>> Good afternoon.
Welcome to the National Cancer Institute's first Twitter Live.
Today, we'll be talking about the latest in liver cancer research.
My name is Dr. Anuradha Budhu, and I'm the Program Manager for the NCI Center for Cancer
Research Liver Cancer Program.
I'm also a research scientist here at the National Cancer Institute, working on functional
genomics of liver cancer and molecular mechanisms of liver cancer, initiation and progression.
Today, I'm pleased to be joined by two NCI colleagues, Dr. Tim Greten and Dr. Katherine
McGlynn.
Would you please take a moment to introduce yourselves?
>> My name is Tim Greten, and I'm the Co-Director of the NCI CCR Liver Cancer Program, and head
of the GI Malignancy Section, and I'm doing both basic research, and I'm also conducting
clinical trials for patients with liver cancer.
>> And I'm Katherine McGlynn.
I'm a cancer epidemiologist in the Division of Cancer Epidemiology in Genetics at the
NCI.
And one of my major research focus has been on studying the etiology of primary liver
cancer.
>> All right, thank you both.
Today, we're discussing our team's latest research into liver cancer.
In conjunction with the topics that will be discussed in this broadcast, we encourage
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All right, let's get started.
For our first topic, let's have a brief overview of liver cancer.
So what can you tell us about the current status of liver cancer in terms of its incidence
and mortality, both in the United States and across the globe?
>> It's probably a good idea to start with global incidence and mortality rates because
about 80% of liver cancer in the world occurs in countries that are--had developing economies.
And about 50% occurs in China alone.
High rate countries in Asia and China are the ones that we've traditionally studied.
However, in the last 30 or 40 years, liver cancer rates have been going up in many developed
countries, including the United States.
So right now, the country with the highest rates in the world is Mongolia.
Their rates run about 90 per 100,000 individuals.
As a comparison, rates in China and some other countries in East Asia, they run in the 20
or 30 cases per 100,000.
Whereas in the United States, the rates are more in the order of about 5 per 100,000.
So they're considerably lower, but going up in the U.S.
In terms of mortality, incidence and mortality are very similar because the prognosis of
liver cancer is poor.
So mortality rates are very similar to incidence rates in almost all regions.
And to emphasize here, we're talking about primary liver cancer, which is a cancer that
arises in the liver.
We're not talking about metastatic liver cancer, which is a cancer that rises in another organ,
and then metastasizes to the liver.
>> And what do we know about the increasing incidence rates in the United States?
Why do we think it's increasing at the rate that it is?
>> Well, there appears to be a couple of things going on.
One is Hepatitis C virus, which got into the U.S. population a number of years ago.
But it was spread for a number of decades in the 20th century before it was discovered.
Once it was discovered in 1990s, we were able to develop a test to get it out of the blood
supply fairly quickly.
So the possibility of being infected now through blood that you would get if you had an operation
say is no longer a concern.
The other fact in the U.S., unfortunately, is like many countries, rates of obesity and
diabetes are really going up.
And we know these are risk factors for liver cancer.
And so we think a lot of what's happening now may be related to this, this constellation
of metabolic disorders.
>> Okay, so we've gotten into this a little bit, but what, what do we know about the risk
factors that actually lead to liver cancer?
We know that there are many of them.
Can we talk a little bit about that?
>> Certainly.
Well, in, in very high rate areas, such as we mentioned previously, in Asia and Africa,
the dominant risk factor is chronic infection with the Hepatitis B virus.
In a few other high rate situations, such as in Egypt and in Japan, the dominant risk
factor is infection with the hepatitis C virus.
So those are the two biggest players.
In fact, it's felt that about then 80% of cancer in the world, liver cancer, is related
to Hepatitis B infection.
But there are other factors, as we just talked about.
Obesity and diabetes.
Smoking is also a risk factor, as is excessive alcohol consumption.
And in some parts of the world, eating foods that are contaminated with Aflatoxin B1 is
also, is a risk factor.
So we know a fair amount.
>> You know, let me maybe just add a few things concerning, you know, the western population,
because, you know, we heard a lot about the incidence rate in the world, and many people
think it may not be a disease that common in the United States, in the western world.
You know, it's still among the number, the first top 10 killers, or causes of cancer-related
death, also men and women.
