858">management of HIV</a> over the past decade. But hepatitis B infection and its prevention and treatment is not <a href="http://www.ncbi.nlm.nih.gov/pubmed/23303802">receiving the same attention</a> or funding. </p>
<p>Hepatitis B is inflammation of the liver, transmitted through contact with the blood or the body fluids of an infected person. It affects more than 75 million people in Africa. </p>
<p>Hepatitis B is an important international public health problem. We know that more people <a href="http://who.us9.list-manage2.com/track/click?u=a6b34fbd46b688a84a907e16d&id=cf881ff7a4&e=80756a560c">die from viral hepatitis</a> (that is chronic hepatitis B and C) than from malaria, HIV or tuberculosis. About 240 million people world wide have chronic hepatitis B infection. Globally, roughly 10% of all people living with HIV are estimated to have <a href="https://aidsrestherapy.biomedcentral.com/articles/10.1186/s12981-016-0107-x">chronic hepatitis B co-infection</a>.</p>
<p>A safe and effective vaccine for hepatitis B was developed more than 20 years ago, making it possible to eliminate the infection. But more resources are needed to tackle the two big challenges around hepatitis: early diagnosis and mother-to-child transmission, which is often underestimated and overlooked.</p>
<p>The main challenge is around getting recognition from public health experts and politicians that viral hepatitis is an important public health issue. Cost effective, rapid tests that perform well are available to identify those who have active infection. These tests need to be rolled out to primary care clinics and to hospitals. </p>
<p>The other challenge is around mother-to-child transmission of the disease. Part of the problem is that routine screening for hepatitis B during pregnancy is still nonexistent in most parts of sub-Saharan Africa. As a result, highly infectious pregnant women remain unidentified and their infants are infected. This perpetuates the cycle of infection in communities.</p>
<p>Receiving the hepatitis B vaccine at birth can prevent the transmission of the hepatitis B virus from an infected mother to her baby. <a href="http://scholar.sun.ac.za/handle/10019.1/99125">Previous research</a> has shown that pregnant women with both hepatitis B and HIV are at high risk of transmitting the infection to their infants.</p>
<p>Yet in South Africa and many other sub-Saharan countries, the vaccine is only administered when the baby is six weeks old, leaving the infant vulnerable to infection at the time of birth.</p>
<p>To change this, the first dose of the vaccine must be brought closer to the time of birth to reduce the risk of perinatal infection and for the implementation of routine screening for hepatitis B virus infection during pregnancy and when HIV is diagnosed. </p>
<h2>A dedicated approach</h2>
<p>The increasing availability of drugs for the treatment of hepatitis infection has exposed the lack of cost-effective methods for diagnosis and monitoring in resource-poor settings.</p>
<p>And earlier this year the World Health Assembly ratified a <a href="http://apps.who.int/gb/ebwha/pdf_files/WHA69/A69_32-en.pdf?ua=1">strategy</a> of elimination. This is the first ever strategy for the elimination of viral hepatitis. No country has yet eliminated infection. The strategy aims to:</p>
<ul>
<li><p>reduce the number of new viral hepatitis infections by 90%; and </p></li>
<li><p>reduce the annual deaths from chronic viral hepatitis from 1.4 million to less than 0.5 million by 2030. </p></li>
</ul>
<p>To prevent hepatitis B-related liver cancer, the hepatitis B vaccine must be available to all those who need it. In particular, the hepatitis B birth dose vaccine should be administered to all infants in order to prevent the onward transmission of hepatitis B from mother to child. Then we need to screen, including those with HIV, for hepatitis B infection. </p>
<p>In this way the prevalence of chronic infection in African communities will be reduced and those most at risk of developing liver cancer will be identified. The tools to eliminate the impact of this infection are in our hands, the question is: do we have the will to use them?</p><img src="https://counter.theconversation.com/content/63134/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Monique Andersson has received research funding from Gilead, Abbott, Alere. </span></em></p>Liver cancer in Africans tends to occur between the ages of 30 and 40. But a study has found that it occurs at a significantly younger age in those who are infected with HIV and hepatitis B.Monique Andersson, Senior Researcher and Pathologist in the Division of Medical Virology, Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/524272016-03-06T19:06:49Z2016-03-06T19:06:49ZInteractive body map: what really gives you cancer?<figure><img src="https://images.theconversation.com/files/109420/original/image-20160127-26823-10cmjm4.png?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption"></span> </figcaption></figure><p>There’s abundant advice out there on what you should or shouldn’t eat, drink, swallow, or stand next to, to avoid cancer. But it’s often lacking in evidence and the jumble of messages can be confusing.</p>
