February 7, 2012

What is the role of a physician assistant in the fields of gastroenterology and hepatology?

GIPA Scope of Practice

GIPA offers the following guidelines for the role of Physician Assistants (PAs) practicing in Gastroenterology and Hepatology. These guidelines are meant to serve as a guide in practice, but are not to take the place of state/federal legislation or other regulatory boards. State laws and regulations define the PA profession in each state and establish registration and competency requirements, as well as the responsibilities of the supervising physician.

In most states the Board of Medical Examiners is responsible for licensing and regulating PAs. Gastrointestinal Physician Assistants (GI PAs) may provide care for patients in various settings including outpatient clinics/offices, HMOs, inpatient hospital settings, and government institutions. Most GI PAs have hospital privileges and membership on the medical staff. GI PAs may also be involved in education, teaching, and administrative functions pertaining to the fields of Gastroenterology and Hepatology. Some GI PAs are involved with research and publication.

GI PAs always practice with the supervision of a physician, but exercise autonomy in diagnosing and treating illnesses within their scope of practice and that of their supervising physician. Individual PA duties are dependent on the scope of his or her supervising physician's practice and the desire of the physician to delegate certain tasks or responsibilities. The range of duties and responsibilities of a GI PA are as varied as the number of different GI practices. Besides performing routine duties such as histories & physical exams, daily patient rounds, patient education, and discharge summaries, GI PA's may perform diagnostic/therapeutic procedures. Whether a GI PA performs these procedures is subject to state regulation, PA training/experience, the scope of the supervising physician, and the needs of the practice. Such procedures may include, but are not limited to:

  • Flexible Sigmoidoscopy
  • Paracentesis
  • Liver Biops

GI PAs report that the most frequent work-ups they are presented with include, but are not limited to, the following chief complaints:

  • Work-up of abdominal pain
  • Work-up of dyspepsia
  • Work-up of nausea/vomiting
  • Work-up of dysphagia
  • Work-up of constipation
  • Work-up of diarrhea
  • Work-up of gastrointestinal bleeding
  • Work-up of elevated liver enzymes

GI PAs obtain medical histories and perform physical exams, order and interpret laboratory data, order and read radiological studies, formulate a differential diagnosis and establish a working diagnosis, formulate a treatment plan, prescribe medication, perform procedures, round in the hospital, and dictate H & Ps and daily progress notes for patients with Gastrointestinal and Liver Disease including, but not limited to the following diagnoses:

  • GERD
  • Esophageal Dysmotility
  • Esophageal Cancer
  • Gastroduodenal Ulcer Disease
  • Zollinger-Ellison Syndrome
  • Gastric Carcinomas
  • Carcinoid
  • Celiac Sprue
  • Whipple’s Disease
  • Ileus/Obstruction/Pseudo-obstruction
  • Gastrointestinal Lymphoma
  • Hepatitis C
  • Hepatitis B
  • Autoimmune Hepatitis
  • Fatty Liver and NASH
  • Alcoholic Hepatitis +/- Cirrhosis
  • Spontaneous Bacterial Peritonitis
  • Primary Biliary Cirrhosis
  • Hemachromatosis
  • Wilson’s Disease
  • Budd-Chiari Syndrome
  • Neoplasms of the Liver
  • Acute and Chronic Cholecystitis
  • Biliary Dyskinesia
  • Choledocholithiasis and Cholangitis
  • Primary Sclerosing Cholangitis
  • Carcinoma of the Biliary Tract
  • Acute and Chronic Pancreatitis
  • Pancreatic Insufficiency
  • Pancreatic Carcinomas
  • Irritable Bowel Syndrome
  • Diverticular Disease
  • Anorectal Disease
  • Crohn’s Disease
  • Ulcerative Colitis
  • Infectious Colitis
  • Microscopic Colitis
  • Ischemic Colitis
  • Colon Cancer Screening

Frequently Asked Questions (FAQs)

Issue Brief

Gastroenterology Physician Assistants
PO Box 82511
Tampa, FL 33682
Phone: (813)988-7795
Fax: (813)988-7796
email: GIPA@Focus-ED.net

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Amateur tattoos carry hepatitis C risk: CDC

By Amy Norton

NEW YORK | Tue Feb 7, 2012 3:27pm EST

NEW YORK (Reuters Health) - If you're planning on getting a tattoo, make sure it's from a professional and not your friend, says a new report from the Centers for Disease Control and Prevention (CDC).

In an analysis of several dozen past studies, CDC researchers found that tattoos from non-professionals appear to carry a risk of the blood-borne liver infection hepatitis C. That included tattoos done by friends or family, or ones done in prison.

On the other hand, there was no evidence that tattoos done by professionals carried a hepatitis C risk.

Hepatitis C is passed through contact with infected blood. In the U.S., there are roughly 18,000 new infections each year, most of which occur when people who inject heroin and similar drugs share tainted needles or syringes.

But in almost 20 percent of acute hepatitis C infections, the person has no known risk factor, said Dr. Rania A. Tohme, a medical epidemiologist at the CDC who led the new study.

Given that -- and the popularity of tattoos -- there have been concerns that the body art could be a risk factor for hepatitis C.

Based on these findings, it's the tattoos from non-pros that consumers should beware, according to Tohme.

"Tattoos and piercings can transmit hepatitis C and other infections if performed under non-sterile conditions," Tohme told Reuters Health in an email. "People should not have tattoos or piercings done by friends or by people who are not trained professionals."

The findings, published in the journal Clinical Infectious Diseases, are based on a collection of studies published since 1994.

In general, people who had tattoos done by non-professionals faced a hepatitis C risk that was two to four times higher than average.

Prison tattoos are a particular concern, Tohme's team writes, because tattooing is so common, and many prisoners may have other risk factors for hepatitis C. And outbreaks of the infection have been linked to tattooing among prisoners.

But no U.S. outbreaks have been tied to professional tattoo parlors.

"To this date, there has been no evidence that tattoos and piercings performed in professional parlors in the United States have been implicated in transmission of hepatitis C virus," Tohme said.

Still, you can take some precautions if you're thinking of inking up.

Tohme said to make sure the tattoo artist is using sterile equipment, including single-use needles and ink that has not been used on anyone else.

"Disposable piercing needles, tattoo needles and razors are used on one person and then thrown away. Reusing needles or razors is not safe," Tohme said.

In the U.S., new cases of hepatitis C infection have fallen sharply since the 1980s, according to the CDC.

But chronic hepatitis C infection remains a major public health problem, the agency says.

Between 75 percent and 85 percent of people infected with hepatitis C develop chronic infection, which can eventually cause serious liver diseases like cirrhosis (scarring of the liver) and liver cancer.

An estimated 3.2 million Americans have chronic hepatitis C, about half of whom are unaware of it. (The initial infection most often causes no symptoms.)

There are medications for treating chronic hepatitis C, though they are not effective for everyone and have side effects like fatigue, nausea, headache and sleep problems.

SOURCE: bit.ly/w6rw3u Clinical Infectious Diseases, online January 30, 2012.

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A protein could reduce need for transplants in patients with acute liver failure

unav

2012/2/6

Cardiotrophine-1 increases survival in animals with acute liver failure, according to research undertaken by scientists at the Applied Medical Research Centre (CIMA in its Spanish initials) of the University of Navarra and the Biomedicine Institute (IBIOMED) of the University of León. The research results were published in the Journal of Virology.
The research showed that a protein, cardiotrophine-1 (CT-1), increases the survival rate of animal models with acute liver failure due to the RHD virus. The work, part of the Biomedical Centre for Research into Hepaticand DigestiveDiseases (CIBERehd), was published in the Journal of Virology, the journal of the North American Microbiology Society.

Acute liver failure is not a common disease (about two thousand cases annually in the United States), and is characterised by the massive destruction of liver tissue due to viral infections, ingestion of toxic products orautoimmune reactions. The only resolutive treatment is a liver transplant, but 30% of patients die without having received a transplant.

Natural defence

CT-1 is a protein that fulfils functions of natural defence against the cell death of the liver. IBIOMED researchers at the University of Leon and the CIMA of the University of Navarra studied itstherapeutic effect on models that developed acute liver failure after inoculation with RHD virus. “we confirmed that, while all the infected animals died within 3 days, 70% of the those models treated with CT-1 survived in the long term. These surprising therapeutic effects are due to the fact that CT-1 attenuates the inflammation and increases the production of molecules with hepatoprotectorand pro-regenerativeactivity”, explained doctors Ms Maria JesúsTuñón and Mr Jesús Prieto, research coordinators.

Research results suggest that this protein could be useful as a treatment in situations of damage due to acute liver failure. Based on these findings, the Food and Drug Administration (FDA) of the United States of America has designated CT-1 as an “orphan medication” for acute liver failure. “If we confirm its effectiveness in clinical trials, we will have a drug that could enhance the prognosis of this class of patients and reduce the need for transplants in these cases”, pointed out Dr.Prieto. Digna Biotech, the biotech company focused on the development of products investigated at the CIMA, has programmed the start of the clinical trials (phase I) for the coming months.

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BioLineRx In-Licenses Second Oral Hepatitis C Treatment

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PRESS RELEASE

Feb. 6, 2012, 7:00 a.m. EST

Worldwide, exclusive deal signed with Genoscience and RFS Pharma for development and commercialization of BL-8030

JERUSALEM, Feb 06, 2012 (BUSINESS WIRE) -- --Advantages of BL-8030 include high specificity, improved resistance profile, reduced toxicity and potentially reduced drug-drug interactions

BioLineRx (tase:BLRX), a biopharmaceutical development company, announced today it has signed a worldwide, exclusive license agreement with Genoscience and RFS Pharma to develop and commercialize BL-8030, an orally available treatment for Hepatitis C. The agreement includes upfront license fees, milestones and royalties payable to both companies, which terms are consistent with BioLineRx's standard in-license agreements.

