How common is liver cancer in Australia?

In Australia, both the incidence and mortality rates of hepatocellular carcinoma (HCC) have been increasing over several decades, and the overall 5-year survival rate currently sits at about 23%.^1,2,3

The increasing rates of HCC in Australia are thought to reflect:^2,4

• revised diagnostic criteria;
• an increased at-risk population due to migration; and
• a rise in metabolic dysfunction-associated fatty liver disease due to rising obesity rates.

You can find out more about liver cancer epidemiology here.

Who’s at increased risk of liver cancer?

We know that patients at risk of hepatocellular carcinoma are those with:⁴

• liver cirrhosis;
• chronic hepatitis B or hepatitis C infection;
• alcohol-related liver disease (ARLD); and
• metabolic dysfunction-associated fatty liver disease (MAFLD).

People with cirrhosis make up 85% to 90% of those diagnosed with HCC.¹

HCC is also disproportionately high among Aboriginal and/or Torres Strait Islander people and migrants to Australia from countries where viral hepatitis is endemic.⁴

Why is liver cancer surveillance so important?

Low 5-year survival rates in people with liver cancer are related to many patients being diagnosed with late-stage disease.⁴ Surveillance of our at-risk patients aims to detect HCC early, when curative treatment is still possible.⁴

HCC surveillance programs aim to improve the rates of early detection and curative treatment of HCC, as well as overall survival in people with cirrhosis.⁴

Who should be tested and what tests are needed for people at risk of liver cancer?

Liver ultrasound is the current standard of care for HCC surveillance – in general, testing should be done every 6 months in people at high risk of liver cancer.⁴

A blood test looking for the tumour biomarker alpha-fetoprotein (AFP) can be used in addition to ultrasound to help improve detection rates.^2,4

HCC surveillance in people with cirrhosis

Surveillance should be offered to people with cirrhosis who are:

• willing to have an HCC diagnosis made and consider treatment if HCC is diagnosed;and
• suitable – well enough to receive HCC treatment and with a life expectancy greater than 6 months.⁴

HCC surveillance in people without cirrhosis

Surveillance is also recommended for some people with chronic hepatitis B (HBV) infection without cirrhosis. Factors such as age, ethnicity and family history also need to be considered in these patients.

According to Cancer Council Australia Guidelines, surveillance is generally recommended for the following people with chronic HPV infection without cirrhosis:^2,4

• Asian or Pacific background men aged 40 years or older
• Asian or Pacific background women aged 50 years or older
• Sub-Saharan African people aged 20 years or older
• Aboriginal and/or Torres Strait Islander people aged 50 years or older
• Aboriginal and/or Torres Strait Islander people with a family history of HCC
• Anyone aged 40 years or older with a family history of HCC

See the Cancer Council Guidelines for more detailed information on HCC surveillance.^1,4

Risk assessment for surveillance

Before surveillance is offered, it’s best to perform an individual risk assessment and discuss the risks and benefits with your patient. It’s important to ensure that they are willing to participate in ongoing surveillance.⁴

Patient factors that need to be considered include:⁴

• age;
• family history of HCC;
• individual risk factors;
• ethnocultural group/region of birth;
• comorbidities;
• functioning (ECOG performance status scale); and
• liver-related health status.

Future considerations for surveillance testing

Unfortunately, there are some barriers to surveillance uptake.² The effectiveness of HCC surveillance can also be impacted by the limitations of the current tests and under-recognition of patients at risk.²

In 2023, the Cancer Council and Daffodil Centre published a report called ‘ Roadmap to Liver Cancer Control in Australia’. This document outlines priority actions for targeted screening for advanced liver disease and HCC surveillance.⁵

One of the priority actions identified for primary care is improved systems for surveillance, including patient recall and abnormal-results notification systems.⁵

Future improvements in HCC surveillance may also be achieved with prediction models that identify patients at risk of HCC, and the use of serum biomarkers as an alternative to ultrasound-based HCC surveillance.²

Why don’t patients get tested?

Why might our patients miss out on HCC surveillance testing? Some of the reasons for missed tests and non-adherence with appointments are similar to any screening tests, such as other commitments (including family and work) and other health priorities. ⁴ Another patient factor at play is poor health literacy.⁴

But suboptimal surveillance uptake is not just down to our patients – it’s thought to be due to a combination of clinical and system-level barriers. ²

Clinician factors that can contribute to reduced patient participation in liver cancer surveillance programs include limited consultation time, competing clinical concerns and not being up-to-date with surveillance recommendations.²[5]

Other barriers^[6] to liver cancer surveillance testing

The uptake of HCC surveillance testing may also be affected by some bigger-picture issues, such as misinformation and language barriers.¹

People living in rural and remote areas of Australia may have limited access to quality ultrasound testing. This means they need to travel and pay for travel costs and accommodation, which can be a further barrier to testing.¹

It’s also known that race and socio-economic status can further affect our patients’ participation in surveillance programs.²

People living in rural and remote areas of Australia may have limited access to quality ultrasound testing. This means they need to travel and pay for travel costs and accommodation, which can be a further barrier to testing.¹

It’s also known that race and socio-economic status can further affect our patients’ participation in surveillance programs.²

Evidence review: Do at-risk patients take part in HCC surveillance programs?

A 2017 Australian retrospective study examined participation in, and adherence to, HCC surveillance. The study looked at patients with chronic hepatitis B who attended a community health centre that was supported by the Integrated Hepatitis B Service.⁴

The overall surveillance participation rate was 75%, and of the 67 patients who underwent HCC surveillance, adherence was considered:
● good in 18 patients (27%);
● suboptimal in 29 patients (43%); and
● poor in 20 patients (30%).

(Good adherence was defined as an average of ≥1 ultrasound every 7 months; suboptimal was an average of ≥1 but <2 scans every 14 months and poor was an average of <1 scan every 14 months.)

How can we improve liver cancer surveillance participation and adherence?

Factors associated with improved HCC surveillance include frequency of clinic visits and specialist service involvement, as well as higher socioeconomic status.⁴

A centralised HCC surveillance program, similar to that used in countries such as Japan and South Korea, may help deliver improved and more equitable care.² The Japanese surveillance program includes free hepatitis testing and surveillance, dedicated educators and public awareness campaigns.

Other strategies that should be considered are clinician education, patient recall systems, nurse-led clinics and outreach invitations.²

Optimising primary care patient recall and abnormal results notification systems are priority actions identified by the 2023 Roadmap to Liver Cancer Control Australia[7].⁵[8]. This can be done by working with your medical practice software provider to set reminders.

What measures are needed to help at-risk Indigenous Australians?

The higher incidence of HCC and poor survival rates among Aboriginal and/or Torres Strait Islander people with HCC may stem from:²
● reduced access to testing;
● socio-environmental inequalities;
● cultural barriers; and
● distrust in the health care system.

While the use of mobile liver clinics in remote Indigenous communities has led to improved rates of HCC surveillance,⁶ further improving outcomes for Indigenous Australians with HCC poses an enormous challenge.⁶

The link between social determinants of health and the high rates of HCC and mortality suggests that to be successful, interventions will need to also involve public health measures that both reduce social disadvantage and improve access to care.⁶

Where can I find educational materials on liver disease?

The Liver Foundation[9] has information for both patients and health professionals[10], including:
● GP information[11];
● nurse information[12]; and
● patient information[13].

ThinkGP[AD14] also has information for GPs on liver disease[AD15], which qualifies as CPD hours for educational activities.