It's quite common.
It's actually number five in men and number eight in women.
So, you know, it's not a disease that we only see in Asian countries.
And I think one of the problems we have, and a lot of research is also going on in this
field, is that we do know the individual risk factors.
But a lot of our patients actually have more than one risk factor.
You know, they may have an underlying liver disease, they may have Viral Hepatitis.
And then on top of that, they may be obese or they may drink alcohol.
And, you know, that is actually oftentimes a problem because then these risk factors
actually act so logistically and increase the risk for developing [inaudible] quite
dramatically.
>> Yes, that's a very good point.
So now that we know a little bit about this current status of liver cancer in the U.S.
and across the globe, and some of the risk factors associated with it, what can you tell
us about how we actually prevent liver cancer?
>> Probably the most important thing to do is to get vaccinated against Hepatitis B virus.
And it's been mandated in many countries for, for years now that babies get vaccinated against
Hepatitis B.
There is no vaccine for Hepatitis C virus, but there are medications now which cure Hepatitis
C virus.
Unfortunately, they're rather expensive still.
But they do cure the infection.
Obesity is something that we hear a lot about.
Being able to control weight, I think that's probably a little bit easier said than it
is done.
But certainly would contribute to decreasing risk.
Also, doing some [inaudible] controlling diabetes may decrease risk as well.
Stopping smoking, again, would be helpful.
And in countries where Aflatoxin is a problem, there are efforts to change how crops are
stored, how they're harvested, and how they're consumed in order to decrease risk associated
with Aflatoxin.
>> Okay, great.
We know that liver cancer is not the same between one individual and another.
What can you tell us about some of the health disparities that occur in liver cancer?
Particularly, we'll start with some of the racial disparities.
>> Well, in the U.S., rates among individuals of European ancestry are considerably lower
than our rates among other persons.
And we know that the highest rates used to be among Asians in the U.S., primarily due
to Hepatitis B infection.
Fortunately, though, with the introduction to the Hepatitis B virus, those rates are
going down now among Asians.
Unfortunately, rates are going up among all other racial ethnic groups.
So we see that by 2030, rates will be highest among Hispanic individuals and among American,
Indian and Alaska native persons, with rates among whites being the lowest still, but increasing.
So there's also, of course, gender disparity in risk.
In most countries, rates among males are about three to four times higher than they are among
females.
So we don't really understand the reason for that, exempt for men do tend to have more
risk factors than women do.
The other notable disparity around the world is in income level, that liver cancer, like
some other cancers, such as stomach cancer and cervical cancer, tends to be a cancer
that is more common in countries that are in developing--and it's associated with poor
access to, poor access to health care and to lower income status.
So it's, it's certainly one that has a number of different disparities over several segments.
>> Okay, so if one has liver cancer, what are some of the signs and symptoms that one
has this disease, and how do we actually detect and diagnose this cancer in the clinic?
>> So unfortunately, there aren't really any typical symptoms for liver cancer.
We have, you know, very non-specific symptoms, such as fatigue, weight loss, pain, change
in skin color, which we call jaundice maybe, which are probably, you know, the main risk
factors.
But, you know, if you really think about them, none of them are really specific and tell
us immediately or raise a flag that this may be liver cancer.
So oftentimes, we actually just identify this accidentally, which should not always be the
case, because, you know, if I just may come back for a second to the risk factors, about
80% of all patients with HCC have an underlying liver cirrhosis.
And that's kind of a pre-cancerous condition, so we recommend those patients to undergo
surveillance by ultrasound and potential [inaudible] testing.
We know that the risk for these patients, depending on the underlying diseases, some
were in the range of 3 to 5% annually to develop an HCC.
And this is very, very important because it will allow us to identify patients not only
at an early stage before potential symptoms may arise, but also at a stage where we can
potentially cure the disease, which is obviously the ultimate goal.
Now, the other symptoms that, or the way how we, how we go on what these symptoms are,
basically, imaging studies, blood tests, or we look at the liver and other organs to see
whether there are any changes using ultrasound initially, or CT scan, and MRI scans.
And then depending on the situation, it may be necessary to take a small biopsy from a
lesion and send this to the pathologist so that he can then ultimately make the diagnosis
of an HCC.