BL-8030 is a potent and selective second generation NS3 protease inhibitor. The NS3 protease is essential for the replication of the Hepatitis C virus (HCV) and is an important target for HCV therapies. BL-8030 has been shown to have excellent antiviral activity against various HCV genotypes. Pre-clinical studies have demonstrated an improved resistance profile against common protease inhibitor mutants, resulting in a lower probability that the virus will develop resistance to treatment. In addition, BL-8030 has demonstrated a good toxicity profile in pre-clinical studies, exhibiting specificity only to the viral protease and lack of activity against a relevant panel of human proteases as well as a clean profile versus human liver enzymes, which is expected to lead to less drug-drug interactions.

BL-8030 was invented by Professor Philippe Halfon and his team at Genoscience and co-developed with assistance from scientists at RFS Pharma, LLC. Prof. Halfon, Co-Founder and President of Genoscience, is a specialist in molecular virology and infectious diseases, especially HIV, HPV (Human Papilloma Virus) and Hepatitis. In addition he is the founder of several biotechnology companies focusing on antiviral drug discovery and development including ACTgene, Alphabio and Genoscience. RFS Pharma was founded by Professor Raymond F. Schinazi; he currently serves as the Frances Winship Walters Professor of Pediatrics at Emory University. He is also a founder of Pharmasset, Idenix, Triangle and ActivBiotics Pharma.

Prof. Philippe Halfon said, "We were impressed by the drug development expertise of the BioLineRx team and are very pleased to collaborate with them on a second HCV project. There is clearly a huge unmet medical need in finding a safe and effective treatment for HCV, and based on pre-clinical results, we believe that our product, especially when combined with other available Hepatitis C drugs, has the potential to become an important addition to HCV combination therapies and bring remedy to millions suffering from this devastating disease."

"We worked closely with the group at Genoscience to determine the optimum characteristic that led to the discovery of BL-8030 and related protease inhibitors," said Dr. Steven J. Coats, Senior Director of Chemistry at RFS Pharma.

"We are privileged and fortunate to partner with two world class groups in the development of viral therapeutics," said Dr. Kinneret Savitsky, CEO of BioLineRx. "Two years ago, we took a strategic decision to enter the dynamic and rapidly growing field of Hepatitis C. Since that time, we have evaluated numerous projects in the field. A year ago, we identified and decided to focus on the in-licensing of the two most promising candidates: BL-8020, which we've recently licensed, and now BL-8030. We will do our utmost to develop these promising drugs as swiftly as possible for the benefit of Hepatitis C infected individuals around the world."

About Hepatitis C

Hepatitis C is a blood borne infection of the liver caused by the Hepatitis C virus (HCV) which becomes chronic in about 85% of cases. According to the World Health Organization (WHO), up to 170 million people worldwide are chronically infected with HCV. In addition, HCV infection is the leading cause of liver transplantation and is a risk factor for liver cancer. The Hepatitis C market is growing rapidly and is forecasted to reach $16 billion in 2015 in the seven major markets (US, France, Germany, Italy, Spain, UK and Japan).

About BioLineRx

BioLineRx Ltd. is a publicly-traded biopharmaceutical development company. It is dedicated to building a portfolio of products for unmet medical needs or with advantages over currently available therapies. BioLineRx's current portfolio consists of five clinical stage candidates: BL-1020 for schizophrenia has commenced a Phase II/III study; BL-1040, for prevention of pathological cardiac remodeling following a myocardial infarction, is currently undergoing a pivotal CE-Mark registration trial and has been out-licensed to Ikaria Inc. for a total deal value of $282.5 million, in addition to sales royalties; BL-5010 for non-surgical removal of skin lesions has completed a Phase I/II study; BL-1021 for neuropathic pain is in Phase I development and BL-7040 for treating Inflammatory Bowel Disease (IBD) has completed Phase I. In addition, BioLineRx has 13 products in various pre-clinical development stages for a variety of indications, including central nervous system diseases, oncology, infectious diseases, cardiovascular and autoimmune diseases.

BioLineRx's business model is based on acquiring molecules mainly from biotechnological incubators and academic institutions. The Company performs feasibility assessment studies and development through pre-clinical and clinical stages, with partial funding from the Israeli Government's Office of the Chief Scientist (OCS). The final stage includes partnering with medium and large pharmaceutical companies for advanced clinical development (Phase III) and commercialization.

For more information on BioLineRx, please visit www.biolinerx.com .

About Genoscience

Genoscience, a biopharmaceutical company located in Marseille, France, is focused on the development of new drugs for the treatment of viral diseases as HCV. Genoscience's innovative technology platform, which combines internal expertise in resistance with unique molecular modeling through its proprietary software (GenMol(TM)), allows for the development of highly targeted molecules, taking into account the phenomenon of resistance. For further information about Genoscience, please refer to http://www.genosciencepharma.com .

About RFS Pharma, LLC

RFS Pharma, LLC was founded in September 2004 and is located in a 26,500 sq. ft. state-of-the-art research facility in Tucker, Georgia. RFS Pharma is a privately owned biotech company committed to the discovery and development of antiviral agents and other human therapeutics. The company capitalizes on its expertise in nucleoside chemistry to develop drugs to combat infections caused by drug-resistant HIV and hepatitis viruses. RFS Pharma's lead product candidate is amdoxovir, which is in advanced Phase 2 clinical studies for the treatment of HIV-1 infections. In addition, the company has identified promising, early stage compounds for hepatitis infections, analogs that are effective against noroviruses, and has a proprietary novel nucleoside prodrug technology. For further information about RFS Pharma, please refer to our website, www.rfspharma.com .

Various statements in this release concerning BioLineRx's future expectations, plans and prospects, including, without limitation, statements relating to the ability to develop and commercialize the BL-8030 project, constitute "forward-looking statements" within the meaning of the Private Securities Litigation Reform Act of 1995. These statements include words such as "may," "expects," "anticipates," "believes," and "intends," and describe opinions about future events. These forward-looking statements involve known and unknown risks and uncertainties that may cause the actual results, performance or achievements of BioLineRx to be materially different from any future results, performance or achievements expressed or implied by such forward-looking statements. Some of these risks are: changes in relationships with collaborators; the impact of competitive products and technological changes; risks relating to the development of new products; and the ability to implement technological improvements. These and other factors are more fully discussed in the "Risk Factors" section of BioLineRx's Form 20-F filed with the Securities and Exchange Commission on July 15, 2011. In addition, any forward-looking statements represent BioLineRx's views only as of the date of this release and should not be relied upon as representing its views as of any subsequent date. BioLineRx does not assume any obligation to update any forward-looking statements unless required by law.

SOURCE: BioLineRx Ltd.

Source

Hepatitis C … Veterans … Vietnam …

Culture: Impact of war on language (155)

By Sami El-Shahed - The Egyptian Gazette
Monday, February 6, 2012 08:48:05 PM

Vietnam War & Health. and Medicine (VII). Hepatitis C. Hepatitis C is a major problem in US military veterans. In several studies of Veteran’s Affairs (VA) Medical Centre patients, we find that 8-9% are positive for hepatitis C antibodies. Some VA Medical Centres had 10-20% of patients with hepatitis C antibodies.


According to Dr Bradford Waters, Professor of Medicine, University of Tennessee, Memphis, the highest rate of hepatitis C is found in the Vietnam era veterans.

Several studies have been initiated to better understand the high frequency of hepatitis C in veterans of the Vietnam conflict. Areas of research include the demographic characteristics, risk factors for infection and the potential role of military service in the acquisition of hepatitis C.
Underlying this research is the question of what is unique about Vietnam or Vietnam-era veterans to help explain a high prevalence of hepatitis C which was not observed in World War II or Korean era veterans, said Professor Waters who is also Staff Hepatologist, Memphis Veteran Affairs (VA) Medical Centre Associate.

The demographics of hepatitis C in US civilians and VA patients are important. Several epidemiological studies have found hepatitis C to be higher in US males, African-Americans, lower socioeconomic groups and in those Americans in the 40 to 60 year old age groups. In addition to serving primarily males, the VA has historically served large populations of disadvantaged, uninsured and minority veterans.

The VA has had well established programmes for the treatment of ethanol and other substance abuse. These substance abuse programmes have often attracted younger veterans with prior intranasal cocaine and intravenous drug use associated with hepatitis C infection.

As a result of the VA programmes’ providing care for the disadvantaged, uninsured and substance abusing veterans, the VA has acquired significant patient populations with high risk for hepatitis C. Many of the highest risk groups for hepatitis C in the US – identified by the Centres for Disease Control: male, poor socioeconomic group, and between the ages of 30-50 (in a 1988-94 study) – have the same demographic criteria met by many Vietnam era veterans seeking care in the VA. Improved screening of VA patients with risk factors for hepatitis C has helped identify increasing numbers of patients with chronic hepatitis C, Dr Waters explained.

A large multi-centre VA study involving twenty six Medical Centres and approximately 5,800 patients was initiated by the San Francisco VA Medical Centre to study demographic factors and treatment response in VA patients.

The role of tattoos in transmission of hepatitis C has been controversial. In this group of Memphis veterans, 30.2% of patients had tattoos. 92.8% of patients reported multiple risk factors for hepatitis C. In analysis of patients with a single risk factor for hepatitis C, intranasal cocaine use, non-combat occupational exposure, surgery, transfusion, intravenous drug abuse (IVDA) and sex with a prostitute were identified, Dr Waters elaborated.

