Your Liver - Q1 2020

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Your Liver Your Liver HEALTHAWARENESSCO.UK

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“Autoimmune liver conditions are often overshadowed by the rising tide of preventable liver disease” Martine Walmsley, Chair of Trustees, PSC Support P6

“One of the best lines of defence we have against liver disease is to prevent the liver damage occurring in the first place”

“Liver disease carries with it a great deal of stigma, which is unfair and unhelpful”

Pamela Healy, CEO, British Liver Trust P2

Professor Roger Williams CBE, Director, Foundation for Liver Research P8

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Help eliminate viral hepatitis, the most overlooked killer of our time Hepatitis B and C claim 1.4 million lives every single year, more than HIV/AIDS and malaria.

WRITTEN BY: DR SU WANG MD, MPH, FACP President, World Hepatitis Alliance

L

iver cancer rates continue to rise largely due to viral hepatitis. Despite these infections being so common, they are often overlooked on the international health agenda. The cost of global indifference is paid in human lives. Suffering from hepatitis could easily be averted, yet little is done. Compared to other infectious diseases, viral hepatitis receives sparse funding for research, prevention, diagnosis and treatment.

I am living with hepatitis B, the apathy and lack of prioritisation for viral hepatitis is alarming. Millions of us are living with this disease, but only 10% of us have been diagnosed. Even fewer are receiving life-saving treatments.

I am a mother, and my four children received the hepatitis B birth dose vaccine as soon as they were born. It means the world to me that each of them is free of the infection.

Yet millions of babies do not receive this birth dose, their mothers must live with the knowledge they have passed on a lifelong disease to their children.

I am a physician, and I see the hope that comes from awareness and science. We have rapid test kits for hepatitis which can give people results at point of care. We need to test widely to find the missing millions and once found, we need to connect them to care. For hepatitis B, we have effective treatments and for hepatitis C, we have cures.

Globally, prices for testing and treatments have gone down, but we need to make sure that individuals can access these lifesaving tools at low cost.

Supporting the affected community We need to support the affected community and amplify their voices. Something powerful happens when people share their story, and we often hear the devastating effects of hepatitis: people’s lives cut short, children losing their parents, communities mourning the many bright futures that become dim. We owe it to them to give the next generation a legacy of NOhep.

What you can do

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Get yourself and your loved ones tested. Nine in ten people with hepatitis have no idea they are living with the disease. A simple blood test will tell you your status.

Join NOhep.org. This is the global movement to eliminate hepatitis. We need your voice to join calls for action and bring more attention to hepatitis.

Celebrate World Hepat it i s Day. L et ’s i nc rea se awareness. Raise your voice with us on 28 July, so the world hears it.

Read more at healthawareness.co.uk

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Three key steps for good liver health WRITTEN BY: PAMELA HEALY CEO, British Liver Trust

The UK is facing a liver disease crisis and the latest statistics from the British Liver Trust make for alarming reading. Deaths from liver disease have increased by 400% since 1970 and it is set to overtake cardiovascular disease as the biggest cause of premature death in the next few years.

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eople who have l iver disease often don’t exper ience s y mptom s i n t he early stages. Three quar ters of people are currently diagnosed at a late stage, when the disease i s so adv a nc e d t h at t here a re few op t ion s for t re at ment or intervention.

When damage to t he liver is i r r e ve r s i ble, it i nc r e a s e s t he r i sk of f u r t her compl ic at ion s, including developing liver cancer and liver failure.

Alarmingly, one in five of us are at risk, yet there is a chronic lack of awareness and funding for the disease.

The British Liver Trust campaigns for change and works t i rele s sly to r a i s e aw a rene s s, i m p r o ve e a r l y d i a g n o s i s a n d detection and support clinicians to give the best possible care.

90% of liver disease is preventable One of the best lines of defence we have aga i n s t l iver d i se a se is to prevent t he liver damage occurring in the first place. Liver d i s e a s e i s prevent able 9 0 % of

the time as it is often caused by either drinking too much alcohol, obesity or viral hepatitis.

Given the chance, the liver has an incredible ability to replace damaged tissue with new cells and regenerate.

Taking steps to look after your liver will give it the chance to recover but it is like an elastic band – it can only stretch so far before it breaks, and the damage to your liver becomes permanent.

The British Liver Trust’s Love Yo u r L i v e r c a m p a i g n r a i s e s awareness of the risk factors and helps people understand how to reduce their risk of liver damage.

Find out more: We offer a free online screener to help people assess their risk of liver disease as well as a national Love Your Liver roadshow offering non-invasive liver scans. The Trust is also calling for there to be improved detection within primary care.

To find out more visit: britishlivertrust.org.uk

Three key steps for good liver health:

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Drin k w it hin recom mended limits and have three consecutive alcohol-free days every week Maintain a healthy weight by eating well and taking more exercise Know the risk factors for viral hepatitis and get tested or vaccinated if at risk.

Read more at healthawareness.co.uk

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The burden of liver disease on the NHS is a ticking time bomb European livers are bearing the brunt of an above-average alcohol consumption. Liver disease is on the rise and likely to keep going.

However, technology exists that can identify liver disease and potentially help GPs and practitioners intervene in the nick of time. procedures, pose a greater risk to the patient and put incredible strain on the body.

What are the risk factors associated with developing liver disease?

INTERVIEW WITH:

DOMINIQUE LEGROS CEO, Echosens

Why is early detection of liver diseases important?

Many kinds of liver disease are what we call ‘silent’ diseases – in that patients may not present with specific symptoms until things have got to the cirrhosis stage, which is end-stage liver disease. At that point, the condition is incredibly difficult to treat, which often leads to life-threatening complications such as liver cancer and internal bleeding.

Difficulty and cost of treating someone w it h end-st age l iver disease are the two key challenges.

For example, transplants are costly

There are two types of liver disease - viral and non-viral (linked to diet, alcohol consumption and lifestyle) and risk factors associated with both. Those who drink excessive amounts of alcohol, have diabetes, hypertension or those who are overweight are the most at risk.

With rates of obesity and alcohol consumption growing, especially within Europe, raising awareness of the risks people pose to their own liver is key.

What is the role of primary care in the early detection of liver disease?

Primary care workers have a vital role in increasing early detection.

