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

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Presentation on theme: "Impact and Scope of HBV and Liver Cancer in the API Community Samuel So, MD, FACS Lui Hac Minh Professor Director, Asian Liver Center Director, Liver Cancer."— Presentation transcript:

1 Impact and Scope of HBV and Liver Cancer in the API Community Samuel So, MD, FACS Lui Hac Minh Professor Director, Asian Liver Center Director, Liver Cancer Program Stanford University School of Medicine

2 Hepatitis B is the Most Common Serious Liver Infection in the World million people worldwide have chronic HBV infection (compare with 40 million living with HIV) 1,2 Without appropriate treatment or monitoring, 1 in 4 person with chronic HBV infection will die of liver cancer, cirrhosis or liver failure HBV takes a 700,000- a million lives a year 1,2 Preventable with a vaccine available for over 25 years Millions worldwide are infected every year without vaccination 1 CDC. Available at: 2.WHO. Available at:

3 Hepatocellular Carcinoma (HCC) from a Global Perspective Ranks 4 th in cancer incidence and 3 rd in cancer mortality Takes about 600,000 lives a year HCC is largely preventable (80% caused by chronic HBV, 15% chronic HCV) Other risk factors: cirrhosis of any etiology (risk of HCC increases to 1-6% per year with cirrhosis Alcohol Viral hepatitis Metabolic diseases (hemochromatosis, tyrosinemia) aflatoxins

4 HBV is Transmitted the Same Way as HIV 1 Birth: From an infected mother to newborn at birth (accounts for % of the cases in Asia) Blood: Direct contact with infected blood Unsafe injections and transfusions Sharing or reusing needles or syringes Open wound contact Sex: Unprotected sex US Incidence of chronic HBV: same as HIV 1 CDC. Available at: HBV is up to 100x more Infectious than HIV

5 HBV is not transmitted by food or casual contact Sharing food or drinks Kissing Shaking Hands Sneezing

6 HBsAg Prevalence High >8% Intermediate 2-7% Low <2% Geographic Distribution of Chronic HBV Infection 1 Goldstein ST, et al. J Infedct Dis. 2002;185: Kim WR, et al. Hepatology. 2004;39: WHO. Available at:

7 Connecting the Dots between HBV and Liver Cancer At a time when the world thought chemicals like aflatoxins is the cause of liver cancer Dr. Beasley, his co-investigator Dr. Lu- yu Huang and Taiwan team of investigators conducted a study of over 22,000 government workers found Risk of liver cancer is 60 times higher in chronic HBV infected persons (which is higher than the association between lung cancer and smoking …20-25 times) Life time risk of dying from liver cancer is 40% in men and 15% in women R. Palmer Beasley, MD

8 Hepatitis B is the Most Common Cause of Liver Cancer in the World Chronic hepatitis B infection is the cause of about 80% of primary liver cancer in the world 1 Risk of HCC in persons with chronic HBV (HBsAg positive) is as high as 0.5% per year Second only to tobacco in causing the most cancer deaths worldwide 1 The World Health Organization named the hepatitis B vaccine “The First Anti-Cancer Vaccine” 1. WHO. Available at:

9 There is now Irrefutable Evidence that Chronic Hepatitis B Causes Liver Cancer In 1997, Taiwan reported a significant drop in liver cancer rates in children under 15 years of age after the adoption of a national universal newborn vaccination program In 2005, HBV was officially recognized as one of 58 known agents that cause human cancer (11th Report on Carcinogens, U.S. Dept of Health and Human Services, National Toxicology Program) Source: Chang MH et al. N Engl J Med. 336(26):1855-9,1997

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11 Comparing HBV and HIV in China HIV 1 HBV 2 650,000 with HIV in % of population 130 million with chronic HBV 10% population 1 Z Sun et. al., J Med Virol 2002, 67: UNAIDS/WHO Epidemiological Fact Sheet accessed at /3by5/support/efs2004_chn.pdf

12 China has the Greatest Burden of Hepatitis B and Liver Cancer in the World 1/3 of the world’s chronic HBV patients live in China million Chinese (1 in 10) have chronic hepatitis B 1 China accounts for about 55% of the 600,000 worldwide deaths from liver cancer each year HBV kills an estimated half a million mainland Chinese each Year 2 1 WHO. Available at: 2 Z Sun et. al., J Med Virol 2002, 67:

13 No HBV Awareness Posters in China! Discrimination of those with HBV is widespread Only adopted National newborn vaccination program in 2002

14 China reported 14 deaths from avian flu between /14/2006 Preparing to vaccinate every bird against avian flu Vaccinate every person against HBV is more urgent!