>> And it should, it should probably be pointed out by us that HCC, or hepatocellular carcinoma,
is the dominant type of liver cancer in most places around the world.
It's not the only type.
>> That's true.
>> Intrahepatic cholangiocarcinoma is the second most common type, and is, in Thailand,
is the most common type.
And the risk factors are different between intrahepatic cholangiocarcinoma and hepatocellular
carcinoma.
>> Okay, what can we say about the current treatment standards of liver cancer?
>> So there really is a variety of treatment options.
And usually, you know, we can divide this actually by early stage or by the different
disciplines that help us treat the diseases.
There are surgical options.
The surgeon can either remove the lesion.
And alternatively, there is the option of doing the liver transplant where the surgeon
removes the whole liver, the entire liver, together with a tumor.
Interventional radiologists have a number of different options.
They can potentially use little needles to what we call ablate lesions using, for instance,
radiofrequency ablation where they take a needle and then basically burn the lesion
in the liver.
Once the disease is, for the advanced, there are other techniques, such as the transarterial
chemoembolization, or TACE.
This is a procedure where the intervention radiologist basically places a catheter into
the hepatic artery and delivers a combination of chemotherapy and small beats to target
the feeding vessels off a tumor.
And then we have systemic treatments, as well as a radiation treatment, to treat patients
with more advanced disease.
>> Are treatment standards the same across different regions of the world, or are there
standards?
>> Well, I think overall, in general, they are similar.
Obviously, they are not identical.
It also depends a little bit on the experience of the different area.
You know, you already heard that this is a very common disease in China, and I would
say the Chinese approach is a little different from the western approach.
And then there are different regulations about transplant, for instance, so that obviously
has an affect on the treatment.
But in general, I would say the treatments are very similar, where we have curative treatment
options, such as the resection and the radiofrequency ablation.
TACE is probably the most common performed procedure in liver cancer.
And then systemic treatments, which are obviously available throughout the world.
And then based on our research, as well as conferences where we report about results
from research, I would say they are very similar throughout the world.
>> Okay.
>> That said, however, in some areas of the world, the poorer countries certainly don't
have the wherewithal to have some of the more modern treatments.
And some countries have no access to radiotherapy at all.
So in those countries, it's much more challenging to treat.
>> Or even the very expensive drugs.
>> Right.
>> Okay, all right, so we've heard a little bit about some of the risk factors for liver
cancer, ways we can prevent liver cancer, the signs and symptoms of this disease, what
can be done in terms of treatment.
Let's discuss a little bit now about what's being done in liver cancer research.
>> Sure.
You know, there is a lot of research.
Basically, you know, from, and you can see this from, from, from the group that is here
from the very early stage where we look at the epidemiology and the understanding of
risk factors to genetic studies where we identify specific genes and identify patients that
are at high risk and understand the cancer biology to develop and other treatment options.
So there's really a vast area of research ongoing.
>> Okay, can you tell us a little bit--we talked a little bit about, you know, one liver
cancer patient is not the same as another.
In our research world, we call this heterogeneity.
Can you talk a little bit about what's being done in terms of studying heterogeneity and
liver cancer?
>> So heterogeneity is a very interesting, but also complicated term.
So I think, you know, we're starting to learn that cancer, in general, is not cancer, you
know?
And even if you talk about one organ, the disease is not the same in every patient.
Now, to make it more complicated, if a patient actually has more than one lesion, even two
lesions may not behave similarly.
And, you know, we have now techniques to identify those lesions and look at the source of these
lesions and see that they may actually be different.
And what we're trying to do is using different genetic approaches to really go to the root
and understand the genetics of this disease for two reasons.
Number one, to understand what the cause of the disease is and how this disease is being--is
developing.
But secondly, also, to potentially identify a treatment, which really fits a specific
combination of markers that we can potentially identify in a tumor.
I would say that still, a future, this is something that is currently not being done
yet, but I think that's certainly an important and interesting field of research.
>> Yes.
And just to add quickly, from the genomics aspect that we work on in the laboratory,
we are trying to identify factors that are perhaps similarly expressed or signaling pathways
that are in common between different groups of individuals so that we can look at particular
groups of liver cancer patients as more homogeneous, what we call subgroups or subtypes, that can
inform us a little bit about some of the mechanisms and signaling pathways that are being altered.