Medical advances during the Vietnam War included rapid evacuation, improved transfusion and high rates of US casualty survival in an era prior to hepatitis C screening of the blood supply. Many Vietnam combat casualties who survived with multiple transfusions would have died on the battlefield in previous conflicts.

Hepatitis C in Vietnam era veterans is an ongoing national problem. Complex challenges remain in the epidemiology and treatment of hepatitis C. Many Vietnam era veterans are now on the front lines of the hepatitis C epidemic. Improved understanding and treatment of these patients will ultimately benefit all Americans with hepatitis C, Dr Waters concluded.

EASL publishes first European Clinical Practice Guidelines for Wilson's disease

Public release date: 7-Feb-2012

Contact: Travis Taylor
easlpressoffice@cohnwolfe.com
44-207-331-5472
European Association for the Study of the Liver

Geneva, Switzerland: The first European Clinical Practice Guidelines (CPGs) for the diagnosis and management of Wilson's disease are published today by the European Association for the Study of the Liver (EASL) on the EASL website -- www.easl.eu.(1) Developed to assist physicians and healthcare providers in the clinical decision making process, the guidelines describe best practice for the diagnosis and treatment of patients with Wilson's disease -- a rare genetic(2) disorder that, if left untreated, is fatal.

Approximately one in 30,000 people worldwide are affected by Wilson's disease -- a condition in which copper is not excreted by the body effectively, leading to excess copper build up, liver failure and damage to the brain. While Wilson's disease may manifest at any age, the majority of patients present between the ages of 5 and 35.

Lead author Professor Peter Ferenci said: "The clinical presentation of Wilson's disease can vary widely, but it must be considered in any patient who presents with a combination of unexplained liver disease and neurological or neuropsychiatric disorders. In the absence of Kayser-Fleischer rings(3) -- which are typical, but not always present -- the guidelines recommend measurement of urinary copper excretion and hepatic parenchymal copper as diagnostic methods of choice. Notably, age alone should not be the basis for eliminating a diagnosis of Wilson's disease."

The CPGs, based on a systematic review of existing literature, provide best practice diagnosis and treatment protocols with an emphasis on:

  • Clinical presentation and prognosis
  • Diagnostic strategies (e.g. serum ceruloplasmin, basal 24-hour urinary copper excretion, genetic analysis)
  • Importance of family screening
  • Treatment options (e.g. chelating agents, zinc, liver transplantation)

With treatment, prolonged survival has become the norm for Wilson's disease patients. The guidelines recommend chelating agents -- drugs that bind to copper and remove it from the body (D-penicillamine or trientine) -- as the initial treatment for symptomatic patients and that, unless liver transplantation is performed, treatment is maintained for life.

Professor Roderick Houwen added: "Unfortunately, as there are no optimally designed randomized controlled trials conducted in Wilson's disease, there is a lack of high-quality evidence to estimate the relative treatment effects of the available drugs. Our evaluation is mostly based on large case series that have been reported in recent decades, which highlights a clear need to conduct more robust randomized controlled trials to better understand treatment for this rare condition."

Professor Mark Thurz, EASL Secretary General, added: "EASL is dedicated to promoting hepatology research and education to improve the worldwide treatment of liver disease. Its series of Clinical Practice Guidelines aims to promote best practice to drive better clinical outcomes and inform both the scientific community and the wider public of the latest developments in the field. We hope these new Wilson's disease guidelines provide clinicians with the most up-to-date, evidence based methods for the management of affected patients."

The Wilson's disease CPGs will be published in the March issue (Volume 56, No. 3) of the Journal of Hepatology -- EASL's official journal.

###

About EASL

EASL is the leading European scientific society involved in promoting research and education in hepatology. EASL attracts the foremost hepatology experts and has an impressive track record in promoting research in liver disease, supporting wider education and promoting changes in European liver policy.

EASL's main focus on education and research is delivered through numerous events and initiatives, including:

  • The International Liver CongressTM which is the main scientific and professional event in hepatology worldwide
  • Meetings including Monothematic and Special conferences, Post Graduate courses and other endorsed meetings that take place throughout the year
  • Clinical and Basic Schools of Hepatology, a series of events covering different aspects in the field of hepatology
  • Journal of Hepatology published monthly
  • Participation in a number of policy initiatives at European level

1. Ferenci P, et al (2011) Wilson's disease: EASL Clinical Practice Guidelines. European Association for the Study of the Liver. Available at http://www.easl.eu/_clinical-practice-guideline

2. Due to mutations of the ATP7B gene on chromosome 13.

3. Kayser-Fleischer rings are a golden-brown discolouring of the eye's corneal rim. The cornea is the transparent front part of the eye that covers the iris, pupil, and anterior chamber.

Source

Hepatocellular carcinoma

Jonathan Manning, Consultant Gastroenterologist, Scottish Borders. Reviewed by Luke Koupparis, general practitioner, Bristol.

Tuesday, 7 February 2012

Key learning points

  • Hepatocellular carcinoma is a well recognised complication of chronic liver disease.
  • Viral hepatitis remains the most common cause with alcohol also a significant contributor.
  • Screening and surveillance is often performed to detect early lesions where possible.
  • Surgery can be considered in fit patients with early stage disease.
  • Palliative therapies are now available with lower toxicities and improved patient survival .
  • Although key, endoscopy is not the only element in managing such patients.

Epidemiology

Hepatocellular carcinoma (HCC) refers to a liver tumour originating from within the liver tissue. Liver metastases are approximately 30 times more common than primary tumours and making this differentiation is imperative to further investigations and management. It ranks as the 5th most prevalent cancer in the world (7% male cancers and 3% female cancers – approximately ½ million cases per year).

Symptoms

Patients may in fact be asymptomatic and have their tumour picked up on routine scanning for other reasons. Others may present with one or a combination of fatigue, abdominal pain, ascites, weight loss, jaundice or abnormal liver blood tests. Any of these should lead to further investigations by the primary care physician, referral to a Gastroenterologist and/or other Specialist.

Aetiology

Cirrhosis is known to be the greatest risk factor for the development of HCC. Significant geographical differences are apparent in relation to this risk factor. HCC rates of 30% are reported in South Africa but lower rates of 20% in Great Britain and North America. This is likely to be related to the larger cohort of chronic Hepatitis B virus (HBV) infection seen in those countries compared to the developed world.

Figure 1: Severe liver cirrhosis with gross ascites.

ascites

In cirrhotic alcoholics there is a four-fold increase in HCC compared to the general non-cirrhotic population. Chronic viral carriage of HBV can increase the HCC risk even in the absence of cirrhosis. The same applies to chronic hepatitis C virus (HCV) infection as well, with a four-fold increase in HCC in HCV patients compared to HBV when cirrhosis is present.

The mechanism of HCC is thought to reflect disorganised DNA during cellular repair or nodule regeneration in the presence of cirrhosis or chronic inflammation. Addressing some of the other chronic liver conditions, iron overload, as seen in genetic haemochromatosis, is also high risk for HCC when cirrhosis is present.

Other high risk cirrhotic patients include alpha1-antitrypsin deficiency, type 1 glycogen storage disease and porphyria cutanea tarda. Primary biliary cirrhosis and chronic active auto-immune hepatitis with cirrhosis are both considered lower risk scenarios than those stated above. However, cirrhotic hepatitis B or C patients co-infected with HIV are possibly at the greatest risk.

Figure 2: Histology showing chronic hepatitis with ground glass hepatocytes.

hepatitis

Diagnosis

Small lesions can be hard to see in a nodular cirrhotic liver and may simply represent a regenerative nodule. Once a liver lesion has been identified, often by ultrasound, several factors, including it’s likely aetiology, need to be considered. Multi-phase CT scanning, or MRI, may be required to define a lesion further and follow-up interval scanning performed as appropriate, if deemed low risk.
The current evidence suggests that the standard initial imaging interval should be 6-monthly. Higher risk patients do not warrant more intensive screening. In addition to appropriate imaging the serum α-fetoprotein level is often monitored as it can be elevated in HCC. However, it may not increase in 20-40% or so. It may also be elevated in the absence of HCC but in the presence of other cancers, such as cholangiocarcinoma. It is also raised in pregnancy.

Liver biopsy is avoided if at all possible due to the high incidence of tumour seeding, particularly if a potentially curative outcome is predicted.

Treatments

This depends on the location, size and number of the tumours and also on the fitness of the patient. Small tumours (<2-3cm) will have a 1-year survival close to 85% but only a 50% 2-year survival. Surgical resection or liver transplantation both offer the only real chance of cure. Tumours that are invading the portal vein or breaching the liver capsule would be considered unresectable and perhaps only amenable to palliative therapies. A size of 5cm is the usual cut off for suitability of a single lesion resection.

Resection offers a greater than 50% 5-year survival with a 70% likelihood of recurrence. Patients with advanced cirrhosis are poor candidates for resection with an increased mortality and risk of liver failure post-operatively. Therefore, a liver transplant offers the best alternative. A shortage of donor organs has lead to live-donor right lobe transplants, with improving results.

Radiofrequency ablation (RFA) is a palliative therapy which can induce tumour necrosis. An electrode is passed via the peripheral vasculature into the liver. Heat can be delivered directly into the lesion and therapy repeated. It can be offered in patients with lesions >2cm, with a procedure-related mortality of 0.3%. Studies have shown upto a 70% 5-year survival with this treatment.

