Liver Cancer Awareness Month: Addressing AAPI Disparities With Dr. Keith Chan

In this interview during Liver Cancer Awareness Month, we discuss with Dr. Keith Chan the need for hepatocellular carcinoma (HCC) liver cancer awareness for the Asian American community.  

Liver Cancer Awareness Month: Addressing AAPI Disparities with Dr. Keith Chan from HMP on Vimeo.

In this insightful interview during Liver Cancer Awareness Month, we discuss with Dr. Keith Chan, M.S., M.D. at Vantage Radiology and Diagnostic Services, the need for hepatocellular carcinoma (HCC) liver cancer awareness, detection, prevention, and advocacy strategies for the Asian American community. Read the full transcript below: 

Dr. Keith Chan:

I'm Keith Chan. I am Cantonese, and I was born and raised in Hong Kong. Growing up there, the focus on liver health was just so different. I remember, as a kid, we were concerned about having clean water. If we ate bad foods, we heard about how we can get Hepatitis A. Then, of course, many years later, I moved to the United States for college and my training, and now I'm a practicing interventional radiologist who treats patients with hepatocellular carcinoma, or HCC.

I live in the great place of Seattle, and we have a diverse immigrant population, including Japanese, Korean, Chinese, Vietnamese, Hmong, Filipino, and many others. What a great time it is to be an interventional radiologist. We have tools where we talk about potential, even curative, treatments for these patients, but HCC still is a deadly disease that is usually asymptomatic until it is advanced, and it makes a huge difference if we can catch these patients in the early stages.

Unfortunately, even in the United States, we have a long way to go in effective HCC screening. In my hospital, several years ago, we were able to create a robust community screening program, and now we're identifying at-risk patients, and getting them on a screening regimen every six months. But despite this effort, in recent years, I still see a very heterogeneous Asian immigrant population, where patients are diagnosed with very late stage HCC, and these are patients that would be alive today if we had caught their disease early enough.

We know that Asian patients are at the highest risk of vertical hepatitis B virus transmission, and that over 70% of the world's HCC occurs in Asia. But growing up there, I don't remember anyone ever talking about it, or any public awareness efforts. This seems like a huge gap that has yet to be addressed.

IO Learning:

Can you provide an overview of the current state of liver cancer awareness, such as unique trends, or risk factors, that stand out in your community, and why do you think this is important for caregivers and healthcare providers treating the Asian American community?

Dr. Keith Chan:

I think we need to step back and look at the state of liver cancer awareness, as a whole, in the United States in 2023. In most communities outside of universities and tertiary transplant centers, awareness of HCC is very poor. Studies have shown that many patients, and their primary care doctors, are unaware that they have cirrhosis. Few doctors know about the international guidelines for semi-annual HCC screening in patients with cirrhosis, or chronic hepatitis B patients, over the age of 40 in men, and over 50 in women. This results in unfortunately a published rate of only 1 in 7 at-risk patients getting screened.

Even though we're working to identify these at-risk patients, and getting them plugged into a screening program, the Asian community needs special attention. Well, why? Well, studies have shown that Asians, as an ethnic group, have the highest HCC incidents in the United States, and that they are 2 times higher than African-Americans, and almost 4 times higher than Caucasian peers. Asians born overseas have a 19 times higher risk of having chronic hepatitis B infection than somebody born in the United States.

Asians have a lower rate of HCC screening than any other ethnic group, and Asians have a lower rate of being within transplant Milan criteria, or getting a liver transplant once diagnosed, in part because they're diagnosed later from the lack of screening. Unless healthcare providers keep these statistics in mind, they might not think about how this population is at risk, or triage them appropriately.

IO Learning:

What specific challenges or barriers do the Asian American population face when accessing cancer screenings and early detection services?

Dr. Keith Chan:

Asians are such a diverse group from so many countries, and with different cultures, socioeconomic status. Some are born here, and they're fluent in English. Others might be immigrants with a language barrier, varying religions, or worldviews, or even, unfortunately, sometimes a distrust of American healthcare providers. The Asians, many of them, they know that they are a racial minority here when they're seeking treatment. If they grew up in a place like I did, there is no public education, or focus on hepatitis B, or HCC.

We can't wait for these patients to come to us. Instead, we need outreach programs to go into these communities, and invite them to learn about their health and establish care. We need to make the effort to meet the patients where they are coming from. Don't lecture them about our guidelines and our data, but instead show them how they are especially at risk, and why the effort is targeted to help them.