And this can be quite informative when we look to whether a patient will benefit from
a particular type of drug.
You know, and that can be determined whether there are signaling mechanisms that this drug
affects.
Is that present in the patient or not?
>> So are these only genetic markers, or are there other markers?
>> No, so we look at genetic markers, we look at genomic markers.
So genomic markers are a slew of markers that can be anything from genes to small RNA species
to small biochemical species called metabolites to factors present, like protein levels, et
cetera.
And we can find them in a variety of different specimens, from tissue specimens to blood
specimens, urine specimens.
So we try to look for these markers that are present in our less invasive biospecimens,
such as blood or serums, so that we don't actually have to go and do invasive procedures,
such as resections or transplants, et cetera, to be able to measure these types of markers.
>> Okay, we mentioned a little bit that in liver cancer, it's not only the liver cancer
tumor itself, but also the role or the status of the liver itself.
And it can be quite affected by what we call cirrhosis or scarring of the liver.
What can we say about current research in terms of what we know about the micro environment
of the liver?
>> So I think, if I may start from a clinical perspective, one of the main problems we have
with liver cancer is that we have to understand that this is a cancer that is actually--that
appears in a diseased organ.
So we actually have to deal with the underlying liver cirrhosis, and we have to deal with
the cancer, which makes the treatment way more complicated.
So that's number one.
And then number two is the environment plays a significant role.
We went through the different risk factors.
Viral hepatitis, alcohol, non-alcoholic fatty liver disease, and they change the environment.
They have significant effects on the environment.
They can change the behavior of the tissue.
They can cause barriers for cells to migrate.
They can change the environment and lead to specific molecules to be elevated, which leads
to elimination of specific immune cells and other cells in the environment.
So I would say we are just starting to understand that there are many factors, and I would say,
you know, this goes all the way, beginning from fatty liver disease, and actually diet
affecting this, to the microbiome and diabetes, et cetera, many factors that all contribute
to the environment and may have an effect on tumor growth without directly actually
being affected by tumor cells.
>> Very important points.
So we've mainly been talking about primary tumor in the liver, but there's also a lot
of research being done on metastatic liver cancer.
So what can you tell us about where tumors tend to metastasize to and what we know about
ongoing research about liver cancer metastasis?
>> So the liver cancer can actually metastasize within the liver.
Then it can metastasize to local lymph nodes.
And other sites, or common sites are the lung, bone, the peritoneum and adrenal glands, which
are, I guess, probably the most common sites.
Now, in terms of treatment, we, as of now, we still put these cancer types, or the different
metastasis really all together and just basically treat them as a systemic disease.
So, in other words, this is really the field where we use either systemic chemotherapy,
or what we call target therapy, or potentially immunotherapy, to treat patients with.
>> So you just mentioned immunotherapy.
Can you tell us a little bit about some of the immunotherapy approaches that are currently
being used to treat liver cancer?
>> So obviously there is a huge interest in immunotherapy, and immune checkpoint inhibitors,
which are basically described as their ability to unleash the immune system and to really
fuel T cells.
One type of treatment that has shown in very early studies promising results, which led
to the approval of these drugs, actually in the second line setting, so I would say a
new checkpoint inhibitors are certainly one type of already-approved immunotherapy, bullet
there is a lot of research ongoing using different mechanisms, using cell-based approaches, identifying
specific antigens that we can target, activating other immune cells and changing the immune
environments so that we potentially get an even more powerful anti-tumor immune response.
>> Great.
So Katherine, what can you tell us a little bit about some of the epidemiology, the large
population-based studies, and the research that's going on there in terms of liver cancer?
>> Well, one thing we're trying to do in our group is really understand what's going on
in the United States.
And because there were no big cohort studies when we got, when we started this endeavor,
what we did was put together a big pooling project that brought together cohorts from
all over the United States.
Each one alone would not be able to study liver cancer because there simply wouldn't
be enough cancers in a particular cohort.
But by bringing them together, we were able to have enough power to study them in the
cohorts.
So we've been trying in that situation to look at the effect of diabetes, obesity, fatty
liver disease.
We've looked at alcohol and tobacco, and looked at the effect of some medications as well.
One that we've seen in several studies that has some promise is the use of non-steroidal
anti-inflammatory drugs.
