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Clinical guidelines

National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people Second edition

Prevention and early detection of liver (hepatocellular) cancer

Author Dr Nadia Lusis
Expert reviewers  Professor Greg Dore

Background

Limited data are available on the incidence and mortality from liver cancer in Aboriginal and Torres Strait Islander people, and different jurisdictions report different results. Northern Territory data showed the age standardised incidence rates were 6.6 times higher in Aboriginal men and 4.5 in Aboriginal women, and the mortality rate ratio was 8.7 for men and 7.0 for women.3 However, in Queensland, based on cancer registry data, no difference was shown in liver cancer incidence or mortality between Aboriginal and non-Aboriginal people.27

Hepatocellular carcinoma (HCC) is almost always preceded by cirrhosis. Major risk factors for cirrhosis (and therefore HCC) in Australia are chronic hepatitis B and C infection, alcoholic liver disease and fatty liver disease. Notification rates for hepatitis B and C are higher for Aboriginal and Torres Strait Islander people. The prevalence of hepatitis B infection in Aboriginal and Torres Strait Islander populations has been estimated to be 2% in the urban areas and 8% in rural areas, compared to less than 1% for the total Australian population.2 Despite 2.5% of the Australian population identifying as Aboriginal or Torres Strait Islander, Aboriginal and Torres Strait Islander people are estimated to account for 16% of the population with chronic hepatitis B infection.28 

Low rates of identification of Indigenous status on infectious disease notifications makes data difficult to interpret. It is estimated that 4% of Aboriginal and Torres Strait Islander people have chronic hepatitis C compared to 1% of non-Indigenous people, however, data quality is poor, with identification of Aboriginal and Torres Strait Islander status for those newly diagnosed with hepatitis C in 2009 occurring in only 39% of reports.28

Some people are at higher risk of being infected with hepatitis B or C (Table 15.1).

Table 15.1. Risk factors for hepatitis B and C infection

Those at higher risk of hepatitis B infection include non-immune household or sexual contacts of people with acute or chronic hepatitis B; people aged 15–30 years; babies born to mothers with hepatitis B infection; people with multiple sexual partners; men who have sex with men; people who inject drugs; people at occupational risk or in prison/detention; and people with chronic liver disease, hepatitis C infection, HIV or impaired immunity
Those at higher risk of hepatitis C infection include people who have ever injected drugs for recreational purposes; people who have ever been incarcerated; those with tattoos and body piercings; recipients of blood products, tissues or organs prior to February 1990 in Australia or anytime overseas; and sexual partners of those with hepatitis C infection if blood has been associated with sexual activity

See also Chapter 8: Table 8.1: Risk factors for sexually transmissible infections and bloodborne viruses
Sources: National Health and Medical Research Council 2008 and Department of Health and Ageing 201010,29

Interventions

Hepatitis B vaccination reduces the risk of chronic hepatitis B infection, which is a risk factor for the development of HCC. Aboriginal people are considered by the World Health Organization to be a priority group for hepatitis B vaccination due to intermediate to high endemicity of hepatitis B infection.30 The US Centres for Disease Control recommends screening and hepatitis B vaccination for all people from geographic areas with a prevalence of hepatitis B of >2%.31 Universal infant vaccination and catch-up adolescent vaccination is currently available through the National Immunisation Program. Vaccination for other groups may be funded through state and territory health department programs.

Hepatitis B antiviral therapy for those with chronic hepatitis B reduces liver disease progression and risk of HCC. Licensed therapies provided through the S100 scheme include tenofovir, entecavir and pegylated interferon.

Hepatitis C antiviral therapy for those with chronic hepatitis C reduces liver disease progression and risk of HCC. Licensed therapy provided through the S100 scheme is pegylated interferon and ribavirin.

Recommendations: Liver cancer prevention and detection
Preventive intervention typeWho is at risk?What should be done?How often?Level/strength of evidence
Immunisation All people Review if hepatitis B vaccination is indicated (see recommendations in Chapter 8: Sexual health and bloodborne viruses and Chapter 2: Child health) See Chapter 8 See Chapter 832
Screening All people Review if hepatitis B and C screening is indicated (see recommendations in Chapter 8: Sexual health and bloodborne viruses) See Chapter 8 See Chapter 832,33
People with chronic liver disease or chronic hepatitis infection Recommend specialist review to consider if screening for hepatocellular carcinoma using alpha fetoprotein (AFP) and ultrasound is warranted  6–12 monthly as part of specialist management plan IIIC34–37
Behavioural Adolescents and adults Assess levels of alcohol consumption and advise about safer levels of alcohol consumption to reduce long terms risk of alcohol related harm (see Chapter 1: Lifestyle, section on alcohol and Chapter 3: The health of young people) As part of an annual health assessment IIIB38
People with overweight/ obesity Advise of the risks of liver disease and promote weight reduction strategies (see Chapter 1: Lifestyle, section on overweight/obesity) Opportunistic GPP39
People at higher risk of hepatitis B or C infection (see Table 15.1) Provide counselling on harm minimisation and promote peer education strategies around safer sex and injecting drug use where relevant (see Chapter 8: Sexual health and bloodborne viruses) Opportunistic and as part of an annual health assessment GPP29
People with chronic liver disease or chronic hepatitis infection Provide counselling regarding risks of alcohol consumption 6–12 monthly as required GPP36
Chemoprophylaxis People with chronic hepatitis B† or hepatitis C infection Assess disease severity and suitability for antiviral treatment
Regular monitoring for disease progression is recommended
Refer to national or local guidelines for management recommendations (see Resources)
See management guidelines and/or contact local services for advice IIIC36,40
* The World Health Organization recommends screening and hepatitis B vaccination for all people from geographic areas with a prevalence of hepatitis B of >2%.30,31 The prevalence of hepatitis B infection in the Aboriginal population has been estimated to be 2% in the urban areas and 8% in rural areas2 
† Hepatitis B surface antigen positive >6 months

