Prevention

Liver Cancer Prevention Policy

The single most important strategy to prevent liver cancer is to prevent infection with hepatitis B virus (HBV) and hepatitis C virus (HCV). Prevention of HBV- and HCV-related liver cancer is also possible through effective treatment of the viral infection. See the Screening section of this chapter for more information.

Vaccination of all infants and adults in high-risk groups is the most effective preventive approach against HBV, with demonstrated long-term efficacy and benefits.

Other effective primary prevention strategies include ensuring a safe blood supply, universal precautions against blood contamination in healthcare settings and harm reduction approaches to reduce transmission from injecting drug use.

Reducing exposure to other factors that increase the risk of developing chronic liver disease, such as alcohol and aflatoxins, also will reduce the proportion of infected people who develop chronic liver disease and hepatocellular carcinoma. Given the mounting evidence of the association of obesity, diabetes and non-alcoholic fatty liver disease with liver cancer, strategies to reduce the prevalence of obesity and related metabolic risk factors will become increasingly necessary^[1]. For individuals with hemochromatosis, family screening, early diagnosis and correcting iron overload can prevent liver fibrosis and hence progression to liver cancer. Research has shown that drinking coffee has a hepatoprotective effect.

HBV Vaccination

An HBV vaccine has been available since 1982. The complete course induces protective antibody levels in more than 95% of infants, children and young adults^[2][3] and provides long-lasting protection^[4][5]. Since the introduction of the vaccine in Australia, there has been a decline in HBV notification rates among those eligible for universal vaccination ^[6].

Ensuring safe blood supply and universal precautions in healthcare settings

Transmission of hepatitis in healthcare settings has been greatly reduced due to the introduction of screening of blood donations prior to transfusion, or manufacture of blood products, and screening of organ donors prior to transplant^[7].

The use of standard precautions in the clinical setting to minimise transmission of blood-borne viruses and other infection control measures has further minimised the risk of hepatitis transmission in healthcare settings.

Harm reduction

In 2010, 39% of newly acquired HBV cases and 79% of newly acquired HCV cases were associated with injecting drug use^[6]. Studies suggest knowledge about hepatitis is poor among this high-risk population^[8] and most do not complete vaccination regimens^[9].

Australian Government investment in needle and syringe programs between 2000 and 2009 was estimated to have prevented nearly 97,000 cases of HCV (and more than 32,000 new HIV infections) and saved $1.28 billion in direct healthcare costs^[10].

HBV and HCV elimination

In 2016, the World Health Organization’s Global Health Sector Strategy on Viral Hepatitis 2016–2021 set a goal to eliminate worldwide viral HBV and HCV by 2030 and outlined five global service coverage targets:

increase hepatitis B vaccination coverage
increase coverage and timely delivery of birth dose vaccinations
ensure blood and injection safety
ensure adequate distribution of sterile syringes to people who inject drugs
increase HBV and HCV diagnosis and treatment

Elimination of HBV and HCV by 2030 would avert 7.1 million deaths from 2015-2030 (WHO 2016). In 2016, the Australian Government endorsed the WHO Global Health Sector Strategy on Viral Hepatitis 2016–2021 to eliminate HBV and HCV by 2030. Australia is currently not on track to achieve this global target ^[11][12].

Alcohol

Evidence shows liver cancer complicates alcoholic cirrhosis at a rate of approximately 1% per annum^[13]. As such, prevention of alcoholic liver disease by curbing alcohol intake has the potential to lower rates of liver cancer in countries where alcohol dependence is high^[14].

See the Alcohol chapter of the National Cancer Prevention Policy for more information on the link between alcohol and cancer.

Obesity

As further evidence of the association of NAFLD, diabetes, and obesity with liver cancer emerges, action is needed to prevent a significant ‘metabolic’ liver cancer burden in the future, including strategies aimed at reducing obesity through improved diet and physical activity.

See the Obesity and overweight, physical inactivity and nutrition chapter of the National Cancer Prevention Policy for more information on the link between these factors and cancer.

Haemochromatosis

Early detection of haemochromatosis, and correction of hepatic iron overload before development of advanced stage fibrosis, prevents complications including liver cancer^[15].

Haemochromatosis is easily detected by serum markers of iron overload and genetic screening of family members. Correction of hepatic iron overload by venesection before development of advanced stage fibrosis is an important strategy to prevent liver cancer^[14].

Coffee

The World Cancer Research Fund and International Agency for Research on Cancer reviewed the evidence and suggested that coffee drinking decreases the risk of liver cancer ^[16][17]. Additionally, International Agency for Research on Cancer suggested that coffee drinking has benefits on liver fibrosis and cirrhosis ^[17]. Coffee drinking may protect against liver cancer by reducing insulin levels and thereby type 2 diabetes risk^[18], which is now an established risk factor^[19].