Transarterial embolisation (TAE) and transarterial chemoembolisation (TACE) are two other alternatives for palliation. Gelofoam or small metal coils can be inserted into the feeding vessels by interventional radiologists. TACE is the same as TAE but with prior injection of a chemotherapeutic agent into the lesion with improved results but higher associated toxicity.

TACE is considered the first line therapy for non-surgical patients with HCC that has no vascular invasion. However, it is much higher risk in those with Child-Pugh B or C due to the possibility of post-treatment liver failure.

Sorafenib, is a multikinase inhibitor, which has shown a survival benefit in palliative patients. Median survival is increased from 7.9 to 10.7 months. It is offered to those patients with preserved liver function who are not suitable for other treatment modalities.

References

  1. Hashem B. El-Serag. N Engl J Med 2011; 365:1118-1127. Hepatocellular Carcinoma.
  2. Nishant Merchant, Calvin S. David, and Steven C. Cunningham. Intl J Hepatol 2011; 2011:142085. Review Article: Early Hepatocellular Carcinoma: Transplantation versus Resection: The Case for Liver Resection.
  3. Bruix J, Sherman M. Hepatol 2011 Mar;53(3):1020-2. AASLD - Management of hepatocellular carcinoma: an update.
  4. Riccardo Lencioni. Oncology Haematology. In Press Jan 2012. Management of hepatocellular carcinoma with transarterial chemoembolization in the era of systemic targeted therapy.

Author and reviewers competing interests: none.

Images: Wellcome.

Source

Aethlon Medical to Present Hepatitis C (HCV) Treatment Technology at the 32nd Annual Dialysis Conference

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PRESS RELEASE

Feb. 7, 2012, 8:15 a.m. EST

SAN DIEGO, Feb. 7, 2012 /PRNewswire via COMTEX/ -- Aethlon Medical, Inc. , the pioneer in developing selective therapeutic filtration devices to address infectious disease, cancer and other life-threatening conditions, announced today that a presentation of the Aethlon Hemopurifier® to treat Hepatitis C virus (HCV) and other infectious disease conditions will occur at the upcoming 32nd Annual Dialysis Conference to be held on February 26-28 at the Henry B. Gonzalez Convention Center in San Antonio, Texas. The presentation, which will be given by Aethlon President Rod Kenley, is scheduled to begin at 9:20 am CST on February 28th.

The Hemopurifier® is a first-in-class medical device that provides rapid real-time clearance of circulating HCV as well as immunosuppressive proteins shed by the virus. The goal of therapy is to improve benefit, dose, duration and tolerability of current and future drug therapies without introducing drug toxicity and interaction risks. Included among the Hemopurifier® treatment opportunities in HCV are the estimated 300,000 infected dialysis patients that currently live with the virus. As a result of their health-compromised end-stage renal condition, dialysis patients are often unable to tolerate HCV drug therapy dosing and duration, resulting in suboptimal treatment outcomes. To optimize outcomes, Hemopurifier® therapy would be combined with reduced dose drug therapy and conveniently administered during regular dialysis, which is scheduled three times per week with each treatment lasting four hours. In regards to the size of the overall HCV treatment opportunity, it is estimated that approximately 4 million Americans and 170 million people worldwide are infected with HCV, which leads to chronic liver disease or cirrhosis, and is the leading cause of liver transplant in the U.S.

On February 1, 2012, Aethlon reported that intermittent administration of Hemopurifier® therapy in just the first three days of standard of care peginterferon+ribavirin (PR) drug therapy resulted in immediate and rapid virologic responses in genotype-1 infected HCV patients not on dialysis. An immediate virologic response (IVR) represents a 2-log or 100 fold reduction of HCV RNA at day-7 of therapy and rapid virologic response (RVR) is defined as undetectable HCV RNA at day-30 of the 48-week PR regimen. Average HCV RNA reduction during the three day Hemopurifier® + PR treatment window was 98.79%. In previous studies of HCV-infected dialysis patients, average per treatment reductions of HCV RNA exceeded 50% when Hemopurifier® therapy was included in series with four-hour dialysis sessions in patients not receiving HCV drug therapy.

Aethlon also anticipates that Hemopurifier® therapy could benefit emerging all-antiviral drug cocktails, which face the challenge of overcoming the rate at which viruses attain drug resistance through rapid mutation. The development of drug-resistant strains can occur quickly owing to the extraordinarily high rate of HCV replication. The clearance of circulating hepatitis C virions, including mutant strains, would inhibit the continued replication of drug-resistant viruses and decrease the likelihood of early onset resistance to emerging all-antiviral strategies.

The Extract-1 Study Protocol

The results reported by Aethlon on February 1st, represent interim data from the first three patients treated with Hemopurifier® therapy under the Extract-1 study protocol, which was initiated in the fall of 2011. Under the Extract-1 study protocol, hard-to-treat genotype 1 HCV patients are enrolled to receive three 6-hour applications of Hemopurifier® therapy during the first three days of standard of care PR therapy. On day one of the Extract-1 protocol, PR therapy is initiated within one hour of first Hemopurifer® therapy completion. Hemopurifier® therapy is then administered again once daily for the next two days in combination with PR therapy. During the Hemopurifier® treatment periods, patients are free to watch movies, read books, and perform other tasks in the comfort of a clinic setting.

Clinical Endpoint Assessments

The aim of the Extract-1 study protocol is to assess the safety and clinical impact of intermittent Hemopurifier® therapy when combined with the first three days of peginterferon+ribavirin (PR) standard-of-care. To date, Hemopurifier® therapy in Extract-1 treated patients has been well tolerated and without device-related adverse events during the Hemopurifier® + PR treatment period. At present, the reported data of the Extract-1 study is not statistically significant and should be considered preliminary. Changes in HCV RNA levels are measured with the Roche Cobas TaqMan assay, which has a quantification limit of 15 IU per milliliter (iu/ml). In addition to measuring changes in HCV RNA, the Extract-1 study protocol will quantify the amount of HCV captured within Hemopurifier® treatment cartridges. The goal of PR treatment is to establish a sustained virologic response (SVR), defined as undetectable HCV RNA 24 weeks after completion of therapy. Primary clinical endpoints of the Extract-1 study measure the impact of Hemopurifier® therapy during the initial phase of PR therapy. Each clinical endpoint is based on changes in HCV RNA from baseline viral load measurements taken prior to Hemopurifier® + PR therapy initiation. These endpoints include:

Day Three (3): the change in HCV RNA from baseline to the end of the Hemopurifier® + PR treatment phase;

Day Seven (7): the change in HCV RNA 7 days from initial baseline. A drop of HCV RNA greater than 2 logs at day 7 is known as an Immediate Virologic Response (IVR). Based on the landmark IDEAL Study of 3,070 HCV genotype-1 patients receiving PR therapy, IVR achievement correlates with 90+% SVR rates, yet is observed in less than 5% of patients;

Day 30: the change in HCV RNA 30 days from initial baseline. Undetectable HCV RNA at day 30 is known as a Rapid Virologic Response (RVR). Based on the IDEAL Study, RVR achievement correlates with an SVR likelihood of 86.2%, which is observed in only 10.35% of patients.

Day 3 Results

Patient E-1.03: Baseline HCV RNA dropped from 5,800,000 IU/ml to 1,840 IU/ml when measured on day 3, representing a 3.49 log reduction. HCV RNA reduction during the 3-day Hemopurifier® + PR treatment phase accounted for 99.96% of the overall HCV RNA reduction reported at day-30.

Patient E-1.02: Baseline HCV RNA dropped from 199,500 IU/ml to 31,550 IU/ml when measured on day 3, representing a 0.80 log reduction. HCV RNA reduction during the 3-day Hemopurifier® + PR treatment phase accounted for 84.21% of the overall HCV RNA reduction reported at day-30.

Patient E-1.01: Baseline HCV RNA dropped from 1,340,000 IU/ml to 54,900 IU/ml when measured on day 3, representing a 1.38 log reduction. HCV RNA reduction during the 3-day Hemopurifier® + PR treatment phase accounted for 95.90% of the overall HCV RNA reduction reported at day-30.

Day 7 Results

On average, the treated patients achieved 2.24 log HCV RNA reduction from baseline at day-7, which is beyond the 2 log reduction that defines the IVR criteria achieved in less than 5% of PR treated patients.

Patient E-1.03: Baseline HCV RNA dropped from 5,800,000 IU/ml to 234 IU/ml when measured on day 7, representing a 4.39 log reduction.

Patient E-1.02: Baseline HCV RNA dropped from 199,500 IU/ml to 17,300 IU/ml when measured on day 7, representing a 1.06 log reduction.

Patient E-1.01: Baseline HCV RNA dropped from 1,340,000 IU/ml to 24,400 IU/ml when measured on day 7, representing a 1.74 log reduction.

Day 30 Results

Two of the three patients achieved a RVR at day 30, which is normally achieved in only 10.35% of patients receiving PR therapy, yet correlates with a 86.2% SVR versus a 30.4% SVR in patients who fail to achieve a RVR. Based on the IDEAL study, it would normally require the enrollment of approximately 20 PR treated patients to accomplish 2 RVR outcomes. It should also be noted that patient E-1.02 missed RVR achievement by 25 iu/ml.

Patient E-1.03: Baseline HCV RNA dropped from 5,800,000 IU/ml to undetectable (<15 IU/ml) when measured on day 30, representing a 5.58 log reduction.

Patient E-1.02: Baseline HCV RNA dropped from 199,500 IU/ml to 40 IU/ml when measured on day 30, representing a 3.69 log reduction.

Patient E-1.01: Baseline HCV RNA dropped from 1,340,000 IU/ml to undetectable (<15 IU/ml) when measured on day 30, representing a 4.95 log reduction.