<p>This body map brings together the evidence on proven cancer causes. Using credible, scientific sources it answers questions about whether alcohol, red meat or sun exposure increase your cancer risk.</p>
<p><iframe id="tc-infographic-171" class="tc-infographic" height="400px" src="https://cdn.theconversation.com/infographics/171/30f81a46480b839121f8fdbb1a104cf6322671ef/site/index.html" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>Cancer occurs when <a href="https://theconversation.com/explainer-what-is-cancer-1673">mutations in a cell’s DNA</a> cause it to replicate without control, invading other tissues. Some cancer-causing mutations can be inherited; others induced, by infection with bacteria or viruses; or by environmental factors such as smoking, sun exposure and eating red meat.</p>
<p>This map’s focus is on induced factors. They are considered “modifiable” because avoiding them lessens your chance of cancer.</p>
<p>Choose your gender and click a risk factor to see which body area can be affected. Clicking the body region will show you how much engaging in risks such as drinking alcohol, taking the contraceptive pill, or eating pickled vegetables, will increase your chance of certain cancers.</p>
<p>When reading the map, keep in mind that every body and circumstance is unique; one risk factor cannot be considered in isolation when applied to a real life context. </p>
<p>Also remember the percentages portrayed are “relative risks” which are different to “absolute risks”. The difference is explained in <a href="http://theconversation.com/its-all-relative-how-to-understand-risk-in-the-cancer-map-55494">this accompanying piece</a>, which will help you understand what relative risk really means for your chances of getting cancer.</p><img src="https://counter.theconversation.com/content/52427/count.gif" alt="The Conversation" width="1" height="1" />
This body map brings together evidence on proven cancer causes. Using credible, scientific sources it answers questions about whether alcohol, red meat or sun exposure increase your cancer risk.Emil Jeyaratnam, Data + Interactives Editor, The ConversationSasha Petrova, Section Editor: EducationLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/487062015-10-28T17:27:44Z2015-10-28T17:27:44ZHepatitis C: behind new wonder drugs lies a terrible dilemma<figure><img src="https://images.theconversation.com/files/97461/original/image-20151006-7371-1q1kmc0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">150m carriers, and rising </span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&autocomplete_id=&searchterm=hepatitis%20C&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=311254835">Jarun Ontakrai</a></span></figcaption></figure><p>There are <a href="http://www.ncbi.nlm.nih.gov/pubmed/21091831">160m carriers</a> of the hepatitis C virus across the world. Combined with the hepatitis B virus, which has <a href="http://www.who.int/mediacentre/factsheets/fs204/en/">240m carriers</a>, this <a href="http://worldhepatitisday.org">causes 1.4m deaths</a> every year. </p>
<p>Yet there are grounds for optimism around hepatitis C. Numerous pharmaceutical companies have recently brought to market new sets of “direct-acting antiviral” medicines to combat the infection. These have been <a href="http://www.hivandhepatitis.com/hcv-treatment/experimental-hcv-drugs/5172-easl-2015-merck-hcv-combination-effective-after-failure-of-first-generation-direct-acting-antivirals">shown to</a> permanently clear the hepatitis C virus in 90% of patients in only a few short weeks, and with negligible adverse effects. It is not an overstatement to say that these antivirals have the potential to do for hepatitis C what <a href="http://aje.oxfordjournals.org/content/early/2010/10/26/aje.kwq320">oral vaccination did</a> for polio. </p>
<p>But there is a fly in the ointment. The new drugs are unaffordable. Take the UK as an example, <a href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/448710/NEW_FINAL_HCV_2015_IN_THE_UK_REPORT_28072015_v2.pdf">where around 214,000</a> people live with hepatitis C. Going by the <a href="https://www.nice.org.uk/guidance/ta330/chapter/2-The-technology">indicated list price</a> of £35,000 per treatment course, it would cost around £7.5 billion to treat every infected person. Even the staunchest hepatitis advocate would concede that since that approaches the entire NHS annual drug budget, treating everyone is not feasible in the short term. </p>
<h2>The moral maze</h2>
<p>This presents a conundrum for policy professionals across the world: if we cannot afford to treat everyone in need immediately, how should we go about allocating the limited number of treatments that we can afford? With direct-acting antivirals now available in virtually all high-income countries, the two main routes available to those in charge of health budgets are as follows.</p>