References

Baffy G, Brunt EM, Caldwell SH. Hepatocellular carcinoma in non-alcoholic fatty liver disease: an emerging menace. J Hepatol 2012 Jun;56(6):1384-91 Available from: http://www.ncbi.nlm.nih.gov/pubmed/22326465.
Floreani A, Baldo V, Cristofoletti M, Renzulli G, Valeri A, Zanetti C, et al. Long-term persistence of anti-HBs after vaccination against HBV: an 18 year experience in health care workers. Vaccine 2004 Jan 26;22(5-6):607-10 Available from: http://www.ncbi.nlm.nih.gov/pubmed/14741151.
Bialek SR, Bower WA, Novak R, Helgenberger L, Auerbach SB, Williams IT, et al. Persistence of protection against hepatitis B virus infection among adolescents vaccinated with recombinant hepatitis B vaccine beginning at birth: a 15-year follow-up study. Pediatr Infect Dis J 2008 Oct;27(10):881-5 Available from: http://www.ncbi.nlm.nih.gov/pubmed/18756185.
van der Sande MA, Waight P, Mendy M, Rayco-Solon P, Hutt P, Fulford T, et al. Long-term protection against carriage of hepatitis B virus after infant vaccination. J Infect Dis 2006 Jun 1;193(11):1528-35 Available from: http://www.ncbi.nlm.nih.gov/pubmed/16652281.
Australian Government Department of Health and Ageing. The Australian immunisation handbook. 10th edition. Canberra: DoHA; 2013 Available from: http://health.gov.au/internet/immunise/publishing.nsf/Content/EE1905BC65D40BCFCA257B26007FC8CA/$File/handbook10.pdf.
NNDSS Annual Report Writing Group. Australia's notifiable disease status, 2010: Annual report of the National Notifiable Diseases Surveillance System. Commun Dis Intell 2012 Mar 31;36(1):1-69 Available from: http://www.ncbi.nlm.nih.gov/pubmed/23153082.
Hilleman MR. Critical overview and outlook: pathogenesis, prevention, and treatment of hepatitis and hepatocarcinoma caused by hepatitis B virus. Vaccine 2003 Dec 1;21(32):4626-49 Available from: http://www.ncbi.nlm.nih.gov/pubmed/14585670.
Day C, White B, Ross J, Dolan K. Poor knowledge and low coverage of hepatitis B vaccination among injecting drug users in Sydney. Aust N Z J Public Health 2003 Oct;27(5):558 Available from: http://www.ncbi.nlm.nih.gov/pubmed/14651407.
Maher L, Chant K, Jalaludin B, Sargent P. Risk behaviors and antibody hepatitis B and C prevalence among injecting drug users in south-western Sydney, Australia. J Gastroenterol Hepatol 2004 Oct;19(10):1114-20 Available from: http://www.ncbi.nlm.nih.gov/pubmed/15377287.
National Centre for HIV Epidemiology and Clinical Research. Return on investment 2: evaluating the cost-effectiveness of needle and syringe programs in Australia. Sydney: NCHECR; 2009. Sponsored by Australian Government Department of Health and Ageing. Available from: http://www.health.gov.au/internet/main/publishing.nsf/content/C562D0E860733E9FCA257648000215C5/$File/return2.pdf.
Kirby Institute. HIV, viral hepatitis and sexually transmissible infections in Australia: Annual surveillance report. Sydney: University of New South Wales; 2018. Sponsored by Department of Health and Ageing. Available from: https://kirby.unsw.edu.au/sites/default/files/kirby/report/KI_Annual-Surveillance-Report-2018.pdf.
McCulloch K, Romero N, MacLachlan J, Allard N, Cowie B. Modeling Progress Toward Elimination of Hepatitis B in Australia. Hepatology 2019 Aug 16 Available from: http://www.ncbi.nlm.nih.gov/pubmed/31419332.
Morgan TR, Mandayam S, Jamal MM. Alcohol and hepatocellular carcinoma. Gastroenterology 2004 Nov;127(5 Suppl 1):S87-96 Available from: http://www.ncbi.nlm.nih.gov/pubmed/15508108.
Asia-Pacific Working Party on Prevention of Hepatocellular Carcinoma. Prevention of hepatocellular carcinoma in the Asia-Pacific region: consensus statements. J Gastroenterol Hepatol 2010 Apr;25(4):657-63 Available from: http://www.ncbi.nlm.nih.gov/pubmed/20492323.
Allen KJ, Nisselle AE, Collins VR, Williamson R, Delatycki MB. Asymptomatic individuals at genetic risk of haemochromatosis take appropriate steps to prevent disease related to iron overload. Liver Int 2008 Mar;28(3):363-9 Available from: http://www.ncbi.nlm.nih.gov/pubmed/18290779.
World Cancer Research Fund/American Institute for Cancer Research. Continuous Update Project Report: Diet, Nutrition, Physical Activity and Liver Cancer. WCRF/ACIR; 2015 Available from: https://www.wcrf.org/sites/default/files/Liver-cancer-report.pdf.
Loomis D, Guyton KZ, Grosse Y, Lauby-Secretan B, El Ghissassi F, Bouvard V, et al. Carcinogenicity of drinking coffee, mate, and very hot beverages. Lancet Oncol 2016 Jul;17(7):877-878 Available from: http://www.ncbi.nlm.nih.gov/pubmed/27318851.
Huxley R, Lee CM, Barzi F, Timmermeister L, Czernichow S, Perkovic V, et al. Coffee, decaffeinated coffee, and tea consumption in relation to incident type 2 diabetes mellitus: a systematic review with meta-analysis. Arch Intern Med 2009 Dec 14;169(22):2053-63 Available from: http://www.ncbi.nlm.nih.gov/pubmed/20008687.
El-Serag HB. Epidemiology of viral hepatitis and hepatocellular carcinoma. Gastroenterology 2012 May;142(6):1264-1273.e1 Available from: http://www.ncbi.nlm.nih.gov/pubmed/22537432.