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

Chapter 15: Prevention and early detection of cancer
Prevention and early detection of primary liver (hepatocellular) cancer
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☰ Table of contents

Recommendations: Prevention and early detection of primary liver (hepatocellular) cancer

Preventive intervention type

Who is at risk?

What should be done?

How often?

Level/ strength of evidence

References

Immunisation

 All people Recommend hepatitis B vaccination as per the National Immunisation Program Schedule (NIPS) and also offer immunisation to any non-infected, non-immune individuals (refer to ‘Recommendations’ in Chapter 14: Sexual health and blood-borne viruses, and in Chapter 3: Child health) Refer to Chapter 3: Child health, and Chapter 14: Sexual health and bloodborne viruses

Shortly after birth, and at age two, four and six months

Catch-up program for non-immune people (may be funded in some jurisdictions)		 Refer to Chapter 14 6,38

Screening

 All people Screen for hepatitis B and C if indicated (refer to Chapter 14: Sexual health and blood-borne viruses, ‘Recommendations’) Chapter 14: Sexual health and bloodborne viruses Refer to Chapter 14 6, 34, 39, 40
People with chronic hepatitis B who are: Aboriginal and/or Torres Strait Islander and >50 years, or have cirrhosis, or have a family history of hepatocellular carcinoma (HCC) Recommend abdominal ultrasound, alpha-fetoprotein screening for HCC as part of specialist management plan Six-monthly III–IIC 41–43
People with advanced liver disease (cirrhosis) not due to chronic hepatitis B Recommend specialist review and consider ongoing screening for HCC with an abdominal ultrasound +/– alpha-fetoprotein Protocols vary (consult clinical guidelines for more detail – refer to ‘Resources’) III–IIC 41–50

Behavioural

 Adolescents and adults Assess quantity and frequency of alcohol consumption and advise about safer levels of alcohol consumption to reduce long-term risk of alcohol-related harm (refer to Chapter 1: Lifestyle, ‘Alcohol’; and Chapter 4: The health of young people) As part of annual health check IIIB 51
People with overweight/obesity Advise of the risks of liver disease and promote weight reduction strategies (refer to Chapter 1: Lifestyle, ‘Overweight and obesity’) Opportunistic and as part of annual health check GPP 52
People at higher risk of hepatitis B or C infection Provide counselling on harm minimisation and promote peer education strategies around safer sex and injecting drug use where relevant (refer to Chapter 14: Sexual health and bloodborne viruses) Opportunistic and as part of annual health check GPP 40
People with chronic liver disease or chronic hepatitis infection Provide counselling regarding risks of alcohol consumption 6–12-monthly, as required GPP 43, 46, 49

Chemo-prophylaxis

 People with chronic hepatitis B infection

Assess disease severity and suitability for anti-viral treatment

Regular monitoring for disease progression is recommended

 Refer to Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) management guidelines listed in ‘Resources’, and/or contact local services for advice IB 41–43, 53
People with chronic hepatitis C infection Assess disease severity and suitability for anti-viral treatment Refer to ASHM management guidelines listed in ‘Resources’, and/or contact local specialist services for advice IIB 46, 48, 49

 


Background

Aboriginal and Torres Strait Islander peoples have an incidence of primary liver cancer that is 2.8 times higher and a mortality rate that is 2.5 times higher than that of the non-Indigenous population.3 Some regions may have even higher rates; for example, in the Northern Territory the age-standardised incidence rates are 5.9 times higher in Aboriginal peoples than in the non-Indigenous population.31,32

Hepatocellular carcinoma (HCC), responsible for the vast majority of primary liver cancer, 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. Some people with hepatitis B may develop HCC without previous cirrhosis.

Reporting of Aboriginal status for hepatitis B virus (HBV) and hepatitis C virus (HCV) infection continues to be a problem, with notifications of newly acquired infections missing recording of Aboriginal status in 63% and 59% of cases respectively.33 From the limited data available, it appears that for Aboriginal and Torres Strait Islander peoples the notification rate for newly acquired HBV is three times, and for newly acquired HCV nearly five times, that of the non-Indigenous population. In addition, evidence of HCV infection acquired in the last two years is 17 times higher compared to the non-Indigenous population.33 While Aboriginal peoples make up 3% of the Australian population, they accounted for 10% of newly acquired HBV infections and 30% of newly acquired HCV infections. For Aboriginal and Torres Strait Islander peoples, notification rates for newly diagnosed HBV are declining, perhaps reflecting the impact of vaccination programs. Conversely, incidence rates of HCV are increasing, perhaps due to higher rates of injecting drug use with needle sharing.33

Risk factors for HBV infection include: non-immune household or sexual contacts of people with HBV; Aboriginal people; babies born to mothers with HBV infection; people with multiple sexual partners; men who have sex with men; people who inject drugs; people at occupational risk; people in prison/detention; people with chronic liver disease, HCV, HIV or impaired immunity.6

Risk factors for HCV infection include: people who have ever injected drugs; people who have been incarcerated; children of HCV-positive mothers; people with tattoos and body piercings; recipients of blood products, tissues or organs prior to February 1990 in Australia or anytime overseas; men who have sex with men with HIV.34


Interventions

HBV vaccination reduces the risk of chronic HBV 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 HBV due to its intermediate to high endemicity.35 Universal infant vaccination is available through the National Immunisation Program (NIP).36 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. A minority of people with chronic hepatitis B require therapy (10–20%), as most people have nonactive disease, with low risk of disease progression. Licensed therapies are able to be prescribed by trained doctors in the community through the section 100 (S100) scheme.

Hepatitis C antiviral therapy for those with chronic hepatitis C is curable in the vast majority of cases (>95%), and thereby reduces liver disease progression and risk of HCC. All adults with chronic hepatitis C are eligible for treatment, with multiple regimens available through the Pharmaceutical Benefits Scheme (PBS), including interferon-free regimens that are highly efficacious and tolerable with treatment courses ranging from 8–24 weeks. These regimens can now be prescribed by general practitioners (GPs) who are experienced in this area, without mandated further training, or otherwise prescribed by GPs in consultation with a specialist, and dispensed in the community through the section 85 (S85) scheme.37 Refer to the end of this section for links to clinical guidelines.
 

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

 





 
 
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