<p>The first can be dubbed the “anti-decision” option. You allow the situation to develop organically, without exerting any guiding hand over who receives treatment now and who waits until later. This circumvents having to make a potentially unpopular decision on rationing. But not all patients have an equal need for treatment – and where demand for a medicine outstrips supply, a decision not to prioritise anyone often amounts to a tacit decision to prioritise unjustly on social criteria. </p>
<p>This is <a href="http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2004.052738">what happened</a> when insulin was made publicly available in the 1920s, for instance, following its discovery by Fredrick Banting. Severe production constraints meant that demand for insulin far exceeded its possible supply and there were no formal criteria to decide who should be prioritised. <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1449336/">As a result</a>, the drug was largely allocated to Banting’s own patients and to the politically well-connected.</p>
<p>The second route is the diametric alternative. Rather than avoiding making a decision, you take the bull by the horns and prioritise explicit groups of patients to accomplish a specific public health goal. The challenge is to identify which goal, for there are several worthy candidates. One might say, for example, that hepatitis C transmission rates among people who inject drugs <a href="https://theconversation.com/doing-the-maths-to-cut-hepatitis-c-in-injecting-drug-users-16435">are too high</a>, and so remedying this problem should be the priority. </p>
<p>Others may take the view that the steady <a href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/448710/NEW_FINAL_HCV_2015_IN_THE_UK_REPORT_28072015_v2.pdf">year-on-year increases</a> in people who develop severe consequences from the infection can’t be tolerated, so we should use the treatments to turn this tide. Both goals are laudable and legitimate, but the costs prohibit prioritising both. In other words, the <a href="http://gut.bmj.com/content/early/2014/11/06/gutjnl-2014-308166.abstract">opportunity cost</a> of prioritising one is to forfeit the other. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/97463/original/image-20151006-7335-1cnjdg3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/97463/original/image-20151006-7335-1cnjdg3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/97463/original/image-20151006-7335-1cnjdg3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=380&fit=crop&dpr=1 600w, https://images.theconversation.com/files/97463/original/image-20151006-7335-1cnjdg3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=380&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/97463/original/image-20151006-7335-1cnjdg3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=380&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/97463/original/image-20151006-7335-1cnjdg3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=478&fit=crop&dpr=1 754w, https://images.theconversation.com/files/97463/original/image-20151006-7335-1cnjdg3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=478&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/97463/original/image-20151006-7335-1cnjdg3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=478&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Classic liver symptom: yellow skin pigmentation.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&autocomplete_id=&search_tracking_id=I2D4uHTahI9lS71DxG5f3Q&searchterm=hepatitis%20C%20liver&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=262039214">Crystal Eye Studio</a></span>
</figcaption>
</figure>
<h2>On the ground</h2>
<p>So what approach are we leaning towards? In the UK a <a href="http://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2015/06/hep-c-cirrhosis-polcy-statmnt-0615.pdf">consensus is emerging</a> that the near-term priority should be treating patients with advanced liver fibrosis – this is <a href="http://www.ncbi.nlm.nih.gov/pubmed/26120969">also being pursued</a> by private and state-funded health insurance programmes in the US. This advanced liver fibrosis subgroup, (<a href="http://www.gov.scot/Resource/0048/00484431.pdf">which accounts</a>) for about 30% of the total hep C infected population in Scotland, exhibits by far the greatest immediate risk of severe liver complications like liver failure and liver cancer, the prognoses for which are very bleak. </p>
<p>The crucial fact that prioritising this group will save the most lives makes it possible to justify the policy both to individual patients and to those who want to see the biggest public health benefit. Scotland, for instance, <a href="http://www.hcvaction.org.uk/resource/scottish-sexual-health-and-blood-borne-virus-framework-2015-2020">expects to</a> reduce new-onset liver failures and liver cancer by 75% to fewer than 50 cases a year by 2020 if this strategy is followed through. With the number of cases currently <a href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/448710/NEW_FINAL_HCV_2015_IN_THE_UK_REPORT_28072015_v2.pdf">rising fast</a>, this would be nothing less than remarkable.</p>
