Building modern hepatocellular carcinoma surveillance programmes: taking steps to address a leading cause of liver cancer death in Asia

August 10, 2023


Building modern hepatocellular carcinoma surveillance programmes: taking steps to address a leading cause of liver cancer death

August 10, 2023

Nuriesya Saleha

Senior Manager, Health Practice, APAC

Nuriesya Saleha is the Senior Manager of the Health Practice team for APAC at Economist Impact. She is part of the Policy and Insights team based in Singapore, working with multi-disciplinary teams across the globe on health projects spanning a range of disease focus areas. Her areas of interests include health systems, and intersections of health with other industries. Nuriesya has been in the healthcare sector for close to 10 years, with a Master in Health Administration from Johns Hopkins University and undergraduate degree in economics and biochemistry. She previously worked at Woodlands Health, an upcoming public healthcare campus in Singapore, developing new clinical models and processes by engaging with various clinical stakeholders. Prior to that, she was involved in managed care related projects at Fullerton Health for the Singapore and Malaysia markets, and did health system operations and research at Johns Hopkins in Baltimore.

Building modern hepatocellular carcinoma surveillance programmes: taking steps to address a leading cause of liver cancer death in Asia is an Economist Impact report, supported by Roche Diagnostics Asia Pacific Pte Ltd.

Hepatocellular carcinoma (HCC) is a leading cause of cancer mortality in Asia, and its incidence is expected to peak within the next decade. Viral hepatitis B and C infections are the primary drivers of HCC in the region. However, metabolic disorders, such as nonalcoholic liver disease (NAFLD), diabetes and lifestyle-related risk factors are growing as contributors to the HCC burden, reflecting changing lifestyles and demographics.

Given the availability of highly effective interventions for HCC, health systems should prioritise identifying HCC cases early. This will facilitate early intervention, and thereby improve patient outcomes and survival. Systematic surveillance programmes that use appropriate diagnostic tools to identify at-risk patient groups are therefore necessary to mitigate the impact of HCC.

Learning from the well-established programmes, as well as from the challenges identified in economies that have not implemented systematic HCC surveillance thus far, this report highlights several important priorities:

Include HCC surveillance in national programmes and strategic plans.

Where the burden of liver cancer or underlying disease (such as viral hepatitis infection or metabolic disease) is high, HCC surveillance and control must be considered a public health priority. HCC surveillance should be included in national strategic planning where appropriate. Local incidence and prevalence of the disease, as well as existing priorities and resources, should dictate where HCC surveillance fits into the national health strategy. HCC might be included in stand-alone HCC plans, viral hepatitis control plans or broader cancer control plans. When these plans are supported by legislation and funding commitments, country examples show HCC patients experiencing better outcomes. Varying instances of the incorporation of HCC surveillance in strategic plans are seen in Japan, South Korea and Taiwan.

Secure sustainable funding commitments.

In order to be successful, programmes need to consider long-term resourcing and financing for HCC surveillance. Funding decisions should be aligned with evidencebased clinical guidelines and best practices wherever possible. This may require investing in additional ultrasound or advanced imaging equipment, more advanced and optimal testing modalities, trained operators, and laboratory capacity. Decision-makers should be aware that expanding programmes without considering the additional costs of testing and resourcing places extra pressure on health systems.

The appropriate level of funding for HCC surveillance is dictated by established health financing systems and ability to pay. Centralised healthcare coverage may offer the best chance to expand HCC surveillance, but economies could also explore the role of private insurance coverage in increasing access to HCC testing. Where HCC testing is not covered by universal health coverage, out-ofpocket (OOP) expenses can deter attendance and lower take-up rates. When transport costs and the wage loss due to missed employment to attend surveillance are considered, low take-up of HCC testing particularly impacts communities with lower socioeconomic status.

Collect, analyse and utilise data to inform programme design.

Modern approaches must prioritise the collection and analysis of data to inform programme design, devise appropriate surveillance modalities and calculate programme cost-effectiveness. Data on HCC epidemiology, patient outcomes, and the human and economic cost of HCC are needed for efficient HCC care. These data should be used by decision-makers to design evidencebased policy, and by relevant stakeholders to advocate for access to surveillance. Effective data sharing is also vital to inform broader public health priorities and update evidence-based clinical practice guidelines. Better data collection and integration will also enable long-term system optimisation and more robust analyses of programmatic impact and outcomes.

Adopt optimal technologies to advance HCC surveillance.

The region must optimise available technologies to improve overall survival of patients through early detection and timely referral for curative treatment. Technology must be adapted to local contextual factors, including epidemiology, resources, and geography. Including tumour markers such as prothrombin induced by vitamin K absence-II (PIVKA-II) and Lens culinaris agglutinin-reactive fraction of alpha-fetoprotein (AFP-L3) can help overcome the limitations of ultrasound and AFP testing. The wider use of advanced imaging techniques, or biomarkerbased statistical diagnostic models could also benefit HCC patients. This recommendation must be supported by consensus-driven clinical practice guidelines and clear funding commitments. Adapting IT systems to support surveillance programmes can improve access to services and patient recall for both rural and urban areas. With more investment, Artificial Intelligence (AI) systems could further facilitate risk-based surveillance approaches and streamline the interpretation of test results.

Mobilise existing resources for HCC surveillance.

Designing an effective surveillance system does not necessarily require significant new resources. Successful examples of Asian surveillance programmes utilise existing resources and meet the needs of affected populations effectively. Simple solutions seen in the region include expanding the range of healthcare professionals who can diagnose and manage HCC, as well as leveraging existing access points to the health system such as primary are and community health workers. Expanding and formalising the use of private healthcare capacity in HCC care, which has been demonstrably effective in other cancers, should be explored further.

Engage a broad spectrum of stakeholders to further surveillance goals.

A multi-stakeholder engagement approach must be adopted to drive optimal surveillance programmes. Key stakeholders include decision-makers from national and local government, physicians, patients, advocacy groups, payers and industry. The role of national clinical champions to bridge the gap between patients’ needs and policymakers’ understanding may help to drive progress.

Raise awareness and provide education on the need for HCC surveillance.

The current awareness and knowledge of HCC and surveillance is suboptimal among both healthcare professionals and the general population. This represents a significant and persistent barrier to surveillance uptake and compliance. There are excellent examples of awareness programmes in the region that utilise expertise from both medical experts and non-governmental organisations (NGOs). Learning from these programmes and applying a coordinated approach to HCC surveillance will offer the best chance for success.

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