Jian-Guo CHEN Qidong Liver Cancer Institute 启东肝癌的预防研究 　　 Jian-Guo CHEN Qidong Liver Cancer Institute 國陳 印建 Chairmen, ladies & Gentlemen, Good afternoon. It’s my great honor to present my topic of “Prevention of liver cancer in Qidong, China” , on behalf of the Qidong Liver Cancer Insitute. 启东肝癌防治研究所

流行趋势 1 I would like to take this opportunity to discuss with you in four aspects: Trends, factors, prevention, and assessment for the liver cancer. First is the secular trends of liver cancer in Qidong, and China as well.

中国肝癌死亡率 1973-1975 1990-1992 2004-2005 (%) 男 女 合计 3 4 2 PLC 死亡率 中标率 顺位 14.93 6.38 10.75 29.01 11.21 20.37 37.55 14.45 26.26 中标率 15.70 6.20 11.00 26.14 9.36 17.83 26.44 9.20 17.86 19.90 8.00 13.90 33.67 12.25 22.99 34.61 12.34 23.48 (%) 17.66 10.05 14.48 21.50 14.01 18.82 22.06 19.33 顺位 3 4 2 There were 3 sets of data on national retrospective survey of death causes in China so far, that is, 1970s, 1990s, and more recent one, 2004-2005. This slide shows that the mortality rate of liver cancer doubled from 10.75 to 26.26 per 100,000 during this 3 decade period. Liver cancer now is the second leading cancer cause, while it was the third in rank in 1970s. PLC 陈建国, 张思维, 陈万青. 中国2004~2005年全国死因回顾抽样调查肝癌死亡率分析. 中华预防医学杂志 2010，44(5):383-389.

1973-1975: 2004-2005: 江苏 上海 浙江 福建 广东 广西 1973-1975年肝癌死亡率 (男性) 中国第3位癌症死因 中国第2位癌症死因 每年死亡33万人 Chen JG, et al. Chin J Prev Med 2010, 44(5):383-389. 江苏 启东 上海 浙江 From this map of the geographic distribution for liver cancer mortality for males in China, you may find that the most prevalent areas are those along the east coast: that is, Jiangsu, …..and Guangxi. Qidong is among the at risk area, here. 福建 广东 广西

癌症发病谱 ---启东 年发病率: 184.77/ 10万 顺位 (1/105) 肝癌 liver ca.（60.69） 癌症发病谱 ---启东 年发病率: 184.77/ 10万 顺位 (1/105) 肝癌 liver ca.（60.69） 胃癌 Stomach (32.97) 肺癌 lung (27.59) 食管癌esophagus (9.34) 直肠癌rectum (8.06) 乳腺癌 breast（6.48） 胰腺癌 pancreas (5.97) 白血病leukaemia（3.84） 脑肿瘤 brain & CNS (3.43) 结肠癌colon (2.93) 膀胱癌 bladder（2.86） NHL （2.78） 宫颈癌 cervix（2.34） 鼻咽癌nasopharynx（1.70） 皮肤癌 skin（1.35） 骨和关节 bone&A.C.(1.32) 多发性骨髓瘤mltp myeloma (1.31) 小肠癌 small intestine (0.94) 胆囊癌 gallbladder (0.78) 卵巢癌 ovary（0.76） A cancer registration system was set up since 1972. The cancer pattern for the past 4 decades showed that liver cancer is always the number one site of cancers, with a mortality rate of 60.69 per 100,000 on average.

Liver Cancer Trend in Qidong 粗率 中标率 世标率 Incidence, per 105 APC A trend analysis shows that the crude incidence rate of liver cancer, the red one, was increased in a APC rate of 1.51% during this period; While age-standarized rates by China population and by World population showed a decreased change of -0.95%, the blue one, and -0.70%, the green one, respectively. Year 启 东 肝 癌 发 病 率 趋 势 Liver Cancer Trend in Qidong

An even longer trend could be found that liver cancer mortality rates have been increased since 1958, according to the statistics from retrospective survey and cancer registration. One of the reasons may be due to the increased aging population in this area. 回顾调查 癌症登记 陈建国，未发表资料

危险因素 2 Next, the main risk factors for liver cancer in Qidong.

