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Managing Liver Cancer as a Global Health Problem
  • Third most fatal cancer in Singapore, affecting 24 in every 100,000 people per year
  • Hepatocellular Carcinoma (HCC) represents 90% of all primary liver cancer cases; often goes undetected with little to no symptoms
  • Raising the bar in the treatment of inoperable liver cancer (HCC)

In Singapore, liver cancer is the third most fatal cancer and it affects about 24 individuals in every 100,000 people per year. Liver cancer is also the second leading cause of cancer-related death worldwide and has an incidence of approximately 850,000 new cases per year. Mortality owing to liver cancer has increased in the past 20 years and the latest estimates indicate that the global health burden of this disease will continue to grow.

Among all primary liver cancers, hepatocellular carcinoma (HCC) is the most common, representing 90% of all cases. Statistics [1] show that the main risk factors for developing HCC in the Asia and Africa regions are: Hepatitis B (70%; Japan is 10-20%), Hepatitis C (20%; Japan is 70%) and alcohol use at 10% which is the same percentage as in Japan. More than 75% of HCC in the world occurs in the Asia Pacific region with an annual incidence of HCC at 20-100 cases per 100,000 people.

HCC is difficult to detect with little to no symptoms in the early stage of disease and often, patients are diagnosed during the advanced stage. Hence, overall survival decreases with the advancing stages of the disease. The overall 5-year survival rate for advanced HCC is less than 5%, further proof that the disease is deadly.

Prof Josep M. Llovet, the Professor of Research, BCLC Group, Liver Unit of IDIBAPS-Hospital Clinic of Barcelona, the Founder and Director of the Liver Cancer Program and Full Professor of Medicine at the Mount Sinai School of Medicine, New York University and the Director, Master in Translational Medicine at the Faculty of Medicine, University of Barcelona, said: “There is a co-relation of Hepatitis B (HBV) and C infections (HCV) to the HCC incidence. Globally, 400 million people are infected with HBV, with 0.2% having chronic hepatitis and 2% having cirrhosis per year running the risk of developing into HCC. There are 170 million people worldwide infected with HCV, with 0.3% having chronic hepatitis and 3-7% having cirrhosis per year running the risk of developing into HCC.”

The Barcelona Clinic Liver Cancer staging classification is the most recognised clinical algorithm for the stratification of patients according to prognosis and treatment allocation.

For liver cancer, only 40% of patients are diagnosed where potentially curative treatments are possible. Treatments may range from operation or resection to liver transplant. For more advanced stages of the disease, transarterial chemoembolization [2] (for intermediate HCC) and multikinase inhibitors [3] have shown survival benefits.

For early stage of HCC or BCLC stage A, surgical operation is the treatment option. Stage B refers to the intermediate stage of HCC where surgery is not possible. At this stage, the standard treatment option is transarterial chemoembolization. However, it is discouraged in patients with advanced liver dysfunction. Stage C is the advanced stage of HCC and systemic therapy with the drug “sorafenib” is the recommended treatment option. Stage D is the terminal stage of the disease where only best supportive care or palliative treatment is considered.

GIDEON which stands for Global Investigation of therapeutic DEcisions in HCC and Of its treatment with sorafeNib is a prospective, observational registry study aimed to evaluate the safety of sorafenib and treatment practices in advanced stage of HCC patients. This large global database allowed for assessment of the use and tolerability of sorafenib in patients with liver dysfunction.

Prof Llovet commented: “The GIDEON study revealed that in clinical practice, the safety profile of sorafenib appeared to be consistent across patients with preserved liver function and those in which the liver was not functioning properly. Findings suggest that sorafenib may be safely used and further indicate the importance of careful patient evaluation when making treatment decisions.”

Liver Cancer in Singapore

According to the Singapore Cancer Registry 2010-2014, liver cancer is the fourth most frequent cancer among male residents in Singapore. Men are also 3 times more likely to develop HCC than women. Though liver cancer occurs more in the older age group from 40 to 50 years old, it can also affect a younger individual who has contracted hepatitis B from birth or hepatitis C in those with certain environmental conditions.

Dr Choo Su Pin, Senior Consultant and the Chief of Gastrointestinal Oncology in Division of Medical Oncology, National Cancer Centre Singapore, said: “The majority of patients with liver cancer have no symptoms. Therefore, it is often detected by chance as a result of an ultrasound test or a CT scan for other unrelated problems. In certain patients, there may be vague symptoms of heaviness or discomfort on the right side of the abdomen. Pain and the loss of appetite or weight loss are usually late symptoms.”

“Treatment options in Singapore for HCC patients are in line with that in U.S. and Europe. Surgery is the treatment of choice for liver cancer as all other methods have not shown to be as effective. However, because liver cancer is frequently associated with liver damage (cirrhosis) in other parts of the liver due to alcohol or hepatitis, surgery for liver cancer is difficult or not possible for a large proportion of patients. In selected cases, liver transplant is another surgical option for liver cancer treatment,” added Dr Choo.

If left untreated, most HCC patients do not survive beyond 6 months. Surgery is the only treatment that allows for a reasonable survival beyond 5 years. However, new tumour growth is common in liver cancer because of the underlying liver disease (i.e. hepatitis or cirrhosis). Based on the Ministry of Health guidelines, patients with established hepatitis B or C carrier status or with liver cirrhosis would benefit from regular AFP estimations and ultrasound examinations. These tests are usually done at 6-monthly intervals depending on the severity of liver damage.

As for prevention, family members of patients with hepatitis B are advised to check their hepatitis B status. If they are not infected and are without protection, it is advisable to go for immunization against hepatitis B. There is currently no immunization for hepatitis C. It is also wise to drink in moderation as alcohol abuse can potentially lead to liver cirrhosis and this increases the risk of liver cancer.

  1. International Agency for Cancer Research. Globocan 2012. Available at: https://www-dep.iarc.fr. September 2, 2015. Bruix J et al. Cancer Cell. 2004;5:215-219. 2. Llovet JM et al. Lancet. 2003;362:1907-1917
  2. A minimally invasive procedure performed in interventional radiology to restrict a tumour’s blood flow.
  3. Tyrosine kinase inhibitors used as an anti-cancer therapy.
Source: Bayer

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APBN Editorial Calendar 2018
Obesity / Outlook for 2018
Searching for the fountain of youth
Women in Science - Making a difference
Digestive health in the 21st century - Trust your guts
Asthma / Dental health
Oncology / Biotech landscape in APAC
Water management / Vaccination
Regenerative medicine / Biotech start ups
Digital healthcare / 3D printing
Bones / Breast cancer
Liver health / Top science research nations & institutions
AIDS / Breakthrough of the year/Emerging trends
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