<p>But let us not lose sight of the wider picture. Viral hepatitis is a global problem whose solution depends not just on making progress in richer countries, but making inroads in poorer countries too – <a href="http://www.who.int/csr/disease/hepatitis/whocdscsrlyo2003/en/index4.html">particularly those</a> in Asia and Africa where the greatest viral hepatitis burden lies. A global problem requires global endeavour. Historically, most governments and the big aid donors have been lacklustre at investing in this cause.</p>
<p>Cue then the <a href="http://www.worldhepatitisalliance.org/sites/default/files/resources/documents/WHS2015%20Glasgow%20Declaration%20on%20Viral%20Hepatitis.pdf">Glasgow Declaration</a>, unveiled at the close of the first <a href="http://www.worldhepatitissummit.com">world hepatitis summit</a>, which was held in the city in September. It is an open letter imploring all governments to work together to eliminate viral hepatitis as a public health concern. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/99694/original/image-20151026-18458-1ptzis6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/99694/original/image-20151026-18458-1ptzis6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/99694/original/image-20151026-18458-1ptzis6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=265&fit=crop&dpr=1 600w, https://images.theconversation.com/files/99694/original/image-20151026-18458-1ptzis6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=265&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/99694/original/image-20151026-18458-1ptzis6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=265&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/99694/original/image-20151026-18458-1ptzis6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=333&fit=crop&dpr=1 754w, https://images.theconversation.com/files/99694/original/image-20151026-18458-1ptzis6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=333&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/99694/original/image-20151026-18458-1ptzis6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=333&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">World Hepatitis Summit, September 2015.</span>
<span class="attribution"><span class="source">GCU</span></span>
</figcaption>
</figure>
<p>Will it be heeded? Certainly the declaration has popular support, and the fact that a world hepatitis summit took place at all is an indication that the tide of apathy may be turning on this Cinderella disease. While governments debate which policies to follow in relation to the new hepatitis C drugs, it will be interesting to see how they have reacted to the declaration by the time of the second world summit in Brazil next year. Watch this space.</p><img src="https://counter.theconversation.com/content/48706/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Goldberg has received fees from MSD, Janssen, Abbvie, BMS and Gilead</span></em></p><p class="fine-print"><em><span>Sharon received grants from the Scottish Government during the conduct of the study mentioned in the article. She has in the past received personal fees from Abbvie, Gilead, Janssen, MSD and Roche; and grants from Janssen.</span></em></p><p class="fine-print"><em><span>Hamish Innes does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>New drug combination cures over 95% of cases but the cost would swallow the entire health budget. Pity the politicians that have to figure this one out.Hamish Innes, Researcher, Glasgow Caledonian UniversityDavid Goldberg, Researcher, Glasgow Caledonian UniversitySharon Hutchinson, Professor of Epidemiology and Population Health, Glasgow Caledonian UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/438182015-07-28T07:49:47Z2015-07-28T07:49:47ZHepatitis B in Africa: the challenges in controlling the scourge<figure><img src="https://images.theconversation.com/files/89812/original/image-20150727-7626-ng15gz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Hepatitis B is commonly transmitted between children, who are not aware that they are carrying the virus. </span> <span class="attribution"><span class="source">Thomas Mukoya/Reuters</span></span></figcaption></figure><p>For far too long, viral hepatitis has been neglected by the international community, policy makers, governments, health care providers and the public. </p>
<p>Although the virus was discovered over 50 years ago and an effective <a href="http://www.hepb.org/professionals/hepatitis_b_vaccine.htm">vaccine</a> has been available for more than 20 years, the complications of chronic hepatitis B infection are still the cause of significant illness and <a href="http://www.aho.afro.who.int/en/blog/2014/07/28/hepatitis-silent-killer-african-region-and-worldwide">death</a> in Africa.</p>
<p><a href="http://www.who.int/mediacentre/factsheets/fs204/en/">Hepatitis B</a> is a viral infection that attacks the liver. It can cause both acute and chronic disease such as liver cirrhosis and cancer.</p>
<p>Globally, hepatitis B affects <a href="http://www.who.int/mediacentre/factsheets/fs204/en/">240 million</a> people. Each year an estimated 650 000 people die from hepatitis B related liver disease or liver cancer. In Africa, there are 75 million people affected by the virus. This ranges from about 13.6% of the population <a href="http://www.ajol.info/index.php/njcp/article/view/113608">in Nigeria</a> to 11% in Senegal and 5.7% <a href="http://www.biomedcentral.com/1756-0500/5/55">in Ethiopia</a>.</p>