15 HCC in the US Estimated incidence for 2006: 18,510 new cases 16,200 deaths (44 deaths/day) Source: Cancer Facts & Figures 2006, American Cancer Society

16 Chronic HBV and HCC is the Greatest Health Disparity between Asian and Caucasian Americans Chronic hepatitis B (1 in 10 Asians) 10% of Asian-Americans vs. 0.1% of Caucasian Americans 1.4 million people chronically infected in U.S. Over 60% are Asian-American HCC incidence (up to 9x higher for Asians compare with white Americans) HCC is the second leading cause of cancer death in Asian men living in the US

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

18 HBV and Liver Cancer is the Greatest Health Disparity Between Asian and White Americans 1,2 Maternal race/ethnicity2002 Births Estimated maternal HBsAg Prevalence Estimated Births to HBsAg positive women White, non-Hispanic2,298, % 2,988 Hispanic 876, % 789 African American 593,6910.5% 2,968 Asian Pacific Islander Foreign born US born 175,264 35, % 1.4% 15, Other 42,3300.5% 212 Total4,021,72623, Asian Liver center 2. Draft ACIP hepatitis B recommendations, CDC 2005

19 Prevalence of Adult (mostly foreign born) API positive for HBsAg in the US 1.Guan R et al. Hepatology 40 (S4): 716A, Chao S. et al. Hepatology 40 (S4): 717A MMWR 55(18): , 2006

20 Source: California Cancer Facts & Figures 2005, American Cancer Society Five Most Common Cancers in Males by Race/Ethnicity California, Rank Asian Laotianliverlungstomachcolorectaloral Cambodianlunglivercolorectallymphomaoral Vietnameselungliverprostatecolorectalstomach Chineseprostatecolorectallungliverstomach Koreanlungstomachcolorectalprostateliver Filipinoprostatelungcolorectallymphomaliver Non-Asian Whiteprostatelungcolorectalbladdermelanoma Hispanicprostatecolorectallunglymphomaleukemia Blackprostatelungcolorectallymphomaoral

21 Trends in 5-Year Survival by Year of Diagnosis in the U.S. Site Breast cancer 75%78%87% Colon cancer 51%58%62% Prostate cancer 67%75%98% Liver cancer 4%6%7%

22 In the U.S.: Liver Cancer Mortality Asians vs. All Races Source: National Cancer Institute – Surveillance Epidemiology and End Results

23 Chronic Hepatitis B is a Silent Killer in the Asian American community 1 Many people don’t know they have been infected Many feel perfectly healthy Routine liver function blood test are often normal Doctors and patients are then fooled that everything is OK If you wait for symptoms (jaundice, pain or swollen belly), it is often too late 1. Asian Liver Center. Available at:

24 Many hepatitis B carrier don’t know that you could have developed a large liver cancer without any symptoms 35 years old Asian American Engineer, Hepatitis B carrier with no symptoms: 14 cm Liver Cancer

25 Liver Cancer Often Strikes at the Prime of Life (35-65 years of age) Brothers in their 30s found to have liver cancer at the same time

26 Dr. Mark Lim Internist “Healthy hepatitis B carrier” Diagnosed with advanced liver cancer at 31years of age Died before 32nd birthday Engardio. San Francisco Chronicle, 2003 Many Doctors do not know about the Importance of Regular Screening for Liver Cancer

27 Many doctors we are training are not aware of the prevalence and risks of chronic HBV (including liver cancer) Survey of Knowledge and Screening Practices of Incoming Housestaff to Stanford Medical Center in 2003 Only 53.5% of incoming PGY-1 were aware Asian Americans has the highest incidence of HBV Only 27.4% knew about the 1 in 4 risk of dying from liver cancer or cirrhosis Only 40% recognized perinatal transmission is the major mode of transmission in Asians 27.1% will order an HBV screening test for Asians

28 It is important to promote awareness and testing of all Asian Americans for HBV Screen for the 1 in 10 API who don’t even know they have been chronically infected Vaccinate those who are not protected “First anti-cancer vaccine” For those who test positive for HBsAg, even though there is no cure Appropriate HBV treatment can reduce risk of liver cancer and cirrhosis regular screening for liver cancer can lead to early detection and successful removal of the cancer

29 Early detection by regular screening is the only way to improve HCC survival 1 Small 1.2 cm HCC detected on routine screening in “healthy” 53 year old Asian HBV carrier with normal AFP and ALT Arterial phase CT Venous phase CT 1 Yang B et al. J Cancer Res and Clin Oncol, 123:375, 1997

30 California Initiative First California Liver Cancer Control Plan (partners include ACS & Dept of Health), that by 2010 all Asians in California should be tested for HBV Aim to have 99% of Asians vaccinated if they are not protected Improve liver cancer survival by 20%

31 First National Hepatitis B Bills (H.R. 4550, S. 3558) (Introduced with bipartisan sponsorship on Dec 2005 in Congress, and June 2006 in Senate) Partners include Congressmen Honda and Charlie Dent, Senators Feinstein and Santorum, AAPCHO, ALF, NYU, Hepatitis International, Hepatitis B Foundation Establish and implement a comprehensive HBV prevention, education, research and medical treatment program Reduce liver cirrhosis and cancer incidence, and improve liver cancer survival caused by chronic HBV infection Write to your Representatives In Congress and Senate!

32 Goals of Healthy People 2010 Increase quality and years of healthy life Eliminate health disparities It’s time to UNITE and ACT NOW to eliminate HBV and liver cancer in the API communities!


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