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THE theme for 2015 World Cancer Day on 4 February is “Not beyond us”, emphasising that solutions to the increasing global burden of cancer exist, and can be achieved using tools that are available today.
Australia has made significant progress in reducing cancer-related mortality. Between 1991 and 2010, the age-standardised mortality rate for all cancers combined fell by 17%, as did the individual rates for many cancers. In contrast, only one major type of cancer demonstrated a significant increase in age-standardised mortality — liver cancer.
Liver cancer survival remains low. The median survival is around 1 year and the 5-year survival is less than 20%. Most liver cancer is caused by chronic viral hepatitis, which affects approximately 450 000 Australians. More than half of these individuals are believed to be in a “liver danger zone”, where the risk of developing advanced liver disease and liver cancer increases substantially.
Although serological testing for hepatitis B has been available for more than 40 years, and national policies recommend routine testing for priority populations, it is estimated that only just over half of the more than 220 000 Australians living with hepatitis B have been diagnosed.
Even for those who have been diagnosed, uptake of treatment and care remains low, with 87% not receiving recommended monitoring, and only around 5% receiving antiviral therapy. This is despite increasing evidence that appropriate antiviral treatment substantially reduces liver cancer incidence in people living with hepatitis B.
What can be done?
Australia’s Second National Hepatitis B Strategy 2014-2017 sets clear targets for addressing this chronic disease, and calls for increased support for GPs to diagnose, monitor and treat chronic hepatitis B. In July last year the Australian Government announced $4.6 million would be invested in increasing access to testing and treatment; however, details on how and when this funding will be made available remain uncertain.
In the meantime, there are a number of things Australian doctors can do to address the increasing number of hepatitis B-related deaths, such as knowing who to test and offering testing.
The priority populations affected by chronic hepatitis B include people born overseas in endemic areas (including Asia, the Pacific and Sub-Saharan Africa), and Aboriginal and Torres Strait Islander people, who together represent two-thirds of those living with hepatitis B in Australia. Further details on indications for testing are available in the National Hepatitis B Testing Policy and in the B Positive resource.
Taking a systematic approach to testing will make interpretation of results straightforward.
Any person living with hepatitis B should have a liver check-up, at least annually, including a HBV DNA viral load (which is available on Medicare). Patients previously diagnosed and not being monitored should be re-engaged as we now know there is no such thing as a healthy carrier of hepatitis B. Short videos for patients explaining the purpose of liver check-ups are available.
Appropriate antiviral treatment reduces the risk of progressive liver disease and liver cancer, and can even lead to regression of fibrosis in cirrhotic patients. Hepatitis B antivirals are available on the Pharmaceutical Benefits Scheme and negotiations to introduce S100 prescribing by GPs and dispensing in community pharmacies are ongoing.
Although substantial increases in access to testing, monitoring and treatment of hepatitis B in general practice will be required, the tools to do so are available today.
Preventing hepatitis B-related liver cancer is truly not beyond us.
Associate Professor Benjamin Cowie is an infectious diseases physician with the Victorian Infectious Diseases Service, Royal Melbourne Hospital, and an epidemiologist at the WHO Regional Reference Laboratory for Hepatitis B, Victorian Infectious Diseases Reference Laboratory, The Doherty Institute.
Rob, I totally agree that universal infant vaccination against hepatitis B, including a birth dose, is critical for achieving eradication of this illness. Prevention of early childhood hepatitis B infection in our region will surely be counted among the great public health success stories of the last 20 years, with millions of future deaths having already been averted.
However vaccination cannot help the 250 – 350 million people already chronically infected worldwide, anywhere between 30 and 70 million of whom will die of liver cancer or liver failure in coming decades without appropriate care and treatment. In the most recent Global Burden of Disease Study published in the Lancet in December 2014, over 650,000 people were estimated to die due to hepatitis B in 2013. When hepatitis B and C are considered together, these viral infections are now estimated to cause more deaths globally than HIV/AIDS.
While prevention, including vaccination, must clearly remain our primary control strategy, we cannot ignore the imperative to scale up access to diagnosis, treatment and care for hepatitis B in populations where this access is unacceptably low – including here in Australia.
Hepatitis B is an eradicable disease. The 37 countries of the Western Pacific Region (which stretches from Mongolia to New Zealand, and western China to Polynesia, and includes Australia) have a goal to eradicate hepatitis B in the Region, and we are making excellent progress (see http://www.wpro.who.int/entity/hepb_control/en/). When we started the programme, about 9% of under 5 year old children in the Region were seropositive for hepatitis B, we are now under 2%, and we are aiming for less than 1% by 2017. The disease is now distinctly rare in formerly high incidence countries like Korea. While treatment is important, prevention is crucial, and a birth dose of hepatitis B vaccine, followed by a schedule of 3 further doses provides lifelong protection. If we immunize all children, we can consign hepatitis B to the dustbin of history within a generation, and treatment will be unnecessary.