主要病因 Factors Attributed to Liver Cancer Hepatitis B Virus Aflatoxin B1 Kensler TW, et al. Nature Rev Cancer, 2003 主要危险因素 乙肝病毒 Hepatitis B Virus 黄曲霉毒素 What can be attributed to the liver cancer prevalence in this area ? The major causal factor for liver cancer is HBV, the aflatoxin B1 could be the another one. Aflatoxin B1

HBsAg携带者的肝癌发病率和相对危险度 1977~2007, 启东 性别 HBsAg (+) HBsAg (-) RR 95%CI 人年 病例数 发病率 1/10万 男 17836.4 118 661.57 113419.0 61 53.78 12.30 8.96-17.04 女 30013.6 55 183.25 194036.0 34 17.52 10.46 6.70-16.54 3.61 3.07 2.60-5.07 1.99-4.82 In a 31-year of follow-up study of persons with or without HBsAg, a marker of HBV infection, 12.30-fold RR, and 10.46 RR were found for males and females; And 3.61 and 3.07 RRs could be seen in the positives and negatives, which shows the sex difference.

HBsAg 携带者和非携带者的 肝癌年龄别发病率 HBV HBsAg 携带者和非携带者的 肝癌年龄别发病率 陈建国, 等. 中华流行病学杂志, 2010, 31(7): 721-726. 发病率 1/10万 Age-specfic rates shows that the incidence in the carriers of HBsAg is always higher than in noncarries at every age groups. Cross-over analysis indicated that the RRs were 3.07, 10.46, and 37.76 for those male HBsAg(-), female HBsAg(+), and male HBsAg(+), if female HBsAg(-), as baseline “1”. These findings also showed the multiplying effect of sex and HBV status on the development of liver cancer. M 37.76 F 10.46 M 3.07 F 1.00 年龄

启东肝癌队列 (1989-2003) 83% 的可分析标本中含有HBV DNA双突变 例肝癌 个标本有足够的血清量 (> 100 μL) 例在2003 -12-31前死亡 355 (69%) 提取到血清DNA 295 (83%) 例在1762T/1764A有突变 This slide shows that about 83% of cases, died before 2003 from a 667 case cohort, contained double mutation at 1762T/and 1764A, based on the DNA recovered test from serum samples. 83% 的可分析标本中含有HBV DNA双突变

HBV双突变增高肝癌的危险性 (阳性率%) 筛检后的死亡年数 年龄 在年轻病例中的双突变更为常见 P = 0.083 P = 0.068 < 1.5 1.5-3 3-5 5-9 >9 筛检后的死亡年数 Diamond graph modeling analysis shows that mutations are more common in the younger cases, and the frequency of mutation was higher in those survived shorter after screening. > 55 45-55 < 45 年龄 Chen JG, et al. CEBP, 2005 在年轻病例中的双突变更为常见 Diamond Graph modeling from Li & Muñoz, Amer. Statistician (2003)

中国科学 B辑, 1983 For aflatoxin B1, correlation between estimated aflatoxin intake and liver cancer rates was found in the eastern coastal areans in China. Experimental studies showed that mildewed corn containing AFB1 could induce liver cancer in animal models such as Qidong hemp ducks and rats. This is a sample of duck liver cancer induced by mildewed corn. 黄曲霉毒素

山 东 200 250 连云港 徐州 Sheyang 淮阴 200 盐城 Dafeng 黄 海 安 徽 江 苏 Haian 扬州 Rudong The distribution of “mould-producing days” was consisitent with the geographic distribution of mortality of liver cancer. This picture shows the isopleth of the “mould-producing days” of aflatoxins in Jiangsu province. Rugao 300 200 南通 镇江 南京 Haimen 150 常州 长 江 启东 可产毒日数等值线（天） 无锡 崇明 150 Isopleth of toxigenic days of aflatoxins 苏州 上海 200 Nanhui 据 汪耀斌,等, 1981 重新绘制 250 300

预防 3 Now let’s move to the part of the prevention of liver cancer.