Beyond high SVR rates, RVR achievement also provides HCV infected individuals the opportunity to reduce PR duration from 48 to 24 weeks (6-month reduction) in RVR patients that maintain undetectable HCV RNA through week 12 of PR therapy. RVR patients are also unlikely to discontinue PR therapy as a result of a non-virological response, which represents the primary reason why 46% of PR therapy patients don't complete their treatment regimen.

RVR achievement also plays a pivotal role in curbing treatment relapse, defined as undetectable HCV RNA at PR completion that again becomes detectable in the 24-week window after therapy completion. As reflected in the IDEAL study, the time to first undetectable HCV RNA correlates with the incidence of treatment relapse. Approximately 50% of patients who achieve complete HCV suppression for the first time by week 24 of therapy suffer from treatment relapse, while less than 10% of RVR patients relapse from therapy.

The Extract-1 study is being conducted at Medanta, The Medicity Institute (Medicity), a $360 million multi-specialty medical institute recently established to be a premier center for medical tourism in India. The principal investigator of the study is Vijay Kher, M.D., Chairman of the Department of Nephrology at the Medanta Kidney & Urology Institute. Dr. Kher previously served as the principal investigator of Hemopurifier® therapy studies conducted at the Apollo and Fortis hospitals in Delhi, India.

Based on the initial Extract-1 study outcomes, Aethlon will seek permission to open up the treatment study to HCV infected individuals who reside outside of India. The company also plans to expand its GMP manufacturing capabilities and upon quantification of HCV capture within Hemopurifier® treatment cartridges, will resubmit an Investigational Device Exemption (IDE) that will request FDA permission to initiate treatment studies in the U.S. The Company is also interested in collaborative clinical opportunities aimed at determining the synergistic effects of Hemopurifier® therapy combined with non-interferon based drug regimens.

About Aethlon Medical

The Aethlon Medical mission is to create innovative medical devices that address unmet medical needs in cancer, infectious disease, and other life-threatening conditions. Our Aethlon ADAPT(TM) System is a revenue-stage technology platform that provides the basis for a new class of therapeutics that target the selective removal of disease enabling particles from the entire circulatory system. The Aethlon ADAPT(TM) product pipeline includes the Aethlon Hemopurifier® to address infectious disease and cancer; HER2osome(TM) to target HER2+ breast cancer, and a medical device being developed under a contract with the Defense Advanced Research Projects Agency (DARPA) that would reduce the incidence of sepsis in combat-injured soldiers and civilians. For more information, please visit www.aethlonmedical.com .

Certain of the statements herein may be forward-looking and involve risks and uncertainties. Such forward-looking statements involve assumptions, known and unknown risks, uncertainties and other factors which may cause the actual results, performance or achievements of Aethlon Medical, Inc. to be materially different from any future results, performance, or achievements expressed or implied by the forward-looking statements. Such potential risks and uncertainties include, without limitation, the ability to recruit genotype-1 hepatitis C infected patients, including dialysis patients, positive results at the conclusion of the Extract-1 study, the ability to attain permission and to attract patients outside of India, the company's ability to expand its GMP manufacturing capabilities, the Company's ability to attain clinical collaborations to determine the Hemopurifier's® effect with non-interferon based drug regimens, there is no assurance that FDA will approve the initiation of the Company's clinical programs or provide market clearance of the company's products, future human studies of the Aethlon Hemopurifier® as an adjunct therapy to improve patient responsiveness to established cancer therapies, the company's ability to raise capital when needed, the Company's ability to complete the development of its planned products, the Company's ability to manufacture its products either internally or through outside companies and provide its services, the impact of government regulations, patent protection on the Company's proprietary technology, product liability exposure, uncertainty of market acceptance, competition, technological change, and other risk factors. In such instances, actual results could differ materially as a result of a variety of factors, including the risks associated with the effect of changing economic conditions and other risk factors detailed in the Company's Securities and Exchange Commission filings.

Contacts:

James A. JoyceChairman and CEO858.459.7800 x301jj@aethlonmedical.com 

Jim FrakesChief Financial Officer858.459.7800 x300jfrakes@aethlonmedical.com 

John P. SalvadorDirector, Communications858.459.7800 x307jps@aethlonmedical.com 

SOURCE Aethlon Medical, Inc.

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Is acupuncture a risk factor for hepatitis C in Asian patients?

4.08PM 07 February 2012

Several years ago, I was refused from donating blood because I had recently received acupuncture as a participant of a trial. Even today, the NHS is very clear on this point: the current leaflet handed out to all blood donors states, 'you must not give blood if you have had acupuncture, unless this was done in the NHS or by statutory registered health care professional'.

But is this wise?

A Californian team investigated 494 patients with hepatitis C in order to determine the risk factors for this infection.1 Specifically they wanted to find out whether the risk factors differ between various ethnic groups. 55% of all patients were Caucasian, 20% Hispanic and 25% Asian.

The laboratory profiles of these sub-groups were similar. 94% and 86% of Caucasians and Hispanics had commonly known risk factors for hepatitis C such as blood transfusion, drug injection or tattooing. For Asian patients, the picture was significantly different: in this population, acupuncture was a prominent risk factor. Some 50% of this subgroup had had acupuncture prior to the infection (Caucasians = 31%, Hispanics = 20%).

Many British GPs regularly see Asian patients; these findings from the US therefore beg the question whether UK Asians might be at similar risks. Patients can, of course, only be infected, if the acupuncture needle is not sterile. Thus the chances of acquiring an infection via adequately handled disposable needles should be zero. All regulated acupuncturists are told to use proper and safe techniques. It follows that, in the UK, the risk of hepatitis C infection through acupuncture should be zero.

But what about the unregulated acupuncturists who Asian patients might consult? What about the TCM-outlets in our high streets? What about amateur Asian acupuncturists who are on no register at all? To the best of my knowledge, there is no research to answer these questions.

To be on the safe side, therefore, acupuncture should be considered as a potential source of hepatitis C, particularly in Asian patients. To prevent such infections, GPs should urge their Asian patients not to frequent unregistered acupuncturists. And to prevent infections via blood donors, the categorical statement by the NHS mentioned above seems correct.

References

1. Ho EY, Ha NB, Ahmed A, Ayoub W, Daugherty T, Barcia G et al. Prospective study of risk factors for hepatitis C acquisition by Caucasian, Hispanic, and Asian American patients. J Viral Hepatitis 2012; 19:e105-e111.

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Cirrhosis patients losing muscle mass have a higher death rate

Public release date: 7-Feb-2012

Contact: Raquel Maurier
raquel.maurier@ualberta.ca
780-492-5986
University of Alberta Faculty of Medicine & Dentistry

These patients should be bumped up on liver transplant lists

Medical researchers at the University of Alberta reviewed the medical records of more than 100 patients who had a liver scarring condition and discovered those who were losing muscle were more apt to die while waiting for a liver transplant. These cirrhosis patients were placed at a lower spot on the transplant list because they had a higher functioning liver and were seemingly less sick than others with the same condition, based on scoring systems physicians commonly use today.

Michael Sawyer, the principal investigator in the recently published review, says the results demonstrate physicians need to consider muscle mass when assessing where a patient with cirrhosis needs to be placed on the transplant list. Muscle mass, which can be seen through CT images commonly ordered for cirrhosis patients, needs to be considered in conjunction with other factors doctors currently look at, says Sawyer, who is a researcher in the Department of Oncology with the Faculty of Medicine & Dentistry and a practising oncologist at the Cross Cancer Institute.

The review conducted by Sawyer and his colleagues was just published in the peer-reviewed journal, Clinical Gastroenterology and Hepatology, in the United States. An editorial about this research was also published in the February issue of the journal.

Sawyer and his team studied 112 patients with cirrhosis who were awaiting liver transplants at the University of Alberta Hospital and discovered 40 per cent of them had muscle wasting or low muscle mass. Cirrhosis is the final phase of chronic liver diseases, characterized by scarring of the liver and poor liver function. Those with low muscle mass lived for about 19 months if they couldn't get a transplant, while those with normal muscle mass lived for about 34 months without a liver transplant.

"Patients with cirrhosis who have low muscle mass are actually more sick than what current scoring systems are telling us and many of them die while waiting on the liver transplant lists," says Sawyer.

"Patients with low muscle mass will get put on the list thinking they can wait for around three years, but really they can only wait for about one-and-a-half years.

"Those in the medical field have been looking for better methods to assess patients with cirrhosis and this may be that missing piece to the puzzle. If we can combine this measure of muscle mass with the current scoring system, it will provide a better way of predicting survival rates of patients awaiting liver transplants."

The team's research was funded by the Alberta Cancer Foundation, who said the findings will improve care for patients. The study originally looked at the incidence of low muscle mass in both cirrhosis patients and patients with liver cancer. The liver cancer findings are yet to be published.

"Dr. Sawyer's research is an example of how new knowledge and the understanding of disease is vital to advancing clinical care," says Myka Osinchuk, CEO of the Alberta Cancer Foundation. "It is gratifying to know that Dr. Sawyer and his team have taken this research to another, unexpected level and are challenging the medical field to a new way of thinking."

Sawyer and one of his teammates, Aldo J. Montano-Loza, who works in the Division of Gastroenterology in the Faculty of Medicine & Dentistry, have already received further funding from the American College of Gastroenterology to continue their work.

Sawyer is hopeful this additional way of assessing cirrhosis patients awaiting transplants will be incorporated into medical practice within the next three to four years.

###

The team recently presented their findings at research conferences in both Canada and Europe.

