Alpha-fetoprotein (AFP) is a blood-based biomarker that’s used together with ultrasound to detect liver cancer, but it’s by no means a perfect test. Experts are hopeful that emerging, specific blood-based biomarkers will prove useful in liver cancer surveillance — potentially as stand-alone tests.

In these series of videos produced by the limbic, A/Prof. Simone Strasser and A/Prof. Jessica Howell discuss:

• how changes in the epidemiology of advanced liver disease – both in Australia and globally – present challenges to the surveillance and monitoring of hepatocellular carcinoma
• discuss ways that specialists can ensure at-risk patients are undergoing surveillance for HCC
• current and future approaches to HCC surveillance and monitoring

Watch the videos below:

The changing epidemiology of advanced liver disease and HCC

HCC surveillance in at-risk patients

Limitations of current HCC surveillance strategies and future solutions

Hepatocellular carcinoma (HCC) is largely preventable, with decades of time to intervene, yet millions still die from it. It is however not incomprehensible why this happens. The journey from liver disease to liver cancer is complex—a myriad of broken healthcare systems, patient behaviors, cultural influences, stigma, funding, and limited healthcare professional (HCP) capacity. At first glance, it seems overwhelming, leaving us with the question—where should we intervene?

Some cancers like breast cancer have high incidence but comparatively low mortality¹. Liver cancer is the opposite; it often goes undetected until it reaches a late stage, resulting in dismal prognosis. Late presentation is a top issue in liver cancer. Without pain receptors, the liver has minimal symptoms until it is damaged beyond cure. People usually die within 6 – 22 months of a late-stage HCC diagnosis.² HCC is known as the ‘silent killer’ and is typically diagnosed at a late stage, which has a <5% 5-year survival rate. If diagnosed early, the 5-year survival rate increases to 40 – 70%.^3&4

Given the complexity, there is no single solution. Rather, it will take concerted action from multiple stakeholders in the system to bring about positive change. That said, there are logical places to start. First, we need to understand the ecosystem. An ecosystem represents factors required to deliver a service, in this case, liver care. It helps identify solution, scope, and strategy by providing a holistic view of actors, processes, flow, influence, and relationships.

Hepatitis B and C are the major causes of chronic liver disease and liver cancer in the world. An ongoing infection causes inflammation in the liver. This extended inflammation can cause scarring, called cirrhosis, and can ultimately lead to liver cancer. The Asia-Pacific region bears the highest overall burden of HBV, with 59% of those living with chronic HBV, 26% of new infections, and 79% of deaths.⁵ Given the shifting etiology with rising fatty liver disease, there is a pressing need to re-assess risk factors and stratify patients to ensure we are not failing to detect. Being able to optimize surveillance protocols based on patient risk will improve efficiency and ability to catch early HCC and drastically improve survival.

To further maximize the benefit of a surveillance program, or any other initiative, it is important to consider surrounding opportunities up- and down-stream. For example, surveillance programs will benefit from upstream awareness efforts to improve throughput, and down-stream availability of treatments. This paper provides an appreciation for the end-to-end patient journey and their needs along the way. Fundamentally, it advocates for the improvement of human life in the midst of receiving liver care, both clinically and experientially.

From the research, a central theme emerged – ultrasound used in HCC surveillance is a major bottleneck. It is the cause of delayed or even missed diagnosis, and stark inequities in care. Biomarkers such as PIVKA-II complementing AFP show promise in lessening this problem while also offering improved sensitivity and specificity for HCC detection.

This White Paper intends to facilitate concerted action among HCPs, patient advocacy groups, payers, and policy makers to reduce liver cancer incidence and mortality in APAC. It shares both holistic ecosystem and detailed human-centric insights as a starting point for change. Working with Key Opinion Leaders (KOLs) we provide tangible examples of active initiatives, and recommendations for taking the next steps.

Download or read the white paper below to find out more.

Stay tuned for interviews with select KOLs featured in the white paper, as they share about their insights and learning points on the initiatives piloted in their country.

Quick Summary

HCC is a leading cause of cancer mortality in Asia. Causes of HCC include viral hepatitis B and C infections, with recent increases in metabolic disorders, such as NAFLD, also playing a factor.

Early HCC interventions are highly effective and can lead to improved patient outcomes and survival. Therefore, HCC surveillance programs are pivotal in detecting HCC early and making the appropriate interventions.

In this whitepaper, HCC surveillance programs in Asia were analysed. The learnings from well established HCC surveillance programs in Asia, as well as the challenges in areas that have not implemented such programs have highlighted 7 priorities for implementing an HCC surveillance program:

1. Include HCC surveillance in national program and strategic plans
   HCC surveillance programs should be fit into the national health strategy where appropriate, taking into account the local incidence and prevelance rates, and existing priorities and resources.
2. Secure sustainable funding commitments
   Long-term resourcing and financing is key to making HCC survaillance programs successful. The current health financign system in the area, and ability to pay should be assessed, while exploring various funding methods such as centralised healthcare coverage or private insurance.
3. Collect, analyse, and utilise data to inform program design
   The development of HCC surveillance program should be based on data, such as HCC epidemiology, patient outcomes, human and economic cost of HCC. These data should be collected and analysed.
4. Adopt optimal technologies to advance HCC surveillance
   Technology can help to improve access to HCC surveillance programs, as well as improve patient outcomes by detecting HCC early. Some examples include: including additional biomarkers such as PIVKA-II, using biomarker based digital algorithms and diagnostic models, using more advanced imaging techniques, and adapting IT systems to support surveillance programs.
5. Mobilise existing resources for HCC surveillance
   Tapping on exisiting resources to expand capacity for HCC care and surveillance., For example increasing the range of HCPs who can diagnose and manage HCC like primary and community HCPs, expanding private healthcare capacity in HCC care.
6. Engage a broad spectrum of stakeholders to further surveillance goals
   Governmental decision-makers, physicians, patients and PAGs, payers and industry need to come together to drive implementation of a robust HCC surveillance programs that address needs of all stakeholders.
7. Raise awareness and provide education on the need for HCC suveillance
   Raising the knowledge among the general population and HCPs on HCC and the importance of surveillance can improve uptake and compliance to surveillance programs.