The risk of hepatitis B depends so much on where they are born. In some wealthy Asian cities, like Singapore, over 95% of the population receives the hepatitis B vaccination. But if you go to other parts of Asia, the vaccination rate can be as low as 10%. Furthermore, many Asians might not even know they have chronic Hepatitis B infection. Screening for Hepatitis B is a must to identify these at-risk individuals, and is part of the CDC's recommendations for all adults in the United States.

A study among Asian Americans with liver disease in San Francisco, I think it was over an 11-year period, found that screening compliance in this subpopulation fell by almost a quarter every year, such that only half of the patients, even, were compliant with their screening after year three, despite education attempts. The patient physician rapport, and bridging the culture gap, is a must. Asian patients might be more private when their doctors ask about their alcohol use. They might feel shame.

They might be more sensitive to the expenses of semi-annual ultrasound screenings, which, for all of us, it's so readily available, and something that we take for granted. But it's not so commonplace where they come from, and this could affect their compliance, and their idea of cost. Programs that have a champion, perhaps even in that ethnicity, who can push these activities, but also be somebody that the patients can relate to, would probably be very helpful.

IO Learning:

Are there any specific strategies that healthcare providers should use to reach and engage with Asian American communities?

Dr. Keith Chan:

Yeah. I think that those efforts are tremendous in what they have done, but obviously, with all the cities across the United States, and the diversity in each city, targeted efforts are a must in each community. I think that the doctors that are the experts in these fields, especially if they do have doctors of that ethnicity, can go out into these communities and actually meet with the patients—have town leadership that can bring everybody together and talk about why there is this awareness effort, how there is this health disparity. Help them understand that we are actually here to tailor a care program and screening program for them, so that these people are willing to comply.

IO Learning:

For interventional oncologists, what about this topic of Asian American liver cancer disparities do you think is most important for them to know?

Dr. Keith Chan:

A lot of what we have talked about pertains to screening and primary care, but by the time the patients see us in interventional oncology, they already have a diagnosis. For us, I think we need to remember that the Asian ethnic group makes up a really small part of the population in most of the large pivotal clinical trials that we use to guide our treatments. Even then, Asians are aggregated together, but Asians might represent different countries, perhaps with different tumoral genetics and expressions.

As somebody who trained in the United States, I think sometimes we apply this one-size-fits-all treatment approach to patients without looking at their race or ethnicity. Perhaps someday, with research to support personalized therapies, based on their genetics and what works best for them, we can provide even better outcomes for each subpopulation.

IO Learning:

What steps can we take in the IO/IR and healthcare field to create better detection, prevention, and treatment models?

Dr. Keith Chan:

In the United States, we have two big buckets of at-risk populations for HCC. One, are the patients with chronic hepatitis B infection. The CDC already recommends all adults get tested. We just need to be thorough and intentional in making sure that all of our primary care patients check that box, and reach out to the communities where people might not have a primary care doctor. The second bucket are the patients who have cirrhosis. We need to find them early, ideally years before they develop a tumor.

This is really hard since compensated cirrhosis is asymptomatic. In our multidisciplinary program, we actually get radiologists to notice possible subtle cirrhosis on imaging, let's say, for something else, like trauma, or they fell off the ladder. We flag these patients for further follow-up. We have a noninvasive liver characterization program using elastography, where we then see if patients might be in the high risk fibrosis grade. Then we have care algorithms for patients with chronic hepatitis B, chronic hepatitis C.

Once a patient is flagged for being at risk with hepatocellular carcinoma, our electronic medical records automatically set reminders for screenings every 6 months. No different than, say, your annual flu shot. Once the screening is positive, we have another algorithm for the best diagnostic imaging, and all of our cases are discussed at a multidisciplinary tumor board.

While we've done a lot on the upfront screening, I think patients hear much less about how successful the treatments are, and how much it can actually extend life or be curative. We need to show patients the carrot, and not only the stick, so that they'll want to comply with screenings and benefit from all this.

IO Learning:

What should providers focus on to close the gap?

Dr. Keith Chan:

I think the biggest gap right now is just the initial upfront part of identifying these patients, establishing their care, getting them screened, and getting them to comply with screening. Essentially, it is to bridge the gap between where they came from, especially those who aren't born here, the Asian immigrants, and getting them to fit into the healthcare system that we have created for everybody else. If we can bridge that gap, and if we can do it in such a way that we're organized, that we have effective outreach and communication to these patients, and help improve compliance, I think we've already done a huge part of the lift to get this problem solved.