Source

February 6, 2012

Coffee Lowers Liver Fibrosis Risk in Certain Patients

Laura Newman, MA

February 6, 2012 — Drinking caffeinated coffee protects against liver fibrosis in patients with nonalcoholic fatty liver disease, according to research published in the February issue of Hepatology.

In introducing the study, Jeffrey C. Molloy, MD, from the Division of Gastroenterology and Hepatology, Wilford Hall Medical Center, Lackland Air Force Base, Texas, and coauthors refer to previous research linking coffee with decreased progression of liver fibrosis in patients with alcoholic cirrhosis, cirrhosis in general, and elevated liver enzymes. "This news is significant," they write, "because any modality that decreases the progression of fibrosis in chronic liver disease, especially if it confers few adverse effects, has the potential to improve morbidity and mortality."

In summing up the import of their findings, they add: "Moderate coffee consumption may be a benign adjunct to the comprehensive management of patients with [nonalcoholic steatohepatitis (NASH)]."

However, Arthur L. Klatsky, MD, from the Kaiser Permanente Northern California Division of Research in Oakland, pins more benefit on "avoiding risk factors, such as obesity, high alcoholic intake, and viral hepatitis," he told Medscape Medical News. "In my opinion, these are much more important than suggesting that people drink moderate amounts of coffee."

He continued: "I don't think that the public should be advised to drink coffee." Dr. Klatsky was not involved in the present study, but he was the lead author of the first paper linking coffee intake to cirrhosis, published in 1992.

The new finding comes from a validated caffeine questionnaire administered to 4 patient groups at the Brooke Army Medical Center Hepatology Clinic in Fort Sam Houston, Texas: negative controls, bland steatosis/not-NASH, NASH stage 0 to 1, and NASH stage 2 to 4. Between March 2010 and March 2011, 306 patients completed the caffeine questionnaires, which also tabulated tea drinking. Overall, coffee drinking accounted for 71.5% of all caffeine consumed. Patients were also questioned about their intake of other caffeinated beverages, such as various teas, cocoa, caffeine-fortified drinks, chocolate, and caffeine pills. No other caffeinated beverages showed a correlation with any dimension of liver protection (eg, NASH, insulin resistance, diabetes, liver enzymes).

Patients with no to early fibrosis received 57.5% of their caffeine from regular coffee, in comparison with those with advanced fibrosis, who consumed only 35.9% of their caffeine from coffee (P = .041). Average caffeine intake varied significantly across the 4 groups on analysis of variance (P = .024). Coffee intake specifically varied between the 4 groups (P = .011).

The authors flagged the finding that patients with bland steatosis/not-NASH and control patients drank less coffee than those patients with NASH/steatosis. They speculate: "It may be that coffee is only beneficial to those [patients with nonalcoholic fatty liver disease] with a propensity for fibrosis (i.e., NASH patients)."

The authors acknowledge several limitations to their analysis; namely, that their study "was not prospective and thus did not follow the effects of differences in fibrosis on clinical outcomes over time," as well as a lack of blinding of the interviewers. They advise further study of the specific components of coffee and their effects on metabolic activities of the liver.

The study's senior author has disclosed that he consults for Amylin. Dr. Klatsky and the other authors have disclosed no relevant financial relationships.

Hepatology. 2012;55:429-436. Abstract

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New Study of Interferon-free HCV Therapy Hailed as 'Watershed Moment' in Hep C Research

02-05031205IFN-free_300

Gastroenterology & Endoscopy News

ISSUE: FEBRUARY 2012 | VOLUME: 63:2

SVR Achieved With Two Direct-acting Antivirals in Absence of Interferon in Small Study

A combination therapy including two investigational direct-acting antiviral agents (DAAs)—asunaprevir and daclatasvir—suppressed hepatitis C virus (HCV) genotype 1 infection in a majority of patients who had previously not responded to treatment, according to results from a small Phase II study published in the Jan. 19 issue of The New England Journal of Medicine (Lok AS et al. 2012;366:216-224).

Success rates were 100% in patients who received the drugs in combination with peginterferon alfa-2a (Peg-IFN) and ribavirin (RBV).

And, most notably, even in patients who received daclatasvir and asunaprevir without Peg-IFN and RBV, sustained virologic response (SVR) was achieved in 36% of patients, making this the first published study to show that SVR can be achieved with an IFN-free treatment in previous null responders.

“The response in some patients to the combination of daclatasvir and asunaprevir alone showed proof-of-concept that a sustained virologic response can be achieved without peginterferon and ribavirin therapy,” concluded the research team, led by Anna S. Lok, MD, professor of internal medicine in the Division of Gastroenterology, University of Michigan Medical School, Ann Arbor.

In an editorial accompanying the study, Raymond T. Chung, MD, director of hepatology and medical director of the liver transplant program at Massachusetts General Hospital, Boston, called the study a “watershed moment in the annals of HCV therapy.

“It shows that sustained virologic response can be achieved without interferon. Implicit in this finding is the concept that two potent agents with complementary resistance profiles, given for a sufficient duration, can impose a stranglehold on viral replication and result in clearance of the virus.”

In this Phase II study, 10 patients received the experimental drugs in combination with Peg-IFN and RBV for 24 weeks. All 10 patients had undetectable viral loads at the end of treatment and at 12 weeks after stopping treatment. Nine patients continued to exhibit SVR at 48 weeks after treatment, whereas one patient had HCV RNA of less than 25 IU/mL at post-treatment week 48 and undetectable HCV RNA 13 days later.

In a separate arm of the study, 11 patients received asunaprevir and daclatasvir alone, without the addition of Peg-IFN and RBV.

Of these, four patients (36%) achieved an SVR at 12 and 24 weeks after treatment. Six patients (55%) had viral breakthrough during treatment, with resistance mutations to both antiviral agents. Breakthroughs occurred as early as treatment week 3 and as late as treatment week 12.

Although only one-third of the patients given the two-drug combination without Peg-IFN and RBV achieved an SVR, investigators and other hepatologists say the finding is “very promising.”

“For years, the concept of IFN-free therapy was hotly debated. Now, we’re very quickly moving toward IFN-free therapy. It’s potentially just around the corner,” said Donald M. Jensen, MD, professor of medicine and director of the Center for Liver Diseases, University of Chicago Medical Center.

“For patients who can wait, they might just have to wait a few more years until IFN-free therapy is on the market,” he said.

Daclatasvir is a first-in-class, highly selective HCV NS5A replication complex inhibitor that has shown picomolar potency in vitro. Asunaprevir is a highly active HCV NS3 protease inhibitor. Both drugs produce robust declines in HCV RNA levels in patients with HCV genotype 1 infection and, taken in combination, there is no clinically meaningful pharmacokinetic interaction.

Hepatologists say that treatment of HCV infection is entering a new era, highlighted by combinations of second-generation DAAs. As more DAAs are developed with non-overlapping resistance profiles, they may reduce dependence on treatment with IFN.

“These data are very encouraging because peginterferon-alfa and ribavirin are associated with many side effects and many patients with hepatitis C choose not to receive treatment for fear that they cannot tolerate those drugs,” said Dr. Lok, in a statement.

The participants in Dr. Lok’s study had previously failed to respond to Peg-IFN and RBV treatment, meaning they represent a difficult-to-treat population with poor expected outcomes. Previous null responders typically do not respond to retreatment with Peg-IFN and RBV and also tend to have a poor response to triple-combination therapy with Peg-IFN and RBV plus a protease inhibitor.

This combination of new DAAs, if supported by larger studies, could help the large number of patients who have not responded to previous treatment.

“Because of this high unmet medical need, there is a necessity for new combination regimens that can increase response rates in that population,” said Dr. Lok.

Study Details

In the current study, investigators screened 56 patients and ultimately enrolled 21 patients in an exploratory cohort to assess the safety and antiviral activity of the new DAAs. All patients were between the ages of 18 and 70 years, had a chronic HCV genotype 1 infection with an HCV RNA level of 105 IU/mL or higher, showed no evidence of cirrhosis and exhibited no response to previous HCV therapy. Of these patients, 90% had interleukin 28B (IL28B) genotype CT or TT, both of which are associated with poor response to Peg-IFN and RBV, and most patients had HCV genotype 1a infection.

Daclatasvir was administered orally at a dose of 60 mg once daily and asunaprevir at a dose of 600 mg twice daily, with no dose reductions permitted. Ten patients also received Peg-IFN 180 mcg per week, administered subcutaneously, and RBV, administered orally twice daily, with doses determined according to body weight.

Investigators believe that the combination of two DAAs increases the resistance barrier, particularly for patients with HCV genotype 1b infection. In this study, all viral breakthroughs occurred in patients with HCV genotype 1a infection.

This study appears to confirm the results of a recent Japanese study, which showed a high SVR rate among patients with HCV genotype 1b infection in a pilot study of 10 previous non-responders who received combination therapy with asunaprevir and daclatasvir (Chayama K et al. Hepatology 2011 Oct 10; 10.1002/hep.24724 [Epub ahead of print]).

The key benefit of treatment with Peg-IFN and RBV appears to be prevention of viral breakthrough. No patient who received the four-drug combination in the current study experienced a viral breakthrough, whereas six patients in the group that received the DAAs alone had viral breakthroughs. All patients who had a viral breakthrough received and initially responded to Peg-IFN and RBV as rescue therapy. Most ultimately had therapeutic failure.

The high frequency of resistance sends a strong cautionary note about these therapies, said investigators. Future studies of combinations of DAAs without Peg-IFN and RBV in patients with HCV genotype 1a infection should proceed carefully, said the investigators.