There is a need to better educate all practitioners on the importance of this, but to also give them the tools and the ability to make a clinical diagnosis without the need to refer the patient to hospital.

To support that effort, accurate screening tools like VCTE™ scanners are being brought into the primary care community. These, along with blood tests, give practitioners the ability to make early diagnoses and consider interventions to prevent the disease progressing to more severe stages, such as cirrhosis.

The VCTE™ scanner works by measuring liver ‘stiffness’.

What are the advantages of VCTE™ scans over other methods of identifying liver disease?

Measuring liver ‘stiffness’ in this way gives practitioners the ability to make a clinical diagnosis, without the need to perform a more invasive test on the patient.

The industry standard method for measuring either the presence or severity of liver disease is to perform a liver biopsy, however it is a costly and invasive procedure that requires trained physicians and a hospital visit.

Since the VCTE™ scanner came onto the market in 2003, liver biopsies have become fa r less common.

The VCTE™ scanner is able to measure both liver stiffness and

the amount of fat in the liver.

Pat ient s who d r i n k exces sive alcohol may well develop this ‘fatty’ liver. This isn’t yet liver disease, but those patients stand at risk of developing liver disease if this is the case.

Who will benefit from a non-invasive liver test?

It’s clear that obesity and alcohol consumption are problems that are getting worse, not better.

In Europe, where alcohol consumption per capita is the h ig he s t i n t he world, a huge percentage of the population is putting themselves at a greater risk, without necessarily knowing it.

VC T E™ scanners allow practitioners, within minutes, to tell patients if they are either at risk of developing liver disease – or they already have it. From there, there are more options available, in terms of stemming the development of liver disease.

WRITTEN BY: JAMES ALDER

FibroScans in the UK Already, there are more than 300 FibroScans installed in the UK. Half a day’s training on the VCTE™ scanners would be enough for someone to effectively identify liver disease – without the need for further, invasive patient tests.

We have partnered with the British Liver Trust in order to ensure the FibroScan technology is more widely available to detect liver disease early. www.echosens.com

Sponsored by

Sources: 1: Lancet Report (2019)

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NHS and pharma industry collaborate to accelerate elimination of hepatitis C in England WRITTEN BY: PROFESSOR GRAHAM FOSTER Hepatitis C Programme Clinical Chair, NHS England and NHS Improvement

As part of the NHS Long Term Plan, the health service is committed to eliminating Hepatitis C, with the most advanced treatments and smart deals with pharmaceutical firms that are not only good news for patients and their families, but taxpayers too.

H

epatitis C not only affects the liver but can lead to a wide range of symptoms, including fatigue and problems concentrating. However, they can improve dramatically once treated effectively and we are already starting to see an impact from the NHS’s hepatitis C elimination programme.

Since England embarked upon the road to hepatitis C elimination, and introduced new treatments, close to 50,000 patients have been treated. Ninety-five per cent are now cured and have been spared the disabling effects of the disease.

Furthermore, the number of people on the waiting list for post-hepatitis C cirrhosis and liver cancer-related liver transplantation had reduced by half in 2017, compared with pre-2015 levels.

Who are the high-risk individuals in this remit?

Hepatitis C is transmitted by bloodto-blood contact. In the UK, most infections happen in people who inject drugs or have injected them in the past. However, it can also be spread through sharing razors or toothbrushes, or from a pregnant woman to her unborn baby.

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Since England embarked upon the road to hepatitis C elimination, and introduced new treatments, close to 50,000 patients have been treated

What diagnosis and treatment options are available to high-risk individuals?

People at risk of hepatitis C can be tested via their GP, addiction centre, or sexual health clinic.

For those who are infected, the amount of damage to the liver can easily be assessed by a special, modified ultrasound scan, that can be performed at multiple locations.

Treatment can then be introduced without delay.

Current treatments for hepatitis C are a course of highly-effective tablets. Increasingly, the NHS is able to provide the full range of diagnostic and treatment ser vices outside of a hospital setting. This allows some of the most marginalised

populations, including those who are experiencing homelessness, to access highly-effective treatment.

How important is crossindustry collaboration on the road to elimination?

The cross-industry collaboration is a key component of the NHS e l i m i n at i o n c a m p a i g n . E a c h company brings slightly different approaches to t he prog ra m me and the collaboration has allowed the NHS to maximise the joint capabilities, enabling us to access some of the most disadvantaged groups in society and increase testing and treatment.

Can we be optimistic about the prospect of hepatitis C elimination in the UK ahead of 2030?

There are a number of challenges ahead but progress to-date, and the commitment from the health and social care sector, gives us confidence that elimination ahead of the global 2030 target can be achieved.

‘Fantastic and unique opportunity’ to end this deadly virus Collaboration, new treatments and reaching out to marginalised communities are helping England achieve its goal of eliminating hepatitis C before 2030.

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ngland has committed to eliminating hepatitis C before 2030, with an ambition of 2025 - a bold vision that could have positive ramifications for the whole of society.

NHS England, patient charities, the third sector and the pharmaceutical industry have come together to find and treat everyone affected by the virus a full five years before the INTERVIEW WITH: World Health Organization’s global target of 2030.

ANDREW DONLON Executive Business Unit Director Despite the significant numbers Liver Disease, of people who are being – and who Gilead Sciences have been – successfully treated for hepatitis C, there are still thousands of patients who are not able to access care, and many who are unaware that they have hepatitis C, said For many, Andrew Donlon, Director of the UK/I treating the virus can be liver disease business unit at Gilead the first time society has Sciences. put their arms around “Many of those with hepatitis C are part of a highly marginalised them and said it cares and stigmatised group in society. about their Gilead is committed to helping this health underserved population.”

The impact of clearing the virus, which can lead to liver disease and liver cancer, can be huge.

Andrew explained: “For many, treating the virus can be the first time society has put their arms around them and said it cares about their health.

Success is possible “With the availability of the curative treatments for hepatitis C, elimination has become a reality, and by working together we can ensure that no one affected by hepatitis C in England is left behind.”

“We have already achieved ‘micro-elimination’ in two drug treatment centres and pretty soon we’ll be able to say the same for several prisons.

That’s where it starts.

“Here, we have a unique opportunity to make England one of the first large major countries in the western world to eliminate hepatitis C,” he said.

