Saturday, September 8, 2012

Hepatitis C and B: Listen to a conversation about liver cancer

Yale Cancer Center  - June 17 2012 - Answers with doctors Dr. Francine Foss and Dr. Lynn Wilson.

This week, Dr. Foss and Dr. Wilson are joined by Dr. Stacey Stein and Dr. Tamar Taddei for a conversation about liver cancer. Dr. Stein is Assistant Professor of Medical Oncology and Dr. Taddei is Assistant Professor of Medicine and Digestive Disease at Yale School of Medicine. 

Just to take one step back from that question, what is very interesting about liver cancer and is different from most of the other cancers that we treat in medical oncology is that it occurs usually in the setting of longstanding liver disease. So for hepatocellular carcinoma, Dr. Taddei is right that most patients have cirrhosis and that can come from different things such as hepatitis B, hepatitis C, and from chronic alcohol use, and even now from something that we see called NASH cirrhosis which is caused by inflammation from fatty liver over many years and so often these patients have predisposing factors which hopefully have been identified by someone early because for early stage liver cancer, there actually may be no symptoms or the symptoms may be more from their underlying liver disease then the cancer per se. We really rely on are our colleagues out in the community to identify these patients who are at high risk for liver cancer such as those with hepatitis B, hepatitis C, and a longstanding alcohol history, and hopefully they are being screened periodically for early cancer because we have much better outcomes when the cancer is found early....

 It is very important to underscore what Stacey just said, which is that you have to have an index of suspicion for underlying liver disease. The CDC has just come out with new guidelines that recommend screening for hepatitis C in all people in the United States born between 1945 and 1965, essentially calling the baby boomer generation, also the hep C generation, because this was when hepatitis C was on the greatest rise in the United States. The epidemiology data suggests that the rise in HCC is directly linked to the epidemiological curves in hepatitis C, such that people who were infected in the 1960s have had a latency period and it takes about 20 to 30 years to develop cirrhosis. So sometime around the 1990s, they might have developed cirrhosis, and as that scarring process progresses over time, that is when the risk factor for liver cancer arises. We are seeing a whole generation of people reach their sort of natural history of liver disease such that they are now at risk for the development of liver cancer. So hepatitis B, although we do not see it as much in the United Stated, it is endemic in other parts of the world and it is very important to compare the epidemiology. In the US, there are between 20,000 to 30,000 new cases of HCC per year, whereas annually there are about 600,000 deaths from HCC around the globe. So there are 350 million people infected with hepatitis B and of those 350 million, between 35 to 87 million will die of hepatocellular carcinoma. So what we see in the US is really the tip of the iceberg. The other major issue in the US is alcoholism leading to cirrhosis and liver cancer and it is important to ask your patients about their alcohol consumption and then, probably the biggest surge in liver disease is related to nonalcoholic fatty liver disease what we call NAFLD in the liver community, and the biggest rise in terms of demographics are in children ages 11 to 19. What is really concerning to us is that that next wave of liver cancer may come in even younger people who have developed fatty liver disease in their childhood, come to cirrhosis in their 20s and 30s, and actually present with liver cancer in their 40s, and that is actually something that we are very concerned about as being the next wave of HCC. Once hepatitis C is actually successfully treated, now that we have drugs that can treat hepatitis C on the order of a 75% cure rate, we are really worried about what the next wave is. All of this has come to pass in the last five years, and we are seeing increasing rates. We have also seen increasing rates in our backyard at Yale-New Haven Hospital, at the Veterans Hospital, and part of the attempt to establish a screening program and detect these patients early is to work across disciplines and to co-localize in clinical settings where we can actually see our patients, deliver a cogent message on what the multidisciplinary plan is and then I can see the patient and Stacey can see the patient, and I can care for their liver disease and she can care of their liver cancer, especially if it is advanced HCC which is really the prevailing role for the oncologist right now, so that helps us to provide very cogent care for the patient.......

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