October is Liver Cancer Awareness month, and Europe has a liver cancer problem. Over the past two decades, there has been a 70% increase in liver cancer-related mortality in the region. 

In 2020, 87,000 Europeans were diagnosed with liver cancer while 78,000 died from the disease in the same year.

Late diagnosis is a serious problem. About half of patients are only diagnosed in an advanced stage of cancer and have less than a year to live.

Liver cancer is the sixth most common cancer and the third biggest cause of cancer-related deaths globally. 

In the US, the rate of deaths from liver cancer increased by 40% from 1990 to 2004 while the overall rate of non-liver cancer deaths declined by 18%.

Projections for the US estimate that in 2030, liver cancer will be the third-leading cause of cancer-related deaths, surpassing breast, colorectal, and prostate cancers.

There are many risk factors for developing liver cancer, and chronic liver diseases caused by viral hepatitis, alcohol, or fatty liver disease are the most important.

Diabetes and obesity 

Non-alcohol fatty liver disease (NAFLD), which is often a consequence of obesity and diabetes, is the leading cause of death among 35 to 49-year-olds in the UK, making NAFLD a health threat that should not be underestimated. (The more severe form of NAFLD is called nonalcoholic steatohepatitis, or NASH).

Outside of COVID-19, NAFLD is also about the fastest growing disease globally. It occurs in about one in four people around the world and has emerged as the most prominent cause of chronic liver disease. 

Experts predict that, over the next decade, NAFLD will become the leading cause of end-stage liver disease and liver transplantation. It is already the fastest-growing cause of hepatocellular carcinoma (HCC), the most common form of liver cancer worldwide.

Faced with a ticking public health time bomb in Europe, we are clearly in a race against time to both prevent and treat this disease before the epidemic worsens and overwhelms health systems.

Better treatment access

Treatment of chronic liver diseases to avoid their progression to precancerous states like cirrhosis significantly reduces the risk of liver cancer, and this has been convincingly demonstrated. 

Improved and equal access to state-of-the-art management of these diseases is a core element in the fight against liver cancer.

Although liver cancer remains one of the few cancers with increasing incidence and mortality, public awareness of liver cancer is much lower than for other cancers. 

As a consequence, patients who have liver cancer and patients who are at increased risk for liver cancer often face stigma in their social lives, and also in the medical settings.

Treatment options for liver cancer have significantly improved over the recent years, which makes early diagnosis the most critical point. Case-finding strategies need to be implemented, at least in at-risk patients, as strongly recommended by clinical guidelines.

Hepatitis B vaccinations

Finally, we must directly tackle the key environmental factors that cause liver diseases and liver cancer. In addition, successful Hepatitis B vaccination programmes need to be continued and expanded as the core element of primary liver cancer prevention as it has the potential to prevent roughly twice as many cancer cases as HPV vaccination.

Earlier this year the European Commission launched its Beating Cancer Plan in response to the fact that the EU region is home to a quarter of the world’s cancer cases and is facing an annual economic impact of €100 billion if urgent action is not taken. 

This plan is precisely what is needed to bring scientific societies, experts and patient groups together to move forward measures that can go a long way towards stopping liver cancer in its tracks.

But these measures need to be coordinated across the region, led by the European Commission, and implemented by EU Member States.

A starting point has to be the setting of standards for awareness, prevention, and management of liver cancer across the region. It is pivotal that we educate and raise awareness amongst everyone: healthcare professionals, patients and families, risk groups, policymakers and the general public.

Liver cancer usually occurs as a consequence of underlying chronic liver disease and cirrhosis. Thus, the EU and Member States should implement preventive measures that include evidence-based strategies to reduce the burden of liver disease, focusing on reducing alcohol consumption and obesity, and on early detection and treatment of chronic liver disease.

Early detection is critical for those patients with liver diseases associated with a high risk of liver cancer such viral hepatis B and C, alcohol-related and non-alcoholic fatty liver disease. The EU and Member States should add liver cancer to their screening list, at least for patients with underlying risk factors. In addition, existing programs providing the opportunity of early case finding of liver diseases should be leveraged where possible. The salivary screening for Hepatitis C using point of care testing is a good example and complements the WHO HCV program aiming at fighting HCC as well.

Inter-disciplinary disease management

But we also need improved access to better disease management for patients with liver cancer across all member states of the EU. This means a more structured pathway for the diagnosis and treatment of patients when they are receiving care in hospital, as an outpatient and then at home. 

That will require better inter-disciplinary cooperation between hepatology, oncology and other relevant disciplines and ideally collaborative clinical guidelines that are driven by comprehensive scientific evidence.

Basic research continues to be a critical element for improving patient outcomes in liver cancer. There is still further knowledge needed about aetiology, rare liver cancer entities, markers and diagnostics which might facilitate early detection even in primary care. 

The EU and Member States should support such research projects and cross-country collaboration by setting up EU-wide platforms with the aim of sharing data and closing the gap between medical knowledge and clinical practice.

The high standard of care in the EU is based on high-level science and research. In order to maintain these standards furthermore and drive improvements, it is essential to collect data collaboratively across all member states. The EU and Member States should support the setting up of specific patient registries for liver cancer. 

The collation of this data would facilitate surveillance, research and the overall management of patients with liver cancer.

Care must be patient-centric. People living with liver cancer and their families should have unrestricted access to information, medical treatment, and measures to improve their quality of life, regardless of their life situation and ethnic origin. All patients with liver cancer should benefit from the same high standards of care wherever they are in Europe.

Thomas Berg is the Secretary-General of the European Association for the Study of the Liver (EASL) and Head of the Division of Hepatology at Leipzig University Medical Center in Germany.

 Maria Buti is the EASL EU Policy Councillor and Professor of Medicine and Chief of Internal Medicine and Hepatology at the Hospital General Universitari Valle Hebron in Barcelona, Spain.