肝细胞癌的预防战略 乙肝疫苗免疫接种 降低黄曲霉毒素摄入: - 改善储存条件 - 生物控制 一级预防 - 膳食改变 化学预防干预: 例如，奥体普拉, 叶绿酸, 西兰花苗, 绿茶 早发现、早诊断、早治疗 一级预防 For the Strategies for Prevention of liver cancer, we have primary prevention and secondary prevention. Primary prevention includes HBV vaccination, aflatoxin comsumption reduction, and chemoprevention. Secondary prevention means early detection, diagnosis and treatment. 二级预防

乙肝免疫接种, 1984-1990, 启东 免疫接种 每年接种和对照人数 年份 对照组 接种组 A controlled study of universal immunization of newborns has been conducted in Qidong since 1984. Its aim is to assess a reduction of the hepatitis B carrier state, of chronic hepatitis, and of liver cancer by early HB vaccination, through long-term follow-up. 年份 免疫接种

冈比亚 启东 台湾乙肝疫苗接种效果 冈比亚 启东 台湾 The preliminary results of vaccine efficacy has been showed in this paper. Briefly, the HBsAg prevalance in unvaccinated vs vaccinated were 7.1% vs 1.7%, showing a 75% efficacy for the period of 1984-1990. However, there is still no sufficent data to show the trends for decline in liver cancer incidence due to vaccination.

某乡玉米作为主粮比例的改变 启东，1998 降低AFB1 摄入 1985年后 玉米作为主粮的比例(%) 村数 生产队数 户数 人数 玉米摄入（%） For aflatoxin prevention, Since 1985, local residents in Qidong changed their staple food from corn to rice, which led a great reduce of intake of aflatoxins. A sampling survey of staple food in a township in 1998 in Qidong showed that residents take rice as their staple food in stead of corn. The proportion of corn, less than 0.5%. This is surely a good example of NATURAL intervention for the reduction of Aflatoxins. 玉米作为主粮的比例(%) 降低AFB1 摄入

化学预防 (在癌变前) 通过合成的或自然的物质来延迟、阻断或逆转致癌作用 (例如，药物、食物、增补剂) Measures for Chemoprevention include Retardation, blockage or reversal of carcinogenesis by synthetic or natural agents.

尿中黄曲霉毒素生物标记物的代谢排泄 相对水平 AFM1 AFB-NAC 奥体普拉 安慰剂 每天 125mg 每周500 mg ( 1 相 ) ( 2 相 ) 尿中黄曲霉毒素生物标记物的代谢排泄 奥体普拉 安慰剂 每天 125mg 每周500 mg A randomized Oltipraz chemoprevention trial of six months was conducted in Qidong in early 1990s. An effective inducer of enzymes that detoxify carcinogens, has resulted in a 2.6-fold increase in the level of excretion of phase II metabolite aflatoxin–mercapturic acid. Kensler TW, et al, CEBP, 1998 Administration of Oltipraz, carried out in Qidong, resulted in a 2.6-fold increase in the level of excretion of aflatoxin-mercapturic acid (which is a detoxification product of the reactive, DNA-damaging intermediate of aflatoxin). Decrease in the lever of AFM1 that is indicative of damage was also seen. Wang et al., JNCI, 91:347, 1999

叶绿酸 对尿中AFB1-N7-鸟嘌呤排泄水平的作用 Effect of 3 Months of Chlorophyllin on Urinary Excretion of Aflatoxin-DNA Adducts 处理 N AFB-N 7-guanine 水平 P 值 安排 (pg adduct/mg creatinine) 安慰剂 tid 82 0.20 (<LOD – 4.10)a 叶绿酸, tid 87 0.09 (<LOD – 0.98) 55% 0.036 a 中值 (范围) LOD = 检测限 In a second clinical trial of chlorophyllin, participants were randomly assigned to two groups, and were given 100 mg of chlorophyllin or a placebo three times a day for four months. Chlorophyllin consumption at each meal led to an overall 55% reduction in median urinary levels of aflatoxin–N7-guanine adducts, excreted in collected urine samples. 100 mg Egner P, Wang JB, et al., Proc. Natl. Acad. Sci. (USA), 2001,98(25): 14601-14606 Chlorophyllin, from the water-soluble salts of chlorophylls, have been found to be effective anti-carcinogens in several animal models,

