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 year1,2
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 4th in cancer incidence and 3rd in cancer mortality
Takes about 600,000 lives a year
HCC is largely preventable (80% caused by chronic HBV, 15% chronic HCV)
Other risk factors:
cirrhosis of any etiology (risk of HCC increases to 1-6% per year with cirrhosis
Alcohol
Viral hepatitis
Metabolic diseases (hemochromatosis, tyrosinemia)
aflatoxins

4. HBV is Transmitted the Same Way as HIV 1
Birth: From an infected mother to newborn at birth (accounts for 40-50% of the cases in Asia)
Blood: Direct contact with infected blood
Unsafe injections and transfusions
Sharing or reusing needles or syringes
Open wound contact
Sex: Unprotected sex
US Incidence of chronic HBV: same as HIV
HBV is up to 100x more
Infectious than HIV
1 CDC. Available at:

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

6. Geographic Distribution of Chronic HBV Infection
High >8%
HBsAg Prevalence
Intermediate 2-7%
Low <2%
1 Goldstein ST, et al. J Infedct Dis. 2002;185:
2 Kim WR, et al. Hepatology. 2004;39:
3 WHO. Available at: 36

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 world1
Risk of HCC in persons with chronic HBV (HBsAg positive) is as high as 0.5% per year
Second only to tobacco in causing the most cancer deaths worldwide1
The World Health Organization named the hepatitis B vaccine “The First Anti-Cancer Vaccine”
1. WHO. Available at:

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

11. Comparing HBV and HIV in China HIV1 HBV2
650,000 with HIV
in 2005
0.05% of population
130 million with chronic HBV
10% population
1 Z Sun et. al., J Med Virol 2002, 67:
2 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 China1
130 million Chinese (1 in 10) have chronic hepatitis B1
China accounts for about 55% of the 600,000 worldwide deaths from liver cancer each year
HBV kills an estimated half a million mainland Chinese each Year2
1 WHO. Available at:
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. Vaccinate every person against HBV is more urgent!
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 Americans1,2
Maternal race/ethnicity
2002 Births
Estimated maternal HBsAg Prevalence
Estimated Births to HBsAg positive women
White, non-Hispanic
2,298,156
0.13%
2,988
Hispanic
876,642
0.09%
789
African American
593,691
0.5%
2,968
Asian Pacific Islander
Foreign born
US born
175,264
35,643
8.9%
1.4%
15,598
499
Other
42,330
212
Total
4,021,726
23,054
1. 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
Guan R et al. Hepatology 40 (S4): 716A, 2004
Chao S. et al. Hepatology 40 (S4): 717A 2004
3. MMWR 55(18): , 2006

20. Five Most Common Cancers in Males by Race/Ethnicity
California,
Rank 1 2 3 4 5
Asian
Laotian
liver
lung
stomach
colorectal
oral
Cambodian
lymphoma
Vietnamese
prostate
Chinese
Korean
Filipino
Non-Asian
White
bladder
melanoma
Hispanic
leukemia
Black
Source: California Cancer Facts & Figures 2005, American Cancer Society

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%
98%
Liver cancer 4% 6% 7%

22. Liver Cancer Mortality Asians vs. All Races
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 community1
Many people don’t know they have been infected
Many feel perfectly healthy
Routine liver function blood test are often normal
Doctors and patients are then fooled that everything is OK
If you wait for symptoms (jaundice, pain or swollen belly), it is often too late
1. Asian Liver Center. Available at:

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

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 survival1
Small 1.2 cm HCC detected on routine screening in “healthy” 53 year old
Asian HBV carrier with normal AFP and ALT
Arterial phase CT
Venous phase CT
1 Yang B et al. J Cancer Res and Clin Oncol, 123:375, 1997

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!