But, they added, further research on combinations of DAAs, with or without Peg-IFN and RBV, should be encouraged.

The most common adverse events in this study were diarrhea, fatigue, headache and nausea, which were mild or moderate in all cases. Grade 3 or 4 neutropenia occurred in six patients, all of whom were receiving Peg-IFN and RBV in addition to the two DAAs. No grade 3 or 4 events related to hemoglobin levels or platelet counts were observed.

“This is an exciting study that means care will be better for patients,” said Andrew J. Muir, MD, clinical director of hepatology, Duke University Health System, Durham, N.C., who was not involved with the study.

“For the first time, patients were cured of HCV without interferon-a. Interferon-a has always been the backbone of HCV therapy but has many side effects that make treatment too difficult for many patients.”

Bristol-Myers Squibb, manufacturer of asunaprevir and daclatasvir, funded this study. Dr. Lok has received consulting fees from Abbott Laboratories, Bristol-Myers Squibb and Gilead Sciences, and grant support from Bristol-Myers Squibb, Gilead Sciences, GlaxoSmithKline, Merck–Schering-Plough and Roche. Dr. Muir has received grant support from Bristol-Myers Squibb, Gilead Sciences, Merck–Schering-Plough, Roche and Vertex Pharmaceuticals. Dr. Jensen has served on advisory committees or review panels for Abbott Laboratories, Boehringer Ingelheim, Genentech/Roche, GlobeImmune, Human Genome Sciences, Merck, Pfizer, Pharmasset, Tibotec and Vertex Pharmaceuticals; he has received consulting fees from Abbott Laboratories, Bristol-Myers Squibb, Genentech/Roche and Vertex Pharmaceuticals; and he has received grant/research support from Boehringer Ingelheim, Genentech/Roche, Tibotec and Vertex Pharmaceuticals.

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Aged-Based Hepatitis Screenings on the Horizon

Posted by Dr. Stephen Vogt ⋅ February 6, 2012

Deaths due to hepatitis C in the United States have already reached 15,000 deaths each year, according to the Centers for Disease Control and Prevention (CDC). This number is expected to rise to 35,000 hepatitis C deaths per year within the next two decades. Baby Boomers account for 75 percent of hepatitis C virus (HCV) fatalities.

An estimated 1.6 million U.S. adults ages 40-64 are currently infected with the hepatitis C virus but have no idea of their disease state. How could this happen? The answer is partly due to the silent nature of HCV infection: it can be without any symptoms for up to 20 years. The other part of the answer is connected to the current standards that limit HCV screenings to those with conventional high risk factors (such as IV drug use, blood transfusion before 1992, or unprotected sex with a known HCV-infected person). Yet a huge portion of people (many of them Baby Boomers) do not fit this risk factor profile.

As I pointed out last year, in “Call for Wider Hepatitis Screenings ,” we can stem this rising tide of HCV deaths by instituting more HCV screenings, particularly age-based screenings for all Baby Boomers. Today, we are getting one step closer to changing the HCV screening process from the current one based on risk factors to a screening process based on birth year.

The CDC is poised to recommend a one-time age-based screening for all Baby Boomers. A new CDC-funded study took a close look at the cost-effectiveness of an aged-based screening for HCV. It was clear that a one-time screening (followed by treatment for infected individuals) for everyone born from 1945-1965 would pay off both financially and in healthier lives. The cost-effectiveness from widespread HCV screenings would be in line with cervical cancer and cholesterol screenings.

A switch to an aged-based screening couldn’t come at a better time. Screening tests are faster and easier than ever (answers can come back as quick as 20 minutes ) and treatments today clear this virus in greater numbers of infected people, giving a meaningful cure to most patients.

Stephen C Vogt, PharmD
President and CEO
BioPlus SP

www.bioplusrx.com

Source:
Rein DB, Smith BD, Wittenborn JS, et al. The Cost-Effectiveness of Birth-Cohort Screening for Hepatitis C Antibody in U.S. Primary Care Settings. Ann Intern Med November 4, 2011 [epub ahead of print]. Highleyman L. AASLD: Deaths Due to Hepatitis C Now Exceed HIV Deaths. Report from the American Association for the Study of Liver Diseases Liver Meeting. November 15, 2011.

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Spinal Cord Stimulation Effective for HIV Neuropathy

Kate Johnson

February 6, 2012 (Miami Beach, Florida) — Constant spinal cord stimulation delivered through a permanently implanted device can offer pain relief to patients with HIV-related polyneuropathy that is refractory to conservative treatment, according to Kenneth Candido, MD, and colleagues. Results were presented in a poster here at the 6th World Congress of the World Institute of Pain.

"We believe that it is not only a new indication, but it offers relief for individuals who were previously left to the devices of primary care physicians who really only have at their disposal the ability to prescribe narcotic analgesics," Dr. Candido, who is chair and professor in the Department of Anesthesiology at Advocate Illinois Masonic Medical Center in Chicago, told Medscape Medical News in an interview during the meeting.

Spinal cord stimulation is a well-established technique currently indicated for the management of failed back surgery syndrome, complex regional pain syndrome, inoperable peripheral vascular disease, and refractory angina pectoris, Dr. Candido and colleagues report.

To date, the team has used the technique in 6 patients with debilitating pain from HIV-related polyneuropathy. The first case is described in the poster.

The patient, a 50-year-old man with a 20-year history of HIV, was receiving highly active antiretroviral therapy (HAART). He had an 8-year history of "excruciating" pain.

"He had ongoing severe peripheral neuropathic pain and burning allodynia in both feet, primarily the plantar surfaces. He had not responded to conservative management, which had included high doses of opioid analgesics, anti-inflammatory medications, antiepileptic drugs, and other adjuvants such as peripheral nerve block therapies and epidural injections," said Dr. Candido.

The syndrome of HIV-related pain tends to have a distal "stocking" distribution in the lower extremities, similar to diabetic peripheral neuropathic pain, he explained. "It has been almost exclusively related to pain below the knees. It tends to be bilateral, and we suspect that the mechanism is similar to diabetic peripheral neuropathic pain, in that there is microvascular disruption either due to the virus attacking the vasculature or, alternatively, due to the HAART therapy, which may have a predisposition for the small blood vessels."

After the patient underwent a trial of temporary spinal cord stimulation, in which 2 eight-electrode leads were advanced into the dorsal epidural space and fluoroscopically guided to T9–T10, with good results, a permanent implant was placed.

"He has now had almost 2 years of reduction in his pain, from a constant level of about 8 out of 10 down to about 1 or 2 out of 10, and we've been able to wean him off his opiate analgesics," said Dr. Candido.

On the basis of this initial experience, 5 other HIV patients have received permanent implants, with similar success.

"The beauty of neuromodulation is that we can tailor therapy to the patient's individual symptoms. While I would say that we've used a lumbar approach and lower thoracic stimulators in all patients, clearly not every individual is exactly alike, so we choose our criteria very carefully and we select the actual placement of the stimulators based on the concordant response that we identify during the trial process. We've individualized it, but by and large every individual has responded favorably to T8 through T10 placement of these electrodes."

Dr. Candido explained that as HIV patients live longer because of HAART, the medical community must find pain relief options that are superior to opiate analgesics, which have the potential for extensive adverse effects, including nausea, vomiting, pruritis, constipation, urinary retention, and respiratory depression.

His group has also permanently implanted continuous intrathecal drug delivery systems in 4 HIV patients who did not want spinal cord stimulators.

"Dorsal column stimulation and/or intrathecal delivery of opioids and adjuvants proves to be the primary modality that we believe should be used as a first-line therapy once individuals are identified with this peripheral neuropathic pain process," he said.

Despite the immunocompromised state of HIV patients, he said no adverse events have been reported.

"We know that individuals who have compromised immune status are always predisposed to...infectious processes.... Infections are found in 1% to 2% of individuals who have a dorsal column stimulator, but...in almost two-and-a-half years, we have not identified any superficial or deep infections associated with the permanent implantation process."

Before proceeding, his group studied the orthopedic literature looking at infection rates among HIV patients with hip and knee replacements. "We haven't seen an increase in the incidence of infection in those individuals, so we extrapolated the orthopedic data to our own neurological/surgical population and found that it was logical and intuitive that we should also not have a high level of systemic infection or even localized infection if we took all the appropriate precautions."

Dr. Candido has disclosed no relevant financial relationships.

6th World Congress of the World Institute of Pain: Abstract 171. Presented February 5, 2012.

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Liver cirrhosis curable (???)

cirrhosis

© Photo: ru.wikipedia.org

Olga Pshenitsyna Feb 5, 2012 16:52 Moscow Time

Russian scientists at the Pharmacology Institute of the Russian Academy of Sciences Siberian Department have developed a unique medication for liver cirrhosis. It is based on a chemical compound that has absolutely no analogues in the world.

Up to now, liver cirrhosis has been deemed as an utterly incurable disease. But the pharmaceutical drug created by Tomsk and Novosibirsk scientists can work wonders for cirrhosis patients. The scientists have been working on this substance for 10 years and their efforts have finally been rewarded. The specific effects of the new medication in the treatment of liver cirrhosis have been experimentally confirmed, while toxicology tests have proven that it is toxic-free, Professor Gleb Zuzkov told reporters this week:

"Experiments on animals have shown that the substance has high hepa-protective efficiency during various chronic liver diseases, including the initial stages of cirrhosis. What’s more, despite being a protein-based ferment, it has no toxic effects."

