Liver Ecosystem Advancement Project (LEAP) highlights New Zealand’s successful National Hepatitis B Screening Program

Listen to the podcast interview with Prof. Ed Gane on New Zealand’s National Hep B Screening and Surveillance Program

The Challenge of Viral Hepatitis and HCC in New Zealand: A Closer Look

Globally, 240 million people are affected by hepatitis B virus (HBV, Hep B), surpassing deaths from tuberculosis, HIV, and malaria in the WHO Western Pacific Region [1]. HBV is a major cause of hepatocellular carcinoma (HCC), with chronic infections accounting for over half of HCC cases [2]. In response, the United Nations aims to reduce HBV infections and deaths by 2030, with vaccinations from 1990 to 2020 preventing an estimated 310 million infections [3].

In New Zealand, HBV significantly impacts Maori (5.6%), Pacific peoples (7.3%), and Asians (6.2%), who represent over 50% of liver disease mortality, compared to 10% among European New Zealanders [1].

Despite a robust healthcare system, New Zealand faces hurdles in enhancing public awareness, fighting stigma, and increasing testing access, as emphasised by Prof. Ed Gane, Chief Hepatologist, Transplant Physician and Deputy Director of the New Zealand Liver Transplant Unit at Auckland City Hospital, and Professor of Medicine at the University of Auckland, New Zealand.

Nearly half of New Zealand’s chronic HBV infections remain undiagnosed [1], leading to late HCC detection.

Advanced-stage diagnoses leave limited treatment options, with life expectancy post-diagnosis ranging from 7 to 22 months [4]. This underscores the need for better HBV screening, diligent follow-up, and robust HCC surveillance to improve outcomes.

In response, the New Zealand National Hepatitis B Screening Program [5] emphasises early detection, public awareness, and healthcare access, serving as a global model for managing HBV and strengthening HCC surveillance protocols to enhance patient outcomes.

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.

Prof MF Yuen & Ronald Lo discuss the liver health ecosystem in Hong Kong, including hepatitis screening and HCC surveillance

Find out more about PIVKA-II in Hepatocellular Carcinoma (HCC) detection, or download our HCC Detection (HD) expert pack by filling in the form below:

Interview transcript:

Ronald Lo:

Hello everyone! Welcome to this video. I’m Ronald, the General Manager of Roche Diagnostics Hong Kong. It’s my honour today to invite Professor Yuen to have a discussion around the topics of hepatitis and hepatocellular carcinoma (HCC). Hello Professor Yuen.

Prof. MF Yuen:

Hi, I am Professor MF Yuen, the Chief of Division of Gastroenterology and Hepatology in the University of Hong Kong.

Ronald Lo:

Again, thank you so much for joining us today. So the first question I would like to get your advice would be, what is the current liver health landscape in Hong Kong; and what are the unmet needs in hepatitis screening and HCC detection in Hong Kong?

Prof. MF Yuen:

At present, Hong Kong still has a high prevalence of 7.8% hepatitis B population, amounting more than 550,000 people. According to the most recent statistics, there were more than 1,700 new cases of liver cancer in 2020. And it is known that more than 80% of Hepatocellular Carcinoma are caused by Hepatitis B infection. Even with this high rate, we do not have population screening program for Hepatitis B infection, and the surveillance for HCC is also suboptimal with respect to the lack of routine regular ultrasound of the liver for Hepatitis B patients. It is mainly due to manpower and financial constraint in the public hospital sector. On top of all these, we do not have a well-organised strategy to deliver disease information to our population. Majority of people do not know the serious disease consequence of Hepatitis B infection which may lead to early death. They also lack of knowledge of early treatment would prevent all these deleterious outcomes.

Ronald Lo:

So I would like to learn from you more, what are the recent advances in the diagnosis of HCC; and how do you see these impacting patient care and the chronic liver disease management in Hong Kong?

Prof. MF Yuen:

From Asian experience, the use of additional biomarkers, such as PIVKA-II, can significantly increase the pick-up rate of HCC at early stage, increase the likelihood for curative treatments, and thus improve the survival. New digital algorithms combining age, gender and biomarkers, such as GAAD and GALAD, have been proposed since 2013, and currently undergoing clinical validations. Recent data presented during APASL 2023 demonstrated that the use of PIVKA-II based algorithm is more cost-effective than current standard of care among Hepatitis B or cirrhotic patients in Hong Kong, which allows an earlier HCC detection and a reduced cost in subsequent HCC treatment.

Ronald Lo:

Let’s switch the gear a bit. So how do you think we can improve the coordination and integration of care among various healthcare providers and systems?

Prof. MF Yuen:

I think the most important step would be the active involvement of different concerned parties, including health care sectors from government, private institutions, policy makers, patient groups, and different NGOs, to establish a core committee which could liaise with different stakeholders to ensure the implementation of different measures to enhance diagnosis rate, screening strategy and treatment.

Ronald Lo:

And to add on, how do you see the future of liver health in Hong Kong, and what steps do you believe need to be taken to improve the patient outcomes?

Prof. MF Yuen:

The future of liver health in Hong Kong depends on whether we could have a statutory body which taking charge of planning, liaising and implementing different measures at different levels.

Ronald Lo:

Thank you Professor. So probably would be my last question. So how do you see the role of the government and the policy in addressing the liver health ecosystem?

Prof. MF Yuen:

Hong Kong government has been working on different policy making processes and decisions by involving different committees. However, the decisiveness should be more enhanced so that policy can be rolled out at a timely manner.

Ronald Lo:

Professor Yuen, thank you so much for your time today and your inspiring insights on the topics of hepatitis and HCC. And I’m sure that there are always many areas that we could further work on together to improve patient outcomes. And thanks a lot for contributing to the “Combating Cancer” educational platform as well. Thank you so much, thank you!

The views and opinions expressed by Prof. MF Yuen are his own views and opinions. Roche disclaims all liability in relation to these views and opinions.