西 兰 花 苗 叉 生 试 验 启 东, 2009 富含硫代葡萄糖甙 富含硫代葡萄糖甙 西兰花苗茶加黑芥子硫甘酶 （莱菔硫烷） 招募50人 in 富含硫代葡萄糖甙 西兰花苗茶加黑芥子硫甘酶 （莱菔硫烷） 富含硫代葡萄糖甙 In a recent randomized, placebo-controlled chemoprevention trial, 50 eligible individuals enrolled into this Cross-over Broccoli Sprouts Trial. At this time they will be asked to refrain from eating cruciferous vegetables for the duration of the study. Following a 5-day run-in period, they will be randomized into one of two treatment arms. The results are to be prepared, and good finding could be expected. 天 筛选180人，合格的50人纳入研究。 要求他们在研究期间限制某些十字科类蔬菜（cruciferous vegetables）的摄入。经过5天的预试期，他们被随机分入两处理组。 180 participants are screened and 50 eligible individuals enrolled into the study. At this time they will be asked to refrain from eating cruciferous vegetables for the duration of the study. Following a 5-day run-in period, they will be randomized into one of two treatment arms.

More Also see: Kensler TW, et al. CEBP, 2005; 14(11): 2606-2613. A previous pilot study has evidenced that broccoli sprout can enhance the body’s detoxifying system to help prevent cancer, as the new reported. Also see: Kensler TW, et al. CEBP, 2005; 14(11): 2606-2613. Egner PA, et al. Chem Res Toxicol, 2008; 21(10): 1991-1996. More

二 级 预 防 无症状者的早期诊断及高危人群的 筛查。 启东：30-69岁 HBsAg 阳性的男性为肝癌筛查的高危险人群。 无症状者的早期诊断及高危人群的 筛查。 启东：30-69岁 HBsAg 阳性的男性为肝癌筛查的高危险人群。 In Qidong’s practice for secondary prevention, which involves the early detection, early diagnosis, and early treatment, we screen high-risk grout, that is, the men aged 30-69 with positive HBsAg.

筛 查 (A) 和 对 照 (B) 队 列 研究设计: 样本量和筛查时间 (X) 3712 1869 In a 1989 screening program, 3712 carriers of HBsAg positivity cohort were screened by AFP every 6 month; the controls were also observed.

. 筛检组 (A: n = 240) 和对照组 (B: n = 108) 肝癌生存率 (2 month prevalent cases excluded) B 组: A 组: I期: 6.0% I期: 29.6% 生存率 The percentage of cases in stage I was signicantly higher in group A (29.6%) than in group B (6.0%), showing screening with AFP resulted in earlier diagnosis of liver cancer. And longer two year survival rate. 生存月 数

肝癌诊断及治疗情况汇总 年度 HBsAg 阳性数 肝癌发现(诊断)情况 肝 癌 治 疗 情 况 总病例数 筛查发现 新病例总数 早期癌 比例 % 晚期癌 新病例 治疗总数 治疗率 2007年 1061 27 16 12 75.00 4 25.00 2008年 1000 33 24 66.67 8 33.33 18 2009年 1033 31 22 81.48 5 18.52 88.89 合计 　3094 91 67 50 74.63 17 25.37 54 80.60

评估 4 Now, let’s give a brief estimation for the trends of liver cancer in Qidong.

Age From this slide, you may find that the incidence of liver cancer is decreasing. For instance, the rates are 34.20 per 100 000 in 1973-77, and only 6.7 per 100 000 in 1998-2002 at age group of 25-29.

By using birth cohort analysis, a decreasing pattern for the age-specific rates under age of 35 was observed in Qidong. Decline trend existed for the younger age groups shows notable reducing changes for those born after the year 1950’s. 启 东 肝 癌 出 生 队 列 发 病 率

肝癌: 增加还是减少? 平 衡 肝 癌 流 行 黄曲霉毒素暴露的降低 老龄化导致高危人群的增加 疫苗接种导致HBV 感染率的下降 How about the liver trends in the future? That’s a question. Because of the benefit from long-term universal vaccination, the HBV infection rate will surely reduced in the younger generation. On the other hand, the aging population would increased fast, so the liver cancer rate will continue increased for years. More than 900 cases a year in Qidong is the resultant of this situation. However, we believe that liver cancer would finally be reduced as the results of prevention. 黄曲霉毒素暴露的降低 但延迟作用仍在起作用

谢 谢 Thanks for your attention 国际抗癌联盟 世界抗癌大会 深圳 2010年8月21日