>> Okay.
>> Aspirin really is one that seems to be somewhat--have somewhat protective effect.
Some of the other medications that we've been able to look at are, among women, menopausal
hormone therapy.
Oral contraceptives, for many years, has been controversial, and has been felt to be increasing
risk.
But in our studies, we have not found that to be the case.
The one medication that we saw that seemed to have a very large effect was the use of
statins, of course, the cholesterol-lowering medications that really seem to reduce risk.
We also looked at drugs to treat diabetes, and we did not find any, any protective effect,
although there's been a lot of interest in Metformin and its ability to decrease risk
of not only liver cancer, but a wide variety of cancers.
We've also been collaborating with other populations to look at the effect.
And we've been trying to study microbiome and working with other populations to do that.
And the effect of bacterial translocation.
Tim mentioned that there's been a lot of interest in microbiome, of course.
You need, you need the proper materials to study that well.
So we turn to studying bacterial translocation because there is a well-known liver access
that gets disrupted in the case of liver disease.
And bacterial products can get into the stemule [phonetic], into the circulation, and we can
detect those, and have been looking at the effect of other etiologies on this.
So there's, there's a wide variety of studies going on.
In my division, we also do genome-wide association studies, which we've been involved with for
both types of the liver cancer we discussed.
So there's, there's been a lot of activity, and we certainly hope now that there will
be more, with more people coming into the field, and with our growing understanding
of what is happening.
>> Okay.
So you mentioned genome-wide association studies.
Can you tell us a little bit more about what that is and how we can put that in concert
with some of our genomics studies that we do on liver cancer?
>> Well, the aim of the genome-wide association studies are to look at genetic susceptibility
to the cancer.
So the large one for hepatocellular carcinoma has been going on in the United States.
It's been coordinated with our extramural colleagues.
And the first part of that study is done.
We hope to be starting the second part, the replication part of that study, fairly soon.
In terms of intrahepatic cholangiocarcinoma, we're currently doing the first part of that
study, which is called the discovery phase, to look for susceptibility genes.
And we hope with, once that is complete, that that will give us a number of targets that
we can test with the second phase of the study.
So these have been done widely in many cancers.
I'm sure people have heard about them in association with breast cancer, colon cancer, or so forth.
But fewer of these types of studies have been done with cancers that are not, that are not
the Big Four cancers in the U.S.
>> So I know you've actually been involved in some of those studies as well, which have
not necessarily been placed in the United States.
>> I have.
So I was just going to follow Katherine and just say it's very nice that you're doing
all of these studies in the United States because we have sort of complementary studies
across different regions of the world, particularly in Asia.
In China, we have been studying Hepatitis B-related liver cancer for quite some time,
and have quite a large population that we've been following over the last few decades.
We also have a study in Thailand called TIGER-LC.
This is a study enrolling about 6,000 individuals who either have liver cancer, hepatocellular
carcinoma, and as Katherine mentioned earlier, cholangiocarcinoma is quite prevalent in northeastern
regions of Thailand.
And so we're taking a look at comparing and contrasting those primary liver cancer types
in that country.
We're also looking at individuals with chronic liver disease who do not yet have cancer,
but who may be prone to having cancer because of the risk factors that are present that
we mentioned earlier.
And comparing and contrasting these individuals to help the population controls.
In addition, we have a study in Mongolia that we briefly mentioned earlier to study liver
cancer there, which has the highest incidence of liver cancer in the world, and has a very
unique etiology of Hepatitis Delta infection.
So I think down the line, it will be very interesting to compare and contrast these
large cohorts across the world, not only to look at the genomic factors and genetic factors,
but also to look at environmental factors, dietary factors, et cetera, and to compare
and contrast race, ethnicity, and all of these other types of disparities that we discussed
earlier.
So I think this is going to be very interesting in the future, and provide a lot of data for
us to perform research on.
>> Great.
Anything else you'd like to update us about on research that we haven't touched on yet?
>> Well, I mean, obviously, you know, there is this huge interest in immunology, ongoing,
based on, you know, recent approval of immune checkpoint inhibitors for treatment of immunotherapy.