WRITTEN BY: AMANDA BARRELL

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Helping the most vulnerable believe in themselves

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ringing hepatitis C services to those most in need is helping people in South Yorkshire believe in themselves and make meaningful change.

INTERVIEW WITH:

MARK CASSELL Nurse Consultant in Viral Hepatitis, Royal Hallamshire Hospital

For many people living with drug and alcohol problems, clearing a hepatitis C infection may be a catalyst for turning their lives around.

The virus, which attacks the liver and can result in disease and liver cancer, is predominantly spread by sharing needles, meaning it disproportionately affects some of the most vulnerable.

Mark Cassell, a nurse consultant

in viral hepatitis at the Royal Hallamshire Hospital in Sheffield, says: “Treating hepatitis C isn’t a priority for many of our patients because they have so many other challenges to deal with – where they are going to sleep, or how they are going to eat, their current challenges with substance use, and significant mental health issues.

“They tend to have lifestyle issues.

Sometimes, people can’t travel to the hospital or find it difficult to remember appointments. Many have very low feelings of self-worth and don’t believe they should or would qualify for treatment.”

Creating change Hepatitis C treatment takes between two and three months and involves a series of clinic appointments. So, instead of asking patients to come to him, Mark goes to them.

“I hold joint clinics with the addiction service nurse prescriber.

When someone comes for review of their drug substitution therapy, they see me too, meaning dual care delivery in one appointment,” he explained.

A round 150 people have successfully commenced treatment since the project launched in South Yorkshire in 2017 and the results have been startling.

M a rk s ays: “ S uc c e s s bre e d s success. For a lot of people, the sense of achievement that comes with successfully clearing the virus has led to them reengaging with other services. One patient, for example, became abstinent from alcohol for the first time in 20 years after going through treatment.”

Believing in people, he said, was the key to helping them to believe in themselves.

WRITTEN BY AMANDA BARRELL

Eliminating hepatitis C? We need to eliminate the stigma first

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o reach marginalised patient populations with hepatitis C, people with experience of the disease are going into communities to share their experiences. It’s a strategy that really works.

INTERVIEW WITH:

RACHEL HALFORD Chief Executive, Hepatitis C Trust

Chances are, if you’re a hepatitis C (HCV) patient, you’re not just dealing with the effects of the disease. You’re dealing with stigma and discrimination, too. “Hepatitis C is associated with drug-use, although you can be infected in many other ways,” explains Rachel Halford, Chief Executive of patientled and patient-run charity, the

Hepatitis C Trust. “Unfortunately, because of this, the discrimination people receive is horrendous.” This can make it difficult to find and treat patients, putting the 2025 HCV elimination target at risk.

Educating the general public and busting the myths about hepatitis C is therefore critical. “Reaching more people with better information would reduce stig ma and also increase the numbers being tested,” says Halford. “That’s key, because HCV shares symptoms with other conditions and, often, diagnosis is given only when your liver has sustained serious damage.”

Sharing real experiences in the community To help marginalised and stigmatised patient populations get the help and support they need, there has recently been a rise in partnerships, new resources and re - en g agement exerc i s e s. For example, the Hepatitis C Trust asks people with lived experience of the disease to go into vulnerable communities and share their stories with disengaged patients, including drug users and the homeless. “We’ve seen this ‘peer-to-peer’ support work really effectively,” says Halford.

“It helps fi nd the people we need to treat, which is so important.”

There is a cure for hepatitis C, and early diagnosis can improve outcomes — so no-one needs to be scared of the disease anymore, notes Halford. “I am confident that we can eliminate HCV by 2025,” she says.

“It’s going to require more work, but we have the treatment, the nursing staff and the funding. And failure is not an option.”

WRITTEN BY TONY GREENWAY

Taking testing and treatment directly to those who need it

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hen hepatitis C patients failed to come to Dr Foxton’s clinic, he decided to take his clinic straight to them.

INTERVIEW WITH:

DR MATTHEW FOXTON Consultant Hepatologist, Chelsea And Westminster Hospital MEDIAPLANET

In 2010, Dr Matthew Foxton, from t he C hel sea a nd West m i n ster Hospital, was asked to set up a dedicated hepatitis C clinic to suppor t person s ex per ienci ng homelessness. He sent out letters and set up appointments, but the patients didn’t come.

In response, Dr Foxton sought inspiration from The Dr Hickey Surgery, a centre that provides pr i ma r y c a re a nd spe c ia l i se d

drug and alcohol support to those experiencing homelessness. This was when the penny dropped.

Rather than asking patients to come to him, Dr Foxton would take his service to them. And so, he set up a weekly clinic at The Dr Hickey Surgery. The clinic is now embedded into the surgery’s wider provision and patients are routinely tested for Hepatitis C. It takes team work to get patients through therapy “The landscape has changed in terms of treatment, but it’s very much a team effort,” continues Dr Foxton. “Lots of us work together to

try and get patients into therapy and through therapy.”

The team work closely with the charity Groundswell, who harness peer suppor t, to engage w it h individuals on the street. Nurses also join members of the NHS Find and Treat team, on community visits, to see how patients are getting on and to conduct blood tests.

“We’re reducing the barriers to the bare minimum,” says Foxton.

The approach is certainly achieving results. The clinics are now full and 90% of those who complete the treatment are cured – a remarkable statistic considering the challenges faced by the patients.

However, to see this success replicated nationally will require even greater collaboration. “We need to join up all the dots in the networks across England, so people don’t fall through the cracks,” concludes Dr Foxton.

WRITTEN BY KATE SHARMA

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Primary biliary cholangitis, and how to manage it WRITTEN BY: COLLETTE THAIN MBE CEO, PBC Foundation

There are many forms of liver disease, most of which are treatable. But many can coexist with other liver conditions, making the journey even more difficult for the patient, and their family.

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rimary biliary cholangitis (PBC) is one of the most rare forms of liver disease. However, it is one of the main causes of liver transplant in adult women in the UK. An autoimmune disease, PBC has no known cause, no cure and affects 1 in 1000 women over 40.

Symptoms of PBC The main symptoms of PBC are fatigue and itch. However, that does not begin to do justice to the severity of the symptoms or the effect they have on a patient’s quality of life.

When patients refer to itchiness they often liken it to feeling ‘spiders crawling underneath the skin.’ Because it is under the skin, with no visible signs, sufferers have been labelled self-harmers, or told they are experiencing tactile hallucinations.

