Liver cancer is an all too common condition in Taiwan, one that has afflicted a number of notable figures, including former secretary-general of the National Security Council Su Chi, legislator Kao Chin Su-mei, former Democratic Progressive Party chairman Shih Ming-teh, and actor Shi Ying. As a popular advertising slogan says, a bad liver puts a damper on life.

The disease’s primary cause is viral hepatitis. According to the Health Promotion Administration, roughly 13,000 Taiwanese die every year from chronic liver disease, cirrhosis of the liver, and liver cancer. More than 80% of those liver cancers are linked to viral hepatitis infections.

The Liver Disease Prevention and Treatment Research Foundation recently established the Good Liver Clinic to better enable the large numbers of liver patients to seek treatment. In the photo, clinic director Wang Hsih-hsi explains how liver disease progresses.

Dr. Yang Pei-ming, a professor of internal medicine with the National Taiwan University College of Medicine (NTUCM) and the president of the Liver Disease Prevention and Treatment Research Foundation, explains that viral hepatitis is an inflammation of the liver arising from a viral infection. There are five types, labeled A to E. Types A and E cause acute hepatitis and are unrelated to liver cancer. In the case of types B, C, and D, the acute hepatitis may become chronic and worsen to the point of causing cirrhosis and cancer.

In the past, hepatitis B, the variety most common in Taiwan, was most often transmitted perinatally. Other pathways involved unsterile needles and shared toothbrushes. When a child becomes infected, the virus avoids an immediate immune response by concealing itself within the epithelium of the liver. That concealment breaks down in the child’s teens, when the immune system has matured sufficiently to detect the virus and initiate an immune response.

When hepatitis becomes chronic, it causes fibroids to grow in the liver. If the fibrosis becomes sufficiently advanced, it may lead to cirrhosis (severe scarring of the liver).

“Individuals with cirrhosis are at high risk for primary liver cancer in the liver’s epithelium,” says Yang. “Patients with hepatitis-B-induced cirrhosis have a 5% risk per annum of acquiring liver cancer.”

The government therefore initiated a program in 1986 that immunizes newborns against hepatitis B. As a result, fewer than 1% of today’s young people are carriers, versus 15–20% of individuals over the age of 30.

The woodchuck hepatitis virus is remarkably similar to human hepatitis B virus. Hence the woodchuck­ has been crucial to animal studies aimed at developing new hepatitis B drugs for humans.

Hepatitis C is a serious problem as well. In fact, some 4% of Taiwanese are carriers.

Although hepatitis C is transmitted via blood and other bodily fluids, sexual transmission and perinatal transmission are rare. Prior to the development of a hepatitis C antibody test, blood transfusions were a frequent source of the infection. Since Taiwan began screening blood supplies for the antibodies in July 1992, infections via this route have become very rare.

Location is also an issue. Studies have found that most of Taiwan’s hepatitis C hotspots are located along our central and southern coast. For example, the infection rate is 55.1% among individuals over the age of 40 in ­Taixi Township, Yun­lin County. Infection rates are quite high in parts of ­Chiayi and Tai­nan as well. Researchers speculate that these high rates resulted from inadequate sterilization of needles in the area’s medical facilities many years ago.

Yang says that the vast majority of hepatitis C patients eventually suffer chronic hepatitis. In the absence of active treatment, the disease is likely to lead to abnormal liver function, fibrosis, cirrhosis, and even malignant tumors. Treatment of infections is essential to prevent such ­outcomes.

Several treatments are available for liver cancer, including electrocautery, surgical excision, target therapy, and even liver ­transplantation. Active treatment offers the best hope of ­improvement.

In 2003, Chen Chien-jen, who was then the head of the Department of Health, pushed for the creation of a national treatment program for hepatitis B and C in an effort to reduce the threat of liver disease to our citizens’ health. By providing reimbursement for treatment under certain conditions, the program has greatly reduced the financial burden on patients. As of the end of 2012, it had helped some 160,000 patients.

The program has had its greatest success treating hepatitis C. The current clinical standard for pharmaceutical treatment of hepatitis C combines interferons with an orally administered antiviral (Ribavirin). Originally developed by Chen Ding-shinn, an academician with the Academia Sinica, and his research team, the treatment is 70–90% effective.

Unfortunately, there is as yet no effective treatment for clearing the hepatitis B virus, which integrates with chromosomes and cell nuclei in the liver’s epithelium. Instead, treatment focuses on the use of antivirals to block viral ­replication.

Neither hepatitis B nor C infections generate any obvious early symptoms and are easy to miss. That, together with the side effects of antiviral treatment, means that patients are often slow to seek care.

In fact, roughly half of Taiwan’s 2.8 million carriers of the two viruses do not seek regular treatment.

“The liver is a ‘quiet’ organ,” says Yang. “Patients can remain symptomless even with ten-centimeter tumors. Many are already in the terminal stage by the time they notice a problem and see their doctor.”

The medical community has been working ceaselessly on the development of new drugs, and new hepatitis treatments that are both more effective and trigger fewer side effects are in the offing.

For example, National Taiwan University Hospital (NTUH) has signed a letter of intent concerning the development of new hepatitis B medications with Janssen Pharmaceuticals, a subsidiary of Johnson & Johnson.

Chen Pei-jer, a professor with NTUMC’s Graduate Institute of Clinical Medicine, will lead the program. He explains that current antivirals have only a 5% cure rate for hepatitis B, and that patients must stay on medication over the long term to control the virus, which creates an enormous burden (National Health Insurance covers a maximum of three years).

Janssen has developed several potential medications, and will conduct animal tests using woodchucks, a technique pioneered by NTUH, to winnow down the candidates. Investigators believe there is a chance that they will isolate a hepatitis B medication that completely eliminates the virus and be able to begin clinical trials in as little as two to three years.

Life is great when your liver is healthy. Aggressive treatment of liver disease is the first step to keeping it that way.