AUG/SEPT 2004
Volume 28 No. 8



Medicare warns
of provider scam

Unacceptable abbreviations chart

Revised & renewed protocols need IRB review, dean says

US News and World Reports Hospital Rankings

Common charges available for patient perusal on request

Role of clinician educators reviewed

Report needle sticks

From Tumor Board to Public Affairs, liver suregon believes in outreach

Infusion treatment area

Hematopathology Moment

 

Samuel So, professor of surgery and director of both the Liver Cancer Program and the Asian Liver Center at Stanford, recruits students to help spread awareness about the dangers of hepatitis B in the Asian and Pacific islander (API) community. Working on projects in So’s lab during the summer were two Stanford undergraduates, Mark Hsu, of Saratoga, and Claire Liu, of Danville.


 

From tumor board to public affairs, liver surgeon believes in outreach

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 such 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, director of Stanford's multidisciplinary Liver Cancer Clinic and Tumor Board.

So also directs the Asian Liver Center and its educational component, the Jade Ribbon Campaign. He now promotes (and initially largely funded personally) his outreach efforts with a sense of missionary zeal, scholarly savvy, and a blizzard of statistics to give his colleagues in family practice a deceptively simple take-home message for their patients of Asian and Pacific Island (API) heritage - all of whom are at disproportionately high risk of 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."

So presents some striking statistics, but in a 2001 open letter to fellow physicians, he first acknowledged that blander statistics seem to drive an apathy that keeps 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 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, he said.

So's campaign is international - he travels extensively to China, the Philippines and other Asian nations where liver cancer takes more lives than heart disease. His goal, he said, is to help 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 are broken due to the little attention and aid they receive for hepatitis B prevention from international aid agencies.

The Jade Ribbon Campaign employs a three-pronged approach to fight hepatitis B through outreach, education and research. (So said the campaign was named for the good luck, and longevity that the jade in traditional Asian culture is expected to bring. Folded like the Chinese character meaning "people", the Jade Ribbon is symbolic of the spirit of the campaign to unite people around the world to eradicate hepatitis B and liver cancer to build a healthier community).

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 doesn't deny his interest in stopping liver cancer is personal, "but I really believe that my perspective is transpacific - I was born in Hong Kong and graduated [summa cum laude] from the University of Minnesota. I went back to Hong Kong, where I graduated from medical school in 1978." He retuned to Minnesota for postdoctoral work in general surgery, immunology and organ transplantation. Then he directed the pediatric transplant program at Washington University in St. Louis. So came to Stanford in 1995 after three years at the California Pacific Medical Center, San Francisco, Liver Transplant Program.

So founded the Asian Liver Center in 1996, and two years later he was named director of the Multidisciplinary Liver Cancer Program and the Liver Tumor Clinic. Last year So was named to the Lui Hac Minh Professorship. He has received numerous academic and public honors. One accolade came in May when he was chosen - and publicized widely along with his message - as one of five "local heroes" during an Asian Pacific American Heritage Month celebration sponsored by public broadcasting station KQED. So felt that his efforts are starting to make a difference. Working with the California Department of Health, the American Cancer Society and others, So helped to craft 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.

"I understand why the problem of liver cancer is sometimes ignored by my fellow citizens in this country, and I understand the biases my fellow surgeons and physicians often have about dealing with this problem from a prevention and screening perspective. But as a scientist, I'm sensitive to the need for proof rather than bluster,"

So said. So said communication and education extend beyond his passion for liver cancer prevention. He is almost a missionary for multidisciplinary medicine.

"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…'. 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. Eventually, we were able to draw in a fine group of colleagues. (It took a lot of donuts and latte at first, but soon my colleagues and I saw a lot of personal benefits for our patients and for ourselves as well)." So said the program offers participants the personal satisfaction of publishing scientific papers as a member of a crack academic team.

"Too often surgeons (including me in my younger days) take an aggressive attitude, 'Let's go in there and see what we can find.' Sure, sometimes that works, but keep in mind surgery, even routine exploratory surgery, is uncomfortable at best…. I have to keep telling myself that quality of life is the bottom line.

"On the surgical and medical side we are developing better noninvasive diagnostic procedures, including radiological techniques that have virtually eliminated the need for most exploratory surgeries. And there is also a human side. When I talk with a patient, I keep reminding myself, if I or a close family member had a fighting chance, I think I would want to do everything I could to survive. But if I had only a few months to live, I wouldn't want to spend that time in postop or chemo. Personally, I'd want to lie on the beach in Hawaii or at least spend some lazy afternoons in Santa Cruz. I talk to patients as if they were members of my family. I say to them, 'You have several options, but if you were a member of my family, I'd...'"

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For further information on Stanford's Asian Liver Center or the Liver Cancer Program, go to: http://livercancer.stanford.edu, and http://www.stanfordhospital.com/clinicsmedServices/
COE/cancer/liver cancer.html
. Information on hepatitis B may also be found on the Centers for Disease Control website: http://www.cdc.gov/ncidod/diseases/hepatitis/b/index.htm
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