When patients talk about the fatigue they experience, they sometimes talk of ‘walking through custard,’ or ‘wearing a lead blanket.’

The dangers of these symptoms These are serious quality of life issues. Some patients with incurable itching have died by suicide. Some have had liver transplants just to cure the itch.

Even if a patient is asymptomatic, there can still be ongoing damage to the liver, making a transplant the only viable solution. Not everyone who needs one is lucky enough to receive a new liver. Those who do know that it is not a cure, but a different set of challenges.

First-line therapy available But among all the gloom, there is good news. PBC is easy to diagnose if clinicians ask the right questions. The antimitochondrial antibodies (AMA) test is important in identifying PBC, as is an alkaline phosphates level (ALP) test.

There is also a first-line therapy that, when dosed appropriately, can help slow down the progression of disease to give patients an average life expectancy. If first-line therapy fails, there are now options and even a brand new licensed second-line treatment.

So, there is good news. We need patients diagnosed earlier, treated appropriately and referred on to specialists if they do not respond to first-line therapies.

These three actions would make a huge difference, not only to PBC patients, but also to the community and to demand on liver transplant services. Until that happens, our work continues.

Read more at healthawareness.co.uk

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Lifestyle changes can’t prevent all liver diseases WRITTEN BY: MARTINE WALMSLEY Chair of Trustees PSC Support (Primary Sclerosing Cholangitis)

Not all liver conditions are preventable. Martine Walmsley, who suffers from the rare liver condition primary sclerosing cholangitis (PSC), highlights the challenges of living with, and managing the condition.

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he impact of alcohol misuse and obesity on the liver is a hot topic because, by making simple everyday changes, serious liver damage can be prevented or, in some cases, reversed.

While this is a significant public health focus, it is important to recognise that other causes of liver failure exist too. For example, more than 30,000 people in the UK are thought to have autoimmune liver conditions such as autoimmune hepatitis, primar y biliar y cholangitis and primary sclerosing cholangitis (PSC).

The body ‘attacks’ parts of the liver PSC affects people of any age, including children. It affects the bile ducts and the liver, and cannot be prevented. In PSC, the body ‘attacks’ parts of the liver, causing infections, scarring and eventually end-stage liver disease and failure, as well as conferring an increased risk of aggressive cancers. Around three quarters of people with PSC also live with inflammatory bowel disease (IBD) in Northern Europe1.

While most people think that the liver can regenerate itself, there is no medical treatment to stop or slow PSC, and around half of PSC patients need a transplant or develop cancer1.

Even though it is rare, PSC is one of the UK’s leading indications2 for liver transplantation.

Diagnosis is difficult PSC is difficult to diagnose because there is no definitive diagnostic blood test, and it doesn’t always present with specific symptoms until the disease is advanced.

Due to the rise in obesity in the world, NAFLD is estimated to affect 24% of the global population, with high prevalence on all continents.

With the current focus on causes of preventable liver disease, our clinicians must not lose sight of other, rarer, possibilities. If someone has abnormal liver blood tests, understanding their context and the history is key. Do they have autoimmune disease in the family?

Do they have IBD? PSC and other autoimmune liver diseases should be considered and followed-up with appropriate investigations and tests.

The increased cancer risk, invisible symptoms such as fatigue, itch and pain, and unpredictable, lifethreatening complications mean that an effective treatment for PSC patients is urgently required.

Research and patient appetite for clinical trials PSC is complex and, despite much prog ress over t he last decade, remains poorly understood. It is a devastating and debilitating diagnosis and comes often at a time when people are trying to hold down full-time jobs and/or have young families at home to care for. PSC patients are understandably keen to take part in clinical trials, hoping the interventions being tested will slow or stop progression of the disease.

I ntere s t i n P S C re s e a rch i s growing, and there are more clinical trials ongoing for PSC than ever before. Investigators are using the latest technology to find new ways to interfere with underlying disease processes, that, hopefully, will lead to a treatment for PSC. Gareth, a PSC sufferer who is taking part in a clinical trial to help find a cure, says: “PSC already takes so much away from us. Usually we are having to react to changing symptoms or worsening of the condition but, by signing up for a clinical trial, we are taking back some of that control.”

Improving the big picture PSC and other autoimmune liver conditions are often overshadowed by the rising tide of preventable liver disease, and care is hampered by already strained health services.

By motivating the general public to make healthier lifestyle choices, we can help people stay liver diseasefree, reduce that strain on clinical services, and so enable those people with liver disease to access the appropriate care they need at the right time, whatever the cause.

References: 1. Weismuller TJ*, Trivedi PJ* et al. Patient Age, Sex, and Inflammatory Bowel Disease Phenotype Associate With Course of Primary Sclerosing Cholangitis. Gastroenterology.

2017;152(8):1975-84 2. NHS Blood and Transplant - Organ Donation and Transplantation Activity Report 2018/19

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Patients with inflammatory liver disease have new hope Breakthroughs in the development of advanced therapies could revolutionise treatment for thousands of people suffering from immune mediated inflammatory liver disease.

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There are three main immune mediated inflammatory liver diseases; primar y biliar y cirrhosis (PBC), primary sclerosing cholangitis (PSC) and autoimmune hepatitis (AIH).

These conditions develop when a patient’s immune system starts to attack its own liver cells, causing inflammation and scarring.

They affect up to 40 per 100,000 people, across a wide range of ethnic groups. Currently there is no cure for these diseases, with many patients’ diseases progressing to the point of transplant. Combined, PBC, PSC and AIH account for more than 10% of all liver transplant activity, but a shortage of suitable organ donors means that many of these patients either wait a long time for a transplant or never receive one.

Advanced therapies Advanced therapies are a new class

of treatments based on genes, cells or tissues, which offer groundbreaking p o s s ibi l it ie s. The s e adv a nc e d therapies are very different from existing treatments. They are living therapies, so the requirements for their manufacture, distribution and storage are very complex.

The UK is a world leader in this field, w it h t he second largest number of cell therapy companies on the planet, and over 100 ongoing advanced therapy clinical trials.

A collaborative and multidisciplinary approach Involved in a number of trials focusing on advanced therapies is the National Institute for Health Resea rch (N IH R) Bi r m i ngha m Biomedical Research Centre (BRC), a specialist centre for immune diseases based across University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham.