The use of electron beam synthesis nanotechnology in the drug’s creation helped obtain unique properties needed to stimulate effective regeneration of liver tissue through stimulating the patient’s own stem cells capable of restoring healthy tissue in a damaged liver. Professor Zuzkov:

"Our medicine has no analogues either among the existing drugs or the ones that are only just being developed. No other substance that has been described in scientific literature so far can boast such a pronounced effect on progenitor cells and their regulation mechanisms as ours."

The wonder medication is currently undergoing pre-clinical tests. The follow-up clinical testing and registration formalities may take around five years.

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February 5, 2012

New treatment for liver cancer patients

Private hospital news : 5 February 2012

BMI The Alexandra Hospital is the first hospital in the North West to provide a new, non-surgical treatment for liver cancer.

The DEBIRI (Drug-Eluting Beads delivering Irinotecan) treatment is for patients suffering from both primary, where the disease originated in the liver or secondary liver cancer - where it travelled to the liver from another organ such as the bowel or breast.

The DEBIRI treatment is minimally invasive and treats patients who have inoperable tumours by shrinking them and making surgery possible.

The procedure involves inserting a catheter – a thin plastic tube - into an artery which supplies blood to the tumour. The tumour is then injected with fluid containing microscopic chemotherapy beads, which directly attack the cancer.

At the same time, the beads obstruct the tumour’s blood supply, depriving it of oxygen and nutrients which prohibit its growth. By injecting chemotherapy directly into the liver, many of the side effects can be decreased or avoided.

The DEBIRI treatment is carried out by a multi-disciplinary team at BMI The Alexandra Hospital, lead by Consultant Medical Oncologist Dr Greg Wilson, and Consultant Interventional Radiologist Dr Finn Farquharson.

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February 4, 2012

Twelve-Week Posttreatment Follow-Up to Predict Sustained Virologic Response for Recurrent Hepatitis C Infection in Liver Recipients

Transplantation. 2012 Jan 18. [Epub ahead of print]

Campos-Varela I, Castells L, Esteban JI, Bes M, Rodríguez-Frías F, Sapisochin G, Allende H, Charco R, Esteban R.

1Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain. 2Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain. 3Transfusion Safety Laboratory, Banc de Sang i Teixits (BST), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain. 4Biochemistry Laboratory, Hospital Universitari Vall d'Hebron, Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain. 5Liver Transplant Unit, Department of HPB-Surgery and Transplant, Hospital Universitari Vall d'Hebron, Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain. 6Pathology Department, Hospital Universitari Vall d'Hebron, Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain.

Abstract
BACKGROUND: The current standard for determining sustained virologic response (SVR) in patients treated for hepatitis C virus (HCV) infection is undetectable serum HCV-RNA 24 weeks after treatment. This study evaluates the value of HCV-RNA determination at 12 weeks posttreatment (W+12) to predict SVR in liver transplant (LT) patients treated with pegylated interferon and ribavirin for recurrent HCV infection.

METHODS: This study, performed in 2001 to 2010, included HCV-LT patients with an end-of-treatment response (undetectable serum HCV-RNA) and HCV-RNA testing at 12 and 24 weeks posttreatment (W+12/W+24). HCV-RNA was detected with a qualitative polymerase chain reaction assay (detection limit 50 IU/mL) and, when positive, measured by quantitative PCR (detection limit 600 IU/mL) up to 2006. Since 2007, a real-time PCR-based test (detection limit 15 IU/mL) has been used. The positive predictive value (PPV) was defined as the probability that SVR would occur in patients with undetectable HCV-RNA at W+12 and W+24.

RESULTS: Of 162 patients treated during the study period, 57 (35%) had end-of-treatment response and were included. Of these, 45 (79%) had SVR and 12 (21%) had virologic relapse. At W+12, HCV-RNA was undetectable in 45 (79%) patients, all of whom had SVR, yielding a PPV for SVR at W+12 of 100% (95% confidence interval, 75.8%-100%).

CONCLUSIONS: Undetectable HCV-RNA at W+12 posttreatment has a high PPV for predicting SVR. HCV-RNA testing to assess SVR at this time point seems as valid as W+24 testing and could be considered for predicting SVR in HCV-LT patients receiving treatment with pegylated interferon and ribavirin.

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A Score Predicting Survival After Liver Retransplantation for Hepatitis C Virus Cirrhosis.

Transplantation. 2012 Jan 19. [Epub ahead of print]

Andres A, Gerstel E, Combescure C, Asthana S, Merani S, Majno P, Berney T, Morel P, Kneteman N, Mentha G, Toso C.

1Abdominal and Transplantation Surgery, Department of Surgery, University Hospital Geneva, Switzerland. 2Clinical Epidemiology, University Hospital Geneva, Switzerland and the Division of Internal Medicine, University Hospital Geneva, Switzerland. 3Division of Transplantation, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.

Abstract
BACKGROUND: Approximately one fourth of patients transplanted for hepatitis C virus (HCV)-induced liver failure progress to cirrhosis within 5 years, potentially requiring retransplantation. Although the relisting decision can be difficult in these patients, a score could help in selection of candidates with the best potential outcomes.

METHODS: A total of 1422 HCV-positive patients having undergone a retransplantation were included in this registry-based study. A multivariate Cox regression was performed, and an Akaike procedure was applied to design a score predicting survival after retransplantation and to allow an internal validation. Retained variables were donor age (DnAge), serum creatinine (Creat), International Normalized Ratio (INR), and serum albumin (Alb) at the second transplantation, recipient age (RecAge) at the first transplantation, and the interval between both transplantations (Int).

RESULTS: The score was designed as 0.23×DnAge+4.86×log Creat-2.45×log Int+2.69×INR+0.10×RecAge-3.27× Alb+40. The receiver operating characteristic area under curve was 0.643 at 3 years, and survivals were 71%, 56%, and 37% for scores <30, 30 to 40, and >40, respectively (log rank <0.0001).

CONCLUSIONS: Overall, the proposed score is specifically designed for HCV-positive patients, accurately predicts survival after a liver retransplantation, and is helpful in the selection of candidates with the best potential outcomes.

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Medivir/Tibotec HCV Drug Development

15-Nov-11

Phase II interferon free combination study with TMC435 and PSI-7977

This interferon free phase II combination study will commence shortly. It will evaluate TMC435 and PSI-7977 in combination with and without ribavirin for 12 and 24 weeks in genotype 1 patients who had a prior null response to Peg-IFN/RBV. The study design is now posted on www.clinicaltrials.gov.

TMC435HPC2002 - Phase II Trial of TMC435 in Combination With PSI-7977 in Prior G1 Null Responders to Peg-IFN/RBV, Hepatitis C-Infected Patients: 12 and 24 weeks, with & without rbv (4 arms), INF-free study

This study is currently recruiting participants.
Verified January 2012 by Tibotec Pharmaceuticals, Ireland

TMC435HPC2002 - Phase II Trial of TMC435 in Combination With PSI-7977 in Prior G1 Null Responders to Peg-IFN/RBV, Hepatitis C-Infected Patients

HCV polymerase collaboration

TMC649128 TMC649128, the first NS5B nucleoside polymerase inhibitor under the collaboration, entered into clinical development in Q1-2011. It was safe and well tolerated at all doses tested for up to 14 days. However the antiviral activity failed to meet the target product profile and therefore the clinical development has now been discontinued.

Nucleotide program

The focus of HCV polymerase collaboration is now on a liver targeted nucleotide polymerase inhibitor program. A clinical candidate has been selected and the project is now in preclinical development stage.

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World Cancer Day: The Five Deadly Types of the Non-Communicable Disease

By Bhaskar Prasad 

February 4, 2012 12:35 AM EST

The World Cancer Day is observed on Feb 4 in honor of the global fight against the non-communicable disease (NCD), which claimed more than 7.6 million lives in 2008 and the World Health Organization says the number is expected to rise above 11 million by 2030.

The data from the World Health Organization Global Status Report on NCDs demonstrate that almost 80 percent of these deaths occur in low and middle income countries and a quarter happen before the age of 60.

The main types of cancer are:

Lung Cancer (1.4 million deaths)

It is the deadliest type of cancer for both men and women. Each year, more people die of lung cancer than of breast, colon, and prostate cancers combined. Cigarette smoking is the leading cause of lung cancer. The more cigarettes you smoke per day and the earlier you started smoking, the greater your risk for lung cancer. There is no evidence that smoking low-tar cigarettes lowers the risk.

Stomach Cancer (740,000 deaths)

Several different types of cancer can affect the stomach. The most common type is called adenocarcinoma, which starts from one of the common cell types found in the lining of the stomach. The rate of most types of gastric adenocarcinoma in the U.S. has gone down over the years. Experts think the decrease may be because people are eating less salted, cured, and smoked foods.

Liver Cancer (700,000 deaths)

In most cases, the cause of liver cancer is cirrhosis, which is the end result of chronic liver damage caused by chronic liver diseases. Alcohol abuse is the most common cause of cirrhosis in the U.S.

Colorectal Cancer (610,000 deaths)

This type of the cancer starts in the large intestine (colon) or the rectum (end of the colon). Nearly all colorectal cancers begin as noncancerous (benign) polyps, which slowly develop into cancer.

Breast Cancer (460,000 deaths)

This type of cancer starts in the tissues of the breast. It can start in the tubes (ducts) that move milk from the breast to the nipple. It can also begin in the parts of the breast, called lobules that produce milk.

It is urgently needed to raise awareness and to bring the growing cancer crisis to the attention of the public, government leaders, and health policymakers.

Stand Up To Cancer and the Union for International Cancer Control (UICC) are launching a Facebook app that they hope will create a digital buzz that will reduce the spread of the disease. UICC notes that urgent action against cancer is vital because of its huge impact on human suffering.

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