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Models and Mentors
By Mike Goodkind
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Faculty liver cancer surgeon Samuel So wants to stop a deadly worldwide epidemic of liver cancer that he's convinced too few people seem to be doing anything about.
And he's perfectly willing to devote a lot of time and attention to public education and prevention, especially if success will keep patients out of his operating room.
As an outgrowth of his research in liver cancer genomics and pioneering techniques of liver resection, So came across an alarming gap in the public health picture: Although 600,000 persons in the world die each year of primary liver cancer, the problem is relatively rare among non-Asians in the United States.
That statistic has kept liver cancer low on the public policy radar screen and has negatively impacted education and research funding, said So, the Lui Hac Minh Professor of Surgery at the School of Medicine.
As the director of the Asian Liver Center and its educational component, the Jade Ribbon Campaign, So has undertaken (and at first largely funded with his own monies) an outreach effort with a sense of missionary zeal, scholarly savvy and a blizzard of statistics. The goal of this effort is to give his colleagues in family practice a simple take-home message for their patients of Asian and Pacific Island (API) heritage who are disproportionately at risk for hepatitis B and resultant liver cancer:
"Test all of your API [Asian and Pacific Islander] patients for hepatitis B. A one-time, simple and cheap screening blood test will stop a cycle of illness and death that systematically falls under the radar screen in this country," said So.
"Many physicians, even if they are API themselves, have been unaware of the unusual risk," So explained. "For example, a few years ago, I talked with a well respected, young, general internist in San Francisco whose parents were born in China. He was a so-called 'healthy' hepatitis B carrier and had recently been diagnosed with liver cancer. He was unaware that he was at high risk for developing liver cancer at an early age. He had not thought during his busy career to screen himself for liver cancer."
Though So presents some striking statistics, in a 2001 open letter to fellow physicians, he first acknowledged that blander statistics seem to drive an apathy that has kept liver cancer off the screening, prevention and early treatment radar screens.
"Nationally, the incidence of chronic hepatitis B virus (HBV) infection (or HBV carrier rate) is only 0.4 percent, and liver cancer is ranked well out of the top-ten list of cancers. That makes liver cancer funding a lower priority target for most sources, including the NIH. In Caucasian, Hispanic, and Black Americans, chronic HBV infection rates are 0.1 percent, 0.1 percent, and 0.5 percent respectively," he said.
However, liver cancer rates are 13, 8, and six times higher in Vietnamese, Korean and Chinese Americans, respectively, than Caucasian American males. Significantly, in the API community, So said, 80 percent of liver cancer is caused by chronic HBV infection - endemic in Asian nations, where 10 to 20 percent of the population is infected at birth or early childhood.
"Eventually in the United States HBV infection and liver cancers may recede among the API population, but how many individuals and families will suffer and die before we reach this statistical balance?," So said.
He also noted the API community is the fastest growing in the Bay Area, comprising a third of the population of San Francisco, and 20 percent of San Mateo, Santa Clara and Alameda counties. Since 80 percent of the API community in California is foreign born, many do not know they are hepatitis B carriers and are not aware of the risk for liver cancer. With its high density of API population, the Bay Area also has the highest incidence of liver cancer in the country, So said.
The Jade Ribbon Campaign employs a three-pronged approach to fighting hepatitis B in the Bay Area through outreach, education and research. The campaign was named for the good luck, and longevity that jade in traditional Asian culture is said to bring. Folded like the Chinese character meaning "people", the Jade Ribbon symbolizes the spirit of the campaign to unite people around the world to eradicate hepatitis B and liver cancer, said So.
Besides an active media and physician campaign, So has enlisted high school and college students, mostly from the API community, to bring the message to their peers and their community through an organized youth council.
Potential patients receive materials custom written in the languages appropriate to each linguistic and cultural audience. "One thing we realized very early was that you can't translate materials directly from English into an Asian language and expect to get your message across. You need to customize each message for the cultural and linguistic sensitivities of specific audiences," So said.
So has also targeted the international health-care arena. Traveling extensively to China, the Philippines and other Asian nations, where liver cancer takes more lives than heart disease, So is working to reinvigorate prevention programs and raise awareness. Screening and vaccination for HBV on a global, particularly Pacific Rim-wide, basis is the key to combating liver cancer, he said. Sadly, he added, most vaccination programs supported by international aid agencies give very little attention to hepatitis B prevention.
So's efforts are, however, starting to make a difference. Working with the California Department of Health, the American Cancer Society and others, So was instrumental in crafting the first liver cancer prevention plan for the state of California that calls for all API to be tested and vaccinated against hepatitis B by 2010.
Beyond liver cancer prevention, his efforts are helping to improve patient outcomes for those diagnosed with the disease. According to So, who is the director of Stanford's Liver Cancer Clinic and Tumor Board, the key to effective care is a multi-disciplinary approach to treatment.
"I pushed hard to start the liver cancer tumor board when I got tired of hearing discussions that could degenerate into a feeling of 'You shouldn't have done that, you should have,'" said So. "I wanted to develop and join a team of internists, surgeons, cancer specialists, as well as diagnostic and interventional radiologists, who would look for the best alternative for the individual patient right from the start."
-Courtesy of Medical Update, a publication of the Medical Staff office
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Posted 3/23/05
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