The UK is a world leader in this field, with the second largest number of cell therapy companies on the planet, and over 100 ongoing advanced therapy clinical trials.

In recognition of Birmingham’s track record in cell and gene therapies, the UK’s innovation agency, Innovate UK, established one of three national centres, the £9 million Midlands and Wales Advanced Therapy Treatment Centre (MW-ATTC), in the city.

WRITTEN BY: PROFESSOR PHILIP NEWSOME Director, MW-ATTC & Deputy Director, NIHR Birmingham BRC

The centre has established a large network of commercial, academic and NHS partners to help deliver advanced therapies to patients across the Midlands and Wales.

P r ofe s s or Ph i l ip N e w s om e , Director of the MW-ATTC and Deputy Director of the Birmingham BRC, says, “Advanced therapies such as mesenchymal stromal cells offer up the promise of new ways of treating patients with immune-mediated conditions such as PSC. I am excited about testing these new therapies and rolling out advanced therapies to patients in the Midlands and Wales.”

Mark Chatterley, the first PSC pat ient i n t he West M id la nds to receive a new treatment of mesenchy ma l st roma l cel l s treatment as part of the MERLIN study, adds, “The fact that people are doing research and trying to make my life better, that’s more than I can put into words.”

The future

Advanced therapies have huge potential to revolutionise the management of many chronic diseases and cancer.

Birmingham has invested heavily to help develop and deliver these advanced therapies and has a proven track record of working with small and medium enterprises, as well as larger companies, to help them develop the products and take them to market.

Sponsored by

Read more at theattcnetwork.co.uk birminghambrc.nihr.ac.uk

The silent metabolic disease affecting millions worldwide

Non-alcoholic fatty liver disease (NAFLD) is associated with risks of cancer, transplant and even death, yet few at risk of developing the disease are aware of the implications.

INTERVIEW WITH:

INTERVIEW WITH:

Due to the rise in obesity in the world, NAFLD is estimated to affect 24% of the global population, with high prevalence on all continents.

DR SLAVICA BRNJIC Chief Executive Officer, VLVbio

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on-a lcohol ic fat t y l iver disease (NAFLD), a condition where fat accumulates in the liver without the excess consumption of alcohol, has become the most common cause of liver disease in the Western world and is quickly rising to become the primary cause of liver transplants1. Due to the rise in obesity in the world, NAFLD is estimated to affect 24% of the global population, with high prevalence on all continents.

“This is related to the so-called Western lifestyle; fast food, lifestyle

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PROF DR ALI CANBAY MD

Clinic Director, University Medical Center, Knappschaftskrankenhaus Bochum

changes, and reduced physical activity,” says Professor Ali Canbay, a hepatologist in Germany.

NAFLD leads to inf lammation in the liver, which gives rise to t he phenot y p e, non-a lcohol ic steatohepatitis (NASH), a potentially fatal condition that affects 12% of the global adult population1.

Diagnosing NASH The golden standard of diagnosing NASH patients is a liver biopsy, where a tissue sample is taken from the liver and assessed by a physician

who determines the spread of fat, inflammation and fibrosis.

This process, however, gives rise to several limitations such as sampling and obser ver variabilit y. More importantly, a biopsy comes with possible health risks for patients such as infection and bleeding.

“A completely reliable diagnosis for NAFLD and advanced NASH can only be made by liver biopsy and histological evaluation. However, it is not possible to biopsy such a large number of potential at-risk patients, especially since a liver biopsy is also associated with ‘sampling errors’ and complications,” says Professor Canbay.

Due to the risks and high costs of

biopsies, non-invasive biomarkers have become commonly used in clinics to identify patients with NASH. One option is to measure M30® to determine the amount of cell death in the liver, which can help in the identification and diagnosis of patients with NASH. “In our clinic, we use a diagnostic model that includes the measurement of M30® to find NASH patients and follow up in their treatment,” says Professor Canbay.

Dr Slavica Brnjic, Chief Executive Officer at VLVbio, explains: “One of the pressing needs in the field is to implement non-invasive and low-cost techniques for diagnosing and staging NASH. Our work at VLVbio is to spread information on the disease as well as increase the acceptance and adoption of non-invasive diagnostic techniques.

“Hopefully, in the near future, more at risk patients will be aware of the disease and patients will be more easily identified and treated accordingly.”

Sources: 1. Younossi Z, Koenig A, Abdelatif D, Fazel Y, Henry L, Wymer M. Global epidemiology of nonalcoholic fatty liver disease- Meta-analytic assessment of prevalence, incidence, and outcomes.

Hepatology. 2016;64(1):73-84.

2. Muthiah M, Sanyal A. Burden of Disease due to Nonalcoholic Fatty Liver Disease. Gastroenterology Clinics of North America.

2020;49(1):1-23.

More info VLVbio develops the unique M30® and M65® biomarker assays for the detection of liver diseases by measuring the amount of cell death in the liver.

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Hepatocellular carcinoma: what you need to know The most widespread form of liver cancer is hepatocellular carcinoma (HCC), a cancer derived from hepatocytes, the main cell of the liver.

WRITTEN BY: DR JEAN-CHARLES NAULT Communications Committee Chair, International Liver Cancer Association

H

CC is the fifth and ninth most frequently diagnosed cancer in men and women respectively. It represents the fourth leading cause of cancer-related death in the world. HCC appears mainly in patients with a chronic liver disease, particularly when this liver disease is advanced and causes cirrhosis.

Causes and diagnosis of HCC The main causes of liver disease are hepatic virus infection (hepatitis B and C viruses), alcohol abuse and metabolic syndrome (obesity, dyslipidaemia, and diabetes).

The most effective way to prevent the development of HCC is avoiding those agents that are able to damage the liver (universal vaccination against hepatitis B virus, avoiding excessive alcohol consumption, etc.), or treating them before the liver develops cirrhosis.

Surveillance of HCC is recommended in patients with cirrhosis that are at high risk of developing liver cancer. This entails an abdominal ultrasound and blood tests every six months and helps detect small tumours that can be cured.

Unlike most cancers, HCC can often be diagnosed without a biopsy.

This is because imaging techniques such as CT scans and MRIs are very accurate indicators that a tumour in the liver is cancerous. If the imaging is inconclusive, a biopsy may be obtained to confirm the diagnosis.

