Policy priorities

In order to halt the growing burden of liver cancer a comprehensive national liver cancer control strategy needs to be developed and implemented. A strategy would build on and strengthen existing frameworks in hepatitis B virus (HBV) and hepatitis C virus (HCV) prevention and control, primary care, hepatocellular carcinoma Optimal Care Pathway and include routine reporting and evaluation. Prioritising ‘best buy’ interventions to reduce liver cancer incidence and mortality in the next five- and 10-year periods is an urgent area for government action.

In the absence of a national liver cancer control strategy, Cancer Council recommends optimising uptake of HBV vaccination in high-risk populations, improving access to diagnosis and treatment for individuals with HBV and HCV and implementing a liver cancer surveillance program in high risk individuals.

Develop and implement national liver cancer control strategy

Increase awareness of risk factors for liver cancer

Low awareness and understanding of viral hepatitis are associated with increased risk of transmission (Balfour 2009), lower likelihood of vaccination^[1], underutilisation of treatment options^[2] and lower likelihood of cancer screening^[3].

As such, increasing awareness of viral and non-viral risk factors associated with liver cancer is essential to reduce the future burden of liver cancer in Australia. An adequately funded public education campaign targeted at high-risk groups is required to increase awareness of risk factors for liver cancer.

Optimise hepatitis B vaccine coverage in high-risk populations

Chronic HBV infection is considered endemic in Aboriginal and Torres Strait Islander communities due to poor vaccine uptake and incomplete vaccination. Low vaccination coverage in populations at risk^[4] has been attributed to a lack of awareness, failure by health professionals to identify and offer vaccinations to at-risk persons, the cost of accessing the HBV vaccine (the vaccine is free in some jurisdictions, but there is often a consultation fee) and failure to complete the full course of three doses.

In Australia, the groups at highest risk of liver cancer due to chronic hepatitis also face the greatest barriers to accessing services. Aboriginal and Torres Strait Islander and some migrant groups face barriers related to cultural, linguistic and/or religious differences, poverty, distance and low literacy. As such, strategies to increase vaccination should be sensitive to culture, religion and in a language that is understood by the target population. Targeted education strategies are key to improving awareness of the benefits of the vaccination for high-risk populations. Better awareness about the benefits of vaccination would likely encourage individuals to seek advice from their health care practitioners. The use of bilingual health promotion officers may be pivotal in helping high-risk populations understand the benefits of vaccinations and the importance of completing a full course. Aboriginal Health Workers may help promote the benefits of completing a full course for Aboriginal and Torres Strait Islander populations. Given the limited evidence of effective strategies targeting priority populations, further research and evaluation to build and share knowledge is recommended.

Primary health care practitioners (especially general practitioners) have a central role in identifying and offering vaccinations to high-risk individuals and should be supported to do this. Options include providing incentives to general practitioners for vaccinating high-risk individuals.

Improve access to treatment for individuals with viral hepatitis B and C

It is estimated that 39% of people with chronic HBV and 20% of people with chronic HCV remain undiagnosed^[5]. Only a small proportion of those who have been diagnosed with chronic hepatitis have received appropriate treatment^[5][6].

Targeted education strategies are also essential to encouraging individuals infected with viral hepatitis to access treatment. Australian modelling has shown that antiviral treatment for chronic HBV is a highly cost-effective way to prevent liver cancer^[7]. A pilot study conducted in NSW demonstrated that general practitioners who were supported to test and manage chronic HBV increased their patients’ uptake of antiviral treatment to rates which were the highest in the country^[8].

One option for increasing access to treatment is to make therapies available outside tertiary centres, that is through primary care and community-based health centres, methadone clinics and other settings. Shifting treatment and care to primary care settings has further potential to increase treatment and follow-up care; especially in rural areas and in a number of high-risk groups. Targeted education and awareness strategies are also essential to encouraging individuals infected with viral hepatitis to access treatment and care.

Improved therapies with lower toxicity and shorter treatment regimens have revolutionised HCV treatment in Australia, with more people having been treated since March 2016 than in the two decades prior. There is a need to raise awareness of the impact of co-factors such as obesity, and alcohol consumption, and the importance of making healthy lifestyle choices to prevent progression to liver cancer, especially among people infected with viral hepatitis.

Implement a liver cancer surveillance program

The key to improving survival for liver cancer is surveillance of high-risk populations allowing for early diagnosis and treatment. Australia currently does not have evidence-based clinical practice guidelines for the prevention and early detection of liver cancer; nor a formal liver cancer surveillance program. The Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine recommends that patients with chronic HBV who have cirrhosis, and other patients with chronic HBV at high risk (determined by family history, ethnicity, age, and sex) be screened with ultrasonography with or without alpha-fetoprotein (AFP) testing every 6 months^[6]. Biannual ultrasound screening is recommended for patients with HCV who have cirrhosis^[9]. The American Association for the Study of Liver Diseases have the same recommendations^[10][11] and with the Infectious Disease Society of America, has made additional recommendations for screening patients with HCV and advanced liver fibrosis^[12]. Similarly, the European Society for Medical Oncology suggests using the same strategy to screen patients who have chronic HBV and cirrhosis or other additional risk factors or have HCV with bridging fibrosis as they are at a higher risk of developing liver cancer than the general population^[13].

Large-scale studies show that surveillance is correlated with significantly better survival outcomes when compared with no surveillance for patients with chronic hepatitis^[14] and patients with cirrhosis^{[15] [16]}. Among patients with cirrhosis, surveillance also improves likelihood of being diagnosed at an earlier stage and undergoing curative treatment^[17].

Surveillance for liver cancer is the accepted standard of care internationally and in Australia for people with chronic HBV and HCV in at-risk groups. Japan has demonstrated a successful model of national liver cancer surveillance which has drastically improved survival rates^[18]. National surveillance for liver cancer has resulted in high detection rates of early stage disease (62% in Japan compared to 30% in Western countries) ^[18]. Liver cancer surveillance in Japan is supported by registries and public education campaigns to increase awareness among high-risk groups.

The number of people requiring liver cancer surveillance in Australia is unknown, however, a population-based study estimates show that around 79% of participants with chronic HBV in a targeted geographic area require liver cancer surveillance^[8].

A liver cancer surveillance program could monitor those at highest risk and allow for early diagnosis and treatment. Population-based registries and targeted communications supporting a surveillance program are required for the greatest benefit. Targeted media campaigns should focus on increasing awareness of risk factors for viral hepatitis in high risk groups and encourage them to see their general practitioner. Priority groups such as people born overseas in high-prevalence areas, and Aboriginal and Torres Strait Islander people would benefit from a liver cancer surveillance program. The implementation of a national surveillance program is an urgent priority area for action in order to address increasing numbers of liver cancer deaths.

Surveillance strategies for patients at high-risk of liver cancer, caused by non-viral factors, are less clear. NAFLD-related cirrhosis is a risk factor for liver cancer; however, liver cancer has also been observed in NAFLD patients in the absence of cirrhosis, but at lower rates^[19][20][21]. As the incidence of NAFLD-related liver cancer is predicted to rise, along with obesity rates, optimal surveillance strategies should be investigated to reduce cancer burden^[22].