Now, to be honest, most of those studies are either being done with the patients directly,
where you test novel approaches, which are currently also being conducted here at the
NCI Clinical Center, or what we do a lot is we try to model this in animals and mice and
try to study how the immune system really responds to tumors and how we can potentially
modify that.
>> Right.
Okay, well, lots of very anxiety research on liver cancer here at the NIH and across
the world.
I'd like to just briefly mention that the NCI CCR Center for Cancer Research has launched
a liver cancer program earlier this year.
This is a multidisciplinary program that aims to consolidate all of the expertise that we
have on liver cancer itself or liver disease and create an interactive and collaborative
environment that will foster more liver cancer research and help with liver cancer care.
This is a program that's going to be multidisciplinary within the National Cancer Institute, within
the various institutes of the NIH, and between the NIH and other institutes in the U.S. and
across the globe.
We will have four main focus areas for this program, and we touched upon these four focus
areas during our discussion.
That is early detection, diagnosis, the study of various populations across the world, and
treatment.
So you can find additional information about this program at our website, ccr.cancer.gov/liver-cancer-program.
So I think now we're going to turn to some of the live questions from viewers.
So here, I think we have our first question, asking whether there are any support groups
for patients with liver cancer and their families.
>> So liver cancer, unfortunately, is actually a disease where there are very few support
groups.
There are, indeed, some support groups for patients with liver disease in general.
And they tend to also cover liver cancer.
There are small groups for patients with primary HCC.
I would say there's a little bit more presence for cholangiocarcinoma, which we have not
discussed that much so far, but which obviously is also a primary liver cancer with the Cholangiocarcinoma
Foundation.
So there are support groups, but I think, you know, it is nothing compared to other
types of cancers, like pancreatic cancer, where we know big groups supporting this,
or breast cancer, et cetera.
>> There are support groups for Hepatitis B, and persons with Hepatitis B infection
or Hepatitis C infection.
But they tend to be a little bit more spread out.
So and perhaps that stood in the way of everyone coming together to have a liver cancer support
group.
>> Okay, thank you.
Okay, we have another question.
How do I know if the symptoms I'm experiencing are caused by liver cancer or by some other
health condition?
>> Well, as I said, that's not an easy question.
And basically, you know, the only recommendation I can give you is that you see your primary
care physician who will have to do some--to talk to you, have to do a physical examination,
blood tests, and then potentially imaging studies.
>> So, let's see, what can you tell us about current liver cancer clinical trials?
>> So there are many ongoing clinical trials, and you can find them all on the website,
www.clinicaltrials,gov, where you can basically just enter the search words liver cancer,
or better publicly, just carcinoma, and then you can even search by area, and you will
find registered clinical trials that are currently recruiting throughout the world, actually.
Obviously in the United States, but throughout the world.
There are trials currently being done at the clinical center here.
These are studies, because we have a lot of interest in HCC, we do studies for patients
with a very early disease.
We perform surgery on these cases.
We do the procedures that I just called earlier, Transarterial chemoembolization, we have colleagues
here that try to improve these techniques, or in collaboration with these colleagues,
we combine this with immunotherapy, with immune checkpoints, inhibitor therapy.
We have studies for patients with more advanced disease where we use combination treatments.
So I would say there are a number of studies for patients with primary HCC.
We also have studies for patients with cholangiocarcinoma, a less common disease where we also try immune-based
approaches.
And on top of that, there are a number of small studies, which are not specifically
only for HCC, but which also include patients with HCC.
And for this, I think the best is to contact directly the Clinical Center to look for specific
studies.
>> Okay, great.
So our next question actually touches, again, on immunotherapy.
So maybe we can just reiterate a little bit here.
Are treatments that increase the body's immune response against tumors being tested in patients
with liver cancer?
>> Yes, absolutely.
So there are a number of studies from phase one to phase there where different types of
immune approaches, either a single agent, or as a combination, or after surgery, currently
being tested I would say throughout the world, definitely in the United States, as well as
at the Clinical Center.
>> Okay, can you tell us a little bit briefly about what kinds of doctors treat liver cancer?
>> So liver cancer is, as I mentioned before, a disease which is a little bit complicated
because you have to consider the underlying disease.
So in most cases, actually, all patients are being seen by a team of physicians, or at
least discussed at an interdisciplinary tumor board, consisting of hepatologists, interventional
radiologists, the pathologist, surgeon, and medical oncologist, where we identify the
best treatment.