Treatments of HCC The application of different treatment options will depend on the tumour stage of the patient and liver function. Liver resection, transplantation and percutaneous ablation (using high temperatures from radiofrequency or microwaves to destroy liver cancer cells) are curative treatments of HCC. Nonsurgical therapies such as transarterial chemoembolisation may be recommended to shrink the tumour or prevent further growth. This allows a mixture of chemotherapy and embolic agent to be delivered directly to the tumour through blood vessels, which effectively blocks the blood supply to the tumour.

Finally, recent advances have been made in treatments of HCC that are not amenable to curative therapies or not accessible to transarterial chemoembolisation.

Several drugs are currently available and act as cancer growth blockers, while several clinical trials testing new drugs are ongoing, with recent data suggesting the potential benefit of immunotherapy to patients with HCC.

Read more at healthawareness.co.uk

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Abused and misunderstood – why we should listen to our livers A recent poll into Liver Disease in the UK1 revealed very few people realise how easily they can damage their liver.

WRITTEN BY: PROFESSOR ROGER WILLIAMS CBE Director, Institute of Hepatology, London and the Foundation for Liver Research Professor of Hepatology, Kings College London

E

ighty-nine per cent of people appreciate that drinking too much alcohol is harmful to the liver. However, when asked to identify the recommended ‘safe’ limits, just 32% of drinkers could correctly identify them.

Despite the fact that an estimated 2 4% of adu lts in Engla nd a nd Scotland regularly drink over the recommended weekly guidelines, 57% of poll respondents felt their current levels of consumption did not affect their health.

But with one in 10 people developing a liver problem, these numbers just don’t add up. We all know someone that has or will develop liver disease. Too many of us are risking our health without realising the harm we may be causing.

How much is too much?

The g uidelines from the Chief Me d ic a l O f f ic er 2 for E n g l a nd recommend adults consume no more than 14 units a week, with consumption spread evenly over three or more days. Experts recommend two alcohol free days a week.

But we don’t order drinks by the unit, thus education on how units translate to what you might be drinking is essential.

Consumers want better information about alcohol The poll also found that the majority

Liver disease carries with it a great deal of stigma, which is unfair and unhelpful

of respondents would not only accept but welcome more insight on alcohol products. Over half (52%) agreed that more information on the calorie content of alcohol would help them make more informed choices.

In July 2019, drinks industry watchdog, the Portman Group, announced it would encourage all alcohol producers to state the 14-unit-a-week recommendation on packaging of alcohol products3.

Even with this policy, there is no sanction if members fail to comply.

The reality remains that there is more information on a pint of milk than a bottle of whisky.

Tackling stigma will help us talk openly about alcohol Very few people are aware that they might experience no symptoms until quite an advanced stage of liver disease. Alcohol is the single biggest preventable cause of the disease but, as the poll shows, too many of us

are drinking excessively without realising it, while the information we need to make better choices is not always clear to see.

What many people also don’t know is that alcohol is a causal factor in more than 60 medical conditions, including mouth, throat, stomach, and breast cancers; high blood pressure; cirrhosis of the liver; and depression.

Liver disease carries with it a great deal of stigma, which is unfair and unhelpful. We need to be more mature about how we choose to reduce our personal risk, as well as how to support those who are diagnosed with a liver problem.

Listen to your liver The liver is an astonishing organ, at the centre of far more of your good health and bodily processes than you might realise. It often suffers in silence, only complaining when problems become far advanced.

Even at an advanced stage of disease, total abstinence from alcohol can improve your liver health. Don’t let your liver suffer in silence.

References: 1. https://www.thelancet.com/journals/lancet/article/PIIS01406736(19)32908-3/fulltext 2. https://assets.publishing.service.gov.uk/government/uploads/ system/uploads/attachment_data/file/489795/summary.pdf 3. https://www.portmangroup.org.uk/the-portman-group-encourages-industry-to-include-14-unit-cmo-guidance-on-labels/

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Meeting the rising challenge of liver cancer in the UK Prevention, early diagnosis and effective treatment are vital in combating this deadly disease.

O

ver the last decade in the UK, cases of primary liver cancer have risen by almost two-thirds (63%) and it has the largest increase in mortality compared to all other cancers.1 Around 5,900 people are diagnosed with liver cancer each year in the UK2, and hepatocellular carcinoma (HCC), accounts for 90% of those cases.1 One of the biggest challenges we face is that liver cancer symptoms often do not appear in the early stages.

As a result, liver cancer tends to be diagnosed at a more advanced stage, reducing the survival chances.3 The symptoms include ones that many of us experience in day to day living, meaning that it’s even harder to know that there is an underlying condition: feeling very full after eating, even if the meal was

small; feeling and being sick; pain or swelling in your abdomen (tummy); jaundice (yellowing of your skin and the whites of your eyes), itchy skin, feeling very tired and weak.3 You can improve your chances of early detection by recognizing earlier symptoms and visit your GP as soon as you have any concerns.

How can we overcome the challenges?

Joanna Dixon-Winkler is the Head of Gastrointestinal and Genitourinary Cancers at Roche UK. Jo has worked across different cancer types with the ambition to improve the lives of patients. She says: “Liver cancer has a low survival rate in comparison to some other cancers. Only 32% of women and 37% of men will survive their cancer for one year or more

Around 5,900 people are diagnosed with liver cancer each year in the UK2 after diagnosis.4 But I believe we can turn this around by focusing on raising awareness of liver cancer to improve prevention, early diagnosis and clinical care, especially in those people we know have a higher risk of developing the disease.

“There is no way to prevent liver cancer completely, but some measures may help to reduce the risk; for example by moderating your alcohol intake, limiting the tobacco use and maintaining a healthy bodyweight.

WRITTEN BY: JOANNA DIXON-WINKLER Head of Gastrointestinal and Genitourinary Cancers, Roche UK “Early diagnosis and treatment are also important: if diagnosed early, it may be possible to remove the cancer surgically. In an advanced cancer stage, treatments such as chemotherapy or targeted therapy are used to slow down the spread of the cancer and relieve symptoms.

However, taking part in a clinical trial could also be part of the care plan.”5 Striving to help everyone in the UK to live longer and healthier lives Jo is optimistic about the future: “Strides are being made ac ro s s t he he a lt hc a re s e c tor, whether in the NHS, academia or the pharmaceutical industry.