<p>In <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0075775">The Gambia</a>, hepatitis B related liver cancer is the most common cancer among men and the third most common in women. </p>
<p>A multi-faceted approach is needed to address the challenges that have allowed this virus to continue unabated in African communities decades after it has been controlled in Western populations.</p>
<h2>Why Africa is still gripped by hepatitis B</h2>
<p>There are various reasons why hepatitis B still prevails in Africa. This includes the lack of information about the virus’ transmission, inaccurate estimates of the disease’s burden and insufficient vaccine coverage.</p>
<p>It is well known that the virus is transmitted through contact with the blood or the body fluids of an infected person. However, the role of child to child transmission and mother to child transmission is often underestimated. </p>
<p>Unsafe injections from poorly sterilised needles and re-used equipment are a major source of new infections. According to the World Health Organisation, <a href="http://www.who.int/mediacentre/news/releases/2015/injection-safety/en/">1.7 million people</a> are infected via unsafe injection practices. These include scarification and cultural body-piercing and tattoo practices using razors and similar sharp objects that are contaminated with infected blood.</p>
<p>But there is a great deal we do not know about hepatitis B in Africa. The burden of the infection and associated diseases is not known. </p>
<p>There is inadequate surveillance of the disease’s patterns because many African countries lack the resources for appropriate disease surveillance and documentation. Laboratories are insufficiently equipped and health care services are poor.</p>
<p>Precise data on the huge disease burden would provide the impetus for change, enhance disease awareness and enable better health care planning.</p>
<h2>Vaccination</h2>
<p>There are three integral components to controlling hepatitis B. This includes treating infected individuals, interrupting the spread of the infection transmission and reducing the deaths associated with advanced liver disease and liver cancer.</p>
<p>The hepatitis B vaccine is safe and prevents infection in up to 95% of cases if it is administered in childhood. </p>
<p>In Senegal, vaccinations have reduced <a href="http://journals.lww.com/jcge/Abstract/2004/11003/Global_Epidemiology_of_Hepatitis_B_Virus.8.aspx">infection rates</a> among children from 18.7% to 2.2%. In The Gambia, the infection rate dropped from 10% to less than 1%.</p>
<p>This vaccination is key to preventing new infections. It, however, has no impact on people who already harbour infection. It will also not have an impact on prevalence of hepatitis B virus related liver disease until several decades after it has been introduced.</p>
<p>The cost of the hepatitis B vaccine was a significant obstacle in the worldwide control of the disease. Even at 50 US cents per dose, it was more expensive than other childhood vaccines recommended by the World Health Organisation’s Expanded Programme on Immunisation (EPI). </p>
<p>But with the support of the World Health Organisation and the Global Alliance for Vaccines and Immunisation, many resource poor African countries have recently initiated universal <a href="http://adc.bmj.com/content/100/Suppl_1/S34.full">infant immunisation</a>. They use a single vaccine that prevents five childhood infections, including hepatitis B.</p>
<h2>A paradigm shift in control</h2>
<p>The 2015 World Health Organisation <a href="http://www.who.int/mediacentre/news/releases/2015/hepatitis-b-guideline/en/">guidelines</a> to manage chronic hepatitis B highlight the importance of adopting a simplified public health approach to controlling the virus. </p>
<p>This includes developing publicly-funded screening and treatment programmes and providing universal access to hepatitis B prevention, care and treatment. Scaling up this programme in African countries will do two things. Firstly it will expand access to the general population. And secondly, it will strengthen the diagnostic services and laboratory infrastructure to support care. </p>
<p>Streamlining such viral hepatitis programmes into the existing health programmes around tuberculosis or HIV may allow shared synergies in terms of the programme’s success and limit its costs.</p>