So I think it's fair to say that in most cases, an individual case should be discussed, at
least by a surgeon interventional radiologist and medical oncologist.
>> Okay, our next question has to do a bit with one of the risk factors for liver cancer.
That is alcohol consumption.
And the question is regarding how much alcohol is too much alcohol when it comes to actually
causing liver cancer.
>> Well, liver cancer has been a cancer where it's really in excessive consumption that
is associated with risk, unlike something like esophageal cancer, where you can--you
have much lower levels that increase your risk.
But in terms of how much is too much, it's difficult to say.
The past month or so, a couple of studies have come out, and one said, having one drink
a day, in fact, not increases the risk of liver cancer, but increases the risk of mortality.
So I don't think we're talking at the level of one drink a day.
But it's a little bit difficult to say how much is too much.
It is, as Tim mentioned, drinking on top of something like Hepatitis C infection, or Hepatitis
B infection, really increases risk.
So if one knows they're a viral carrier, they should really endeavor not to drink at all.
>> Okay, very good point.
Okay, so I think this is our last question.
We've heard a bit about liver cancer occurring in adults.
What can we say about liver cancer in children?
Does this cancer also occur in children?
And is it the same disease or a different disease that occurs in a child versus an adult?
>> So there are different diseases actually which occur in children.
And now we really start talking about very rare diseases.
So there is something which is called the hepatoblastoma, which is a primary liver cancer
in children, which is different than the HCC.
There is an even more rare form called Fibrolamellar HCC, which can occur in children, as well
as young adults.
So we do see this disease also in children, but I would say that's really the exception.
>> Okay.
>> Now, in China, we used to see HCC in young people.
And even in adolescents, you can get HCC.
In one of the demonstrations that the Hepatitis B vaccine was having an effect was we saw
rates start to go down in younger people.
It's, it's too soon yet really to see an effect on the overall population because most liver
cancer isn't diagnosed until the 60s among people in their 60s.
But we've seen rates come down among very young people in China as a result of the vaccine.
>> Okay.
>> So it does--HCC can occur at a young age, unfortunately, if you have an insult like
Hepatitis B that tends to be transmitted at birth.
>> Okay, very good.
All right, well, thank you both.
I think that's all the time that we have today for questions.
Do either of you have anything you'd like to briefly add before we go?
>> Well, you know, let me just--I think there's three things I want to point out.
So number one is, you know, don't think that liver cancer is a disease that only occurs
in Asia.
It's a common disease in the western world, including the United States, number one.
Number two, it's a very complicated disease, you know?
We touched about risk factors.
We touched upon, you know, the gut-liver axis, the anatomy of the liver, which is very distinct,
which is also leading, or making this area of research, I think, one of the most interesting
areas of research.
And I think that's why there are so many scientists here at the NCI working on this field, because,
you know, other than many other cancers where you basically have an organ and then you have
the healthy organ and you have a diseased organ, in this particular case, it is very,
very different, and only the interdisciplinary, not only treatment, but actually interdisciplinary
research, what we are doing in this liver cancer problem that we have here is, is capable
of leading to significant advances in our understanding of the disease, and then developing
future treatments.
>> And one final comment about risk factors, again, it's, in thinking about something Tim
said, is the dominant risk factor, if you can really call it that, is having cirrhosis.
And so any individual with cirrhosis really needs to be in close contact with his or her
physician to make sure there is no advancement here.
So having, having access to quality health care certainly makes a lot of difference in
when people are seen and what can be done about their disease.
So it's very important, though, with cirrhosis to get constant follow-up.
>> Very good point.
All right, I'd like to thank you both for a very informative discussion today.
And I'd like to thank all of our audience members for joining us and asking very interesting
and important questions.
I'd like to remind our viewers that this video will appear on the National Institute's Twitter
feed, NCI's Periscope Channel, and NCI's YouTube channel.
Any questions and the comments that we didn't get to today will be answered shortly via
Twitter.
And as a reminder, you can always contact the NCI Contact Center at 1-800-4-CANCER,
or by visiting cancer.gov/contact for any live chat help.
Thank you all for tuning in to the latest social media event hosted by the National
Cancer Institute.
Thank you again, and goodbye.
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