Collectively, we are passionate about researching and developing new ways to prevent, diagnose, and manage liver cancer.”

References: 1. https://britishlivertrust.org.uk/6-facts-about-liver-cancer/ 2. https://www.cancerresearchuk.org/about-cancer/liver-cancer/ about-liver-cancer 3. https://www.nhs.uk/conditions/liver-cancer/ 4. https://www.ons.gov.uk/peoplepopulationandcommunity/ healthandsocialcare/conditionsanddiseases/bulletins/ cancersurvivalinengland/adultstageatdiagnosisandchildho odpatientsfollowedupto2016#cancer-survival-in-englandpatients-diagnosed-between-2011-and-2015-and-followed-upto-2016-national-statistics 5. https://www.nhs.uk/conditions/liver-cancer/treatment/

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Bringing the UK up to speed with Europe on Introducing the fourth new cancer technologies pillar of cancer care

Innovative Cancer Care Fund to boost liver cancer survival rates

Introducing innovative cancer treatments in the UK has historically been frustrated by a convoluted process when it comes to new tech. The Innovative Cancer Care Fund is set to arrest the UK’s slide behind other EU nations when it comes to making them available.

Emerging non-drug technologies have the potential to save lives affected by liver cancer, but the full benefit will only be seen if access to NHS treatment is improved.

D

r Jon Bell has a difficult job, which has been made tougher in the past by not being able to prescribe innovative technologies to cancer patients in need – despite them having been proven to make a difference in other countries or even INTERVIEW WITH: elsewhere in the UK. “Within Europe, DR JON BELL Consultant Interventional technologies proven Radiologist, The Christie NHS to benefit cancer Foundation Trust patients are generally introduced quicker than here in the UK, where there are more barriers to overcome before patients can access that treatment. This potentially contributes to our cancer outcomes being worse than other western countries.

“The Innovative Cancer Care Fund is being developed to put decision-making power in the hands of people who work in cancer care. The goal is to increase the availability of therapies to clinicians within the NHS “This could make a huge difference to cancer patients in the UK. Currently, important therapies - such as selective internal radiation therapy (SIRT) – are making big differences to cancer patients right now. However, that therapy and others are not widely available on the NHS – despite their proven positive impact in other countries. It takes a lot of time in this country to adopt innovative technologies within cancer treatment. The whole point is to identify a source of funding - that we know will benefit patients - giving us the option to make use of those technologies early in patients’ treatment plans.

How does it differentiate from the Cancer Drugs Fund?

“The cancer drug fund exists to give a two-year window to test innovative drug therapies that NICE and the NHS can’t fund due to a lack of patient data and other factors. That covers pharmaceuticals, but it doesn’t work with medical devices.

“The Innovative Cancer Care Fund, on the other hand, will purely review devices and technologies with the end goal of reducing the time it takes to make viable new treatments available on the NHS. “The potential impact of the fund is huge.

It could mean life-changing solutions for so many patients. It’s difficult telling a patient there’s nothing we can do when there often is. There may be tangible examples out there where people have been helped by an innovative technology yet, for them, it’s not available.

Our lack of efficiency means we’re failing patients “We’re falling behind in this area to some degree. We’re failing patients with a process that’s not streamlined enough to support innovation. Removing some of that bureaucracy should enable those within cancer care to recommend these treatments for the right patient groups at the right stage of their treatment, which could in turn make a massive difference to our overall cancer outcomes.”

Interventional oncology is a relatively new, technologically advanced field of medicine that’s been hailed as the ‘fourth pillar of cancer care’ – but what is it and how is it saving lives?

I

nterventional oncology (IO) is a relatively new and innovative area of medicine revolutionising the treatment of a range of cancers – particularly those of the liver. Dr Peter Littler, Consultant Interventional Oncologist at Newcastle’s Freeman Hospital, said the field, which uses image-guided, minimally-invasive procedures, represented a new type of treatment.

Interventional oncology (IO)- opening more doors for patients “Over the last 20 years – a short time period in medical terms – interventional oncology has established itself as a great option for many patients,” he explains.

“It is now considered the fourth pillar of cancer care, along with medical oncology, radiation oncology and surgery. It’s really exciting because it offers new and minimally invasive options for cancer patients.”

Interventional oncology treatments are usually delivered via a needle or tiny nick in the skin. They are well tolerated with patients able to go home the same or the following day.

Such treatments are safe for a wide range of patient groups including the elderly and those with co-existing illnesses.

Minimal damage IO is different because it targets and kills cancerous cells while INTERVIEW WITH: protecting healthy tissue. This avoids the DR PETER LITTLER majority of unpleasant Interventional Oncologist, side effects associated Freeman Hospital with traditional chemotherapy and carries far lower risks than surgery.

Common methods include ablation, a potentially curative treatment, which uses an image-guided needle, to burn small tumours away, and intra-arterial procedures, such as transarterial chemoembolisation (TACE) and selective internal radiation therapy (SIRT).

During TACE, tiny, chemotherapy-containing ‘beads’ are delivered through blood vessels to block the cancer’s blood supply and deliver a highly targeted chemotherapy effect.

SIRT is delivered in a similar way, but uses millions of tiny radiotherapy beads to seed and kill tumours.

Both approaches, which can be used in conjunction with other treatments, offer fresh hope to people facing a lifethreatening liver cancer diagnosis, says Dr Littler.

The selective radiation treatment (SIRT) can shrink large and inoperable liver tumours, allowing the remaining healthy liver to grow enough to enable curative surgery.

“It’s an amazing feeling, as a doctor, to know that your intervention can cure a cancer, extend a person’s life, or enable potentially curative surgery,” Dr Littler concludes.

A

proposed new Innovative Cancer Care Fund will help patients and the NHS to access novel non-drug therapies faster. Every day, 16 people are newly diagnosed with liver cancer. But, fewer than two in every ten will access live-saving surgery: the damage to their liver is just too great or the cancer too widespread.

Championing the use of other technologies There have been huge advances in Chemotherapy treatments, especially for bowel cancer spread to the liver or primary cancer that develops in a liver with cirrhosis.