<p>The burden of hepatitis B is high in countries that can ill afford the cost of dealing with hepatitis B. This is a preventable disease and indeed one that can be eradicated by vaccination. There is an urgent need for governments and international stakeholders to increase the <a href="http://www.biomedcentral.com/1472-698X/3/2">funding</a> for hepatitis B in Africa as was done successfully for HIV, tuberculosis and malaria control.</p><img src="https://counter.theconversation.com/content/43818/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Olufunmilayo Lesi does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Hepatitis B vaccines have been available for over 20 years but the virus is still endemic in Africa, with the continent carrying over one third of the globe’s case load.Olufunmilayo Lesi, Associate Professor of Medicine in the College of Medicine, University of LagosLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/314432014-09-10T05:29:56Z2014-09-10T05:29:56ZObesity takes patients one step closer to liver cancer<figure><img src="https://images.theconversation.com/files/58601/original/gvyfgwsz-1410279508.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Too much fat is not good.</span> <span class="attribution"><a class="source" href="http://en.wikipedia.org/wiki/File:Fatmouse.jpg">Human Genome wall for SC99</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>Liver cancer is one of the most deadly diseases in the world with around 700,000 patients being diagnosed and more than 600,000 patients dying of the disease annually, according to the <a href="http://www.cancer.org/cancer/livercancer/detailedguide/liver-cancer-what-is-key-statistics">American Cancer Society</a>. It is more common in the sub-Saharan and southeast-Asian countries, where hepatitis and alcohol abuse are the main causes. These two factors trigger liver cirrhosis, leading to cancer.</p>
<p>The deadly disease is now spreading to rich countries. What is particularly disturbing in there is that about 40% of the patients get liver cancer without viral infection or symptoms of alcohol abuse. But they were obese and had an intense form of fatty liver disease called non-alcoholic steatohepatitis, or NASH.</p>
<p>However, obesity alone cannot explain the cause of liver cancer. If it was the only risk factor, there would have been a lot more instances of liver cancer in obese patients than normal patients. But that wasn’t the case. </p>
<p>Michael Karin, professor of pharmacology, University of California at San Diego wanted to find out the exact link. In an experiment with mice, he noticed that obese mice eating a diet rich in fat did not suddenly develop liver cancer. Yet, these obese mice had a higher risk of liver cancer if they were exposed to some sort of cancer causing agent such as a chemical called diethylnitrosamine. He started looking for a naturally occurring risk factor that could tilt the balance from mere liver damage to liver cancer.</p>
<p>Karin suspected that a phenomenon called endoplasmic reticulum (ER) stress may have a role to play. ER stress happens whenever the cells of the liver have to work extra hard to produce more proteins. After the proteins are made, they are neatly shaped into their proper form. If there are too many proteins being made at the same time, the cell doesn’t have enough machinery available to package the proteins and it goes then into panic mode, known as ER stress.</p>
<p>Conditions such as hepatitis, diabetes or even long-term obesity in the patient can cause ER stress. Karin wanted to confirm whether ER stress pushed obese mice first towards intense fatty liver state, or NASH, and then ultimately towards liver disease.</p>
<p>Karin used a mutant strain of mice whose liver cells could artificially be made to temporarily undergo ER stress. The liver cells of these mutant mice produce an enzyme called urokinase plasminogen activator that causes ER stress. The enzyme stays within the cells for some time and then gets degraded, relieving ER stress. So the mice are completely healthy with no liver problems.</p>
<p>But Karin found that when the ER-stressed mice were fed a diet rich in fat, unlike the normal mice that simply turned obese, these mice started accumulating a lot of fat in their livers. Instead of temporary ER stress, the liver cells of these mice showed persistent signs of ER stress throughout their life, undergoing slow damage and death, eventually leading to liver tumours. Their results have been published in the journal <a href="http://dx.doi.org/10.1016/j.ccr.2014.07.001">Cancer Cell</a>.</p>
<p>However, it is not all bad news. Karin noticed that if he could stop the process whereby ER stress causes inflammation and damage in the livers, the tumours stopped growing. He achieved this by blocking signalling molecules of the TNF pathway. The molecules of this pathway attract white blood cells called macrophages into the liver, causing inflammation. </p>
<p>On blocking signalling through the TNF pathway, he noticed that the liver stored less fats, making the mice look healthier. Karin thinks that drugs blocking this pathway, along with surgery and chemotherapy could be the answer to keep liver cancer under check in obese patients.</p><img src="https://counter.theconversation.com/content/31443/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anwesha Ghosh does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Liver cancer is one of the most deadly diseases in the world with around 700,000 patients being diagnosed and more than 600,000 patients dying of the disease annually, according to the American Cancer…Anwesha Ghosh, PhD student in Biology, University of RochesterLicensed as Creative Commons – attribution, no derivatives.