Resources

The Australian immunisation handbook (NHMRC): hepatitis B chapter
www.immunise.health.gov.au/ internet/immunise/publishing.nsf/ Content/Handbook-hepatitisb

Australia and New Zealand chronic hepatitis B recommendations (Gastroenterological Society of Australia and Digestive Health Foundation)
www.gesa.org.au/ files/editor_upload/File/Professional/CHB.pdf

HIV, viral hepatitis and STIs: a guide for primary care (Australasian Society for HIV Medicine: further resources will be available through ASHM in 2012, including information on access to new treatment options for some people with chronic hepatitis C infection)
www.ashm.org.au/ default2.asp?active_page_id=133.

References

  1. Cunningham J, Rumbold AR, Zhang X, Condon JR. Incidence, aetiology, and outcomes of cancer in Indigenous peoples in Australia. Lancet Oncology 2008;9(6):585–95.
  2. Australian Bureau of Statistics & Australian Institute of Health and Welfare. The health and welfare of Australia’s Aboriginal and Torres Strait Islander peoples 2008, ABS cat no. 4704.0. Canberra: ABS, 2008. Cited October 2011. Available at www.aihw.gov.au/ publications/index.cfm/title/10583.
  3. National Health and Medical Research Council. The Australian immunisation handbook, 9th edn. Canberra: Commonwealth of Australia, 2008. Cited October 2011. Available at www.health.gov.au/ internet/immunise/publishing.nsf/content/handbook-home.
  4. Moore SP, O’Rourke PK, Mallitt K-A, et al. Cancer incidence and mortality in Indigenous Australians in Queensland,1997–2006. Med J Aust 2010;193(10):590–3.
  5. National Centre in HIV Epidemiology and Clinical Research. Bloodborne viral and sexually transmissible infections in Aboriginal and Torres Strait Islander people: surveillance and evaluation report 2010. Sydney: National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, 2010. Cited October 2011. Available at www.med.unsw.edu.au/ nchecrweb.nsf/resources/ATSIP-1/$file/ATSIP2010_WEB201102.pdf.
  6. Department of Health and Ageing. Third National Aboriginal and Torres Strait Islander Blood Borne Viruses and Sexually Transmissible Infections Strategy 2010–2013. Canberra: Commonwealth of Australia, 2010. Cited October 2011. Available at www.health.gov.au/ internet/main/publishing.nsf/Content/ohp-national-strategies-2010-atsi-bbv.
  7. World Health Organization. Hepatitis B vaccines. WHO position statement. WHO Weekly Epidemiological Record 2009;40(84):405–20.
  8. Centers for Disease Control and Prevention. Recommendations for identification and public health management of persons with chronic hepatitis B virus infection. MMWR Morb Mortal Wkly Rep (serial on the internet), 2008. Cited October 2011. Available at www.cdc.gov/ mmwr/preview/mmwrhtml/rr 5708a1.htm.
  9. Mathew JL, El Dib R, Mathew PJ, Boxall EH, Brok J. Hepatitis B immunisation in persons not previously exposed to hepatitis B or with unknown exposure status. Cochrane Database Syst Rev 2008 Jul 16;Jul 16;(3):CD006481.
  10. Ghany MG, Strader DB, Thomas DL, Seeff LB. Diagnosis, management, and treatment of hepatitis C: an update. Hepatology 2009 Apr;49(4):1335–74.
  11. Wun YT, Dickinson JA. Alpha-fetoprotein and/or liver ultrasonography for liver cancer screening in patients with chronic hepatitis B. Cochrane Database Syst Rev 2003(2):CD002799.
  12. Zhang B-H, Yang B-H, Tang Z-Y. Randomized controlled trial of screening for hepatocellular carcinoma. J Cancer Res Clin Oncol 2004;130(7):417–22.
  13. Gastroenterological Society of Australia and Digestive Health Foundation. Australia and New Zealand chronic hepatitis B (CHB) recommendations, 2009. Cited November 2011. Available at www.gesa.org.au/ files/editor_upload/File/ Professional/CHB.pdf.
  14. National Cancer Institute. Liver (hepatocellular) cancer screening. Bethesda, MD: National Cancer Institute, 2010. Cited October 2011. Available at www.cancer.gov/ cancertopics/pdq/screening/hepatocellular/ HealthProfessional/page1.
  15. Bagnardi V, Blangiardo M, La Vecchia C, Corrao G. A meta-analysis of alcohol drinking and cancer risk. Br J Cancer 2001;85(11):1700–5.
  16. Peng L, Jiyao W, Feng L. Weight reduction for non-alcoholic fatty liver disease. Cochrane Database Syst Rev 2011;Jul 15;(6):DOI: 10.1002/14651858.CD003619.pub.
  17. Bradford D, Hoy J, Matthews G. HIV, Viral hepatitis and STI’s: a guide for primary care. Sydney: Australasian Society for HIV Medicine, 2008. Cited October 2011. Available at www.ashm.org.au /images/publications/monographs/HIV_vir al_hepatitis_and_STIs_a_guide_for_primary_care/hiv_vira l_hepatitis_and_stis_whole.pdf.
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