These treatments may control the disease for a period of time but a cure INTERVIEW WITH: requires surgery PROFESSOR DEREK MANAS and our aim is to Consultant Hepatobiliary get as many people and Transplant Surgeon, as possible to Newcastle Hospital curative surgery, says Professor Derek Manas, Consultant Hepatobiliary and Transplant Surgeon at Newcastle Hospital. That’s why he’s championing the use of other technologies.

“In some people they turn out to be a real game-changer,” he explains. The Innovative Cancer Care Fund aims to bring non-drug treatments onto a par with drug therapies for cancer, which are funded and supported in use in the NHS by the Cancer Drug Fund.

“The CCF has been very successful in widening treatment availability, but adoption of non-drug therapies has really fallen behind,” says Professor Manas.

The right treatments at the right time Emergent non-drug techniques such as selective internal radiation therapies (SIRT) would be covered by the Innovative Cancer Care Fund, opening up the possibility of potentially curative treatment options to an additional three in ten people diagnosed with liver cancer.

The Innovative Cancer Care Fund could also cover techniques such as cryotherapy, thermal ablation and Irreversible electroporation, which have a proven role in treating other cancers.

As factors such as obesity drive rates of liver cancer ever upwards, there is more need for patients to be able to access the right treatments at the right time.

Professor Manas says, “Patients tolerate these treatments very well, often with minimal pain, and an improved quality of life.” As a result, they are often out of hospital faster, with subsequent savings to the NHS. WRITTEN BY AILSA COLQUHOUN

WRITTEN BY AMANDA BARREL

WRITTEN BY JAMES ALDER CAUTION: The law restricts these devices to sale by or on the order of a physician. Indications, contraindications, warnings and instructions for use can be found in the product labelling supplied with each device. Products shown for INFORMATION purposes only and may not be approved or for sale in certain countries. This material not intended for use in France. 2020 Copyright © Boston Scientific Corporation or its affiliates. All rights reserved. (copyright statement only required if not otherwise on material)

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TheraSphere® Ytrrium90 are glass beads for SIRT. Specifically engineered to treat liver cancer.

“SIRT saved my life” From cancer patient to says liver cancer marathon hero: how an survivor Innovative Cancer Care Fund “Without SIRT, I would be dead by now,” says Martyn Griffiths, who was told he had liver cancer after a routine chest X-ray discovered it by chance.

W

hen Martyn Griffiths was told he had a tumour the size of a grapefruit on his liver, his world fell apart.

But, six years after being told he could have just 12 months to live, the father-of-two, 61, is back at work and enjoying spending time with his family.

His remarkable recovery, he said, was due to undergoing two selective INTERVIEW WITH: internal radiation therapy (SIRT) MARTYN GRIFFITHS procedures, which were able to Liver Cancer shrink the tumour to a suitable size Survivor for surgical removal. “There is no doubt in my mind that if I hadn’t had the SIRT, I would be dead now. Without it, I would not have survived,” said Martyn, a Chartered Building Surveyor from Darlington.

Shock diagnosis Martyn’s cancer was discovered by chance when the clinician carrying out a routine chest scan happened to spot a shadow on his liver. At the time, he was told it was nothing to worry about, but when he was referred to Freeman Hospital in Newcastle, Martyn and his wife Elaine were given the devastating news.

“When they told me, I literally fell on the floor. I had no symptoms. I’d been working and felt fine. I spent the rest of the day in a daze” he said. “It was December 2014 and my main worry was telling the kids that close to Christmas, even though they are in their 20s.”

Bright future Fortunately, Martyn was under the care of one of the few hospitals in the UK to provide SIRT, which works by feeding radiotherapy-laden, microscopic beads into the body via an artery. Once in the blood supply, they seek out and destroy cancer cells.

While SIRT is not available on the NHS, Freeman Hospital provides it thanks to charitable donation.

Martyn is still under the supervision of his specialist team, but he is currently clear of cancer and is back to normal life.“Having the treatment was a no brainer. I wanted to live,” he said. Martyn is extremely grateful to the Freeman Hospital Consultants and all the Care Staff for the considerable level of expert care.

WRITTEN BY AMANDA BARREL

could save lives

WRITTEN BY: VANESSA HEBDITCH Director of Communications & Policy, British Liver Trust

The British Liver Trust is joining forces with other health charities to call for improved access to innovative cancer therapies for patients.

E

very day in the UK, 990 people are diagnosed with cancer, while death rates from liver cancer have soared by around 50% in the last decade.

Unfortunately, liver cancer is ex tremely difficult to treat as patients often have underlying liver disease that must be treated alongside the cancer. There are very few treatment options and only 12% of patients survive for five years.

UK patients are missing out Innovative cancer drugs are made available to patients through the Cancer Drugs Fund. However, other emerging ground-breaking cancer treatments such as ablation or embolisation ‘technologies’ are not included.

Many of these treatments are currently available across Europe, the USA and Canada. However, patients in the UK are missing out.

Health charities, oncologists and other clinicians are calling for access to these types of treatment to be made available through a new ‘Innovative Cancer Care Fund’.

Professor Abid Suddle, a consultant from Kings College Hospital NHS Trust, said, “For some patients, these types of interventional oncology treatments are the most clinically appropriate option and they need to

“SIRT has undoubtedly extended my life. I have had precious time with my wife and children – what price do you put on that? be a key part of the Government’s Cancer Strategy. It is much more difficult to get these treatments through traditional commissioning mechanisms as randomised control trials are problematic due to the small number of patients who will benefit and the fact that you cannot offer a ‘placebo pill.’”

Mark’s story Mark Thornberry, aged 59, is one patient who has benefitted from t he s e t re at me nt s . D i a g no s e d with liver cancer in April 2017, he was advised that he only had six to nine months to live after his cancer spread following an initial conventional treatment.

At the time, his hospital was participating in a clinical trial for

selective internal radiation therapy (SIRT). This is a type of internal radiotherapy. Radioactive beads are placed into a blood vessel and carried directly to the tumour site in the liver where the radiation destroys the cancer cells.

For Mark, SIRT proved to be a game changer. The non-invasive nature of the treatment and limited side effects meant he was able to run an ultra-marathon only six weeks after the treatment and his life expectancy has gone up significantly.

Mark said, “SIRT has undoubtedly extended my life. I have had precious time with my wife and children – what price do you put on that? These treatment options should be made available for any patients who might benefit.”

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