Wonderful. And I was very encouraged, actually, to hear Dr. Carruthers' talk. I would add to all the incredible accomplishments that have been so far made and recognition of different gaps that we have to fill, also training of the mentors to be much more effective in really addressing the mentoring across differences. So our talk is focusing on community-based interventions for eliminating liver cancer. These are my disclosures. In this talk, I will be talking about the San Francisco Cancer Initiative and its mission. As part of this talk, I will also highlight a number of efforts that have been made in the San Francisco and Bay Area with respect to preventative measures related to liver cancer that were prior to this initiative but had led to some of the recommendations of the task force within these initiatives. I will also discuss the Liver Cancer Task Force objectives and goals, the partnerships that have been made within the community, academia, and other types of organizations, its accomplishments, and the future goals. The San Francisco Cancer Initiative is a collaborative effort that was initiated in 2016 in support by UCSF to really reduce the incidence of cancer in San Francisco by engaging health care systems, government, community leaders, and residents of the city. The focus of this program was on significant cancers that had been identified as being impacted by known interventions, screening, and education, and that they really disproportionately impacted minority communities. And these cancers included breast, colorectal, liver, prostate, and tobacco cause. As is evident mirroring the nation, indeed in 2016 when the initiative was initiated, these five types of cancers represented the most common cause of cancer death in the San Francisco, Bay Area, as well as California. And these percentages have remained the same to date. The strategy that was implemented in reducing the cancer incidence was really to address cancer screening endeavors, diet and exercise, focus on social determinants, and tobacco use. And the UCSF would be providing the scientific backbone in the city while the city public health and non-profit agencies would then supply the staff and resources, physical space, to really reach the at-risk populations. The mission that was set out by this initiative was to explore the key contributors of cancer disparity in addressing adverse social and economic conditions, enhancing awareness of prevention measures, making sure that there's enhanced access to screening and healthcare, to align and support collaborative effort to improve health within the community, and to really build sustained and strong relationships between different groups who were actually implementing or encouraged to implement innovation citywide. This was to be a model, San Francisco was to be a model, to be then replicated and extended across the nation. This was an ideal time for us to initiate this initiative in light of the very important and remarkable recent advances in several areas in cancer with respect to precision population health, data information technology, and cancer treatment measures. San Francisco's diversity size and its really commitment to social justice made the city an ideal place to implement this innovative initiative, and that we had leaderships in various sectors, including public and private, that had already been deeply immersed in cancer care and public health initiatives and very forward-thinking. To that effect, a liver cancer task force was then initiated. It was recognized that while the rates of cancer mortality in many of the cancers, nearly all but two, were decreasing over time, that indeed the rate of cancer in liver was rising from 2007 to 2016 at a rate of 2% per year in males and 2.5% per year in females. In San Francisco, the ninth most common cause of cancer is liver cancer, and in fact it is the fifth most common cause of cancer death. But importantly, as you can see, there was a significant disparity with regards to non-white groups with rates of cancer, both among males and females. The San Francisco Cancer Initiative brought together several partnerships that are listed here, from academia, institutions, community endeavors, and government. The cancer task force then, in light of several initiatives already in place that I will discuss in a minute, came up with a potential three goals, to reduce preventative cause of liver cancer, to enhance screening of liver cancer, and to focus on treatment of liver cancer. To do so, the objective was to increase the rates of hepatitis B and C screening, prevention, and treatment, and to leverage the already existing institutional efforts that exist currently in place in San Francisco to enhance that, and to collaborate with physicians and clinicians and create a patient navigation telephone line, and to leverage ongoing and new community initiatives that were happening at around the same time, namely Hep B free campaign and end Hep C campaign, that I will go through in a minute as well. We also focused on increasing liver cancer screening efforts, as prior work had shown that there's certainly gaps in the liver cancer screening, with respect to both patient, provider, and system barriers, and the facilities to these endeavors had been identified through several initiatives, specifically in the underserved populations, with a significant proportion of minority populations. There was also an attempt to increase coordination and capacity for liver cancer treatment trials in San Francisco, to really provide an opportunity to individuals who had difficulty accessing these innovative measures across various institutions. A little bit about Hepatitis B campaign. This was initiated in 2007. It's an innovative collaborative of public-private partners. This partnership encompasses healthcare sector, nonprofit, academia, elected official, business community, and media, to enhance hepatitis B screening, treatment, and linkage to care. It's been recognized as a national model for testing and education and linkage to care, and it's been certainly incredibly effective. With regards to evaluation of gaps in these measures within the underserved population, a survey that was conducted in the San Francisco Safety Net Healthcare System, and the review of concurrent 20,000 Asian-American population adults with hepatitis B risk, there was an optimal HPV screening and vaccination rates. Only 60% of these individuals were screened for hepatitis B, and about half of these groups were actually vaccinated while they were susceptible. Most of the providers within the system were really knowledgeable about hepatitis B, with respect to the old efforts that were happening city-wise, and had favorable attitudes towards screening, but that there was significant unfamiliarity with the ASLD guidelines or screening guidelines. There was favorable provider attitude towards HPV screening that was associated with enhanced screening, but having higher patient numbers in clinic, meaning competing priorities, provider barrier scores were all negatively associated with screening. In evaluating gaps in hepatitis B monitoring and management within the infected population, while provider familiarity with ASLD guidelines and patient factors, such as risk population, Asian race and age, were positively associated with recommended HPV disease monitoring, certainly provider and practice factors, such as provider age, knowledge, and perceived barriers were also negatively associated with liver cancer screening. In looking at liver cancer screening rates within this population, and evaluating about 1,500 Asian Pacific Islander population with chronic hepatitis B, it was noted that while these patients were identified at risk, and some were screened, that the rates of screening decreased over time. Importantly, when we looked at individuals who had developed cancer, the receipt of prior screening improved survival in those individuals. And this was related truly to the benefit of the identification of cancer when the liver function is much better, and that there is availability and option for curative options for these patients. These efforts and others within other integrated systems, such as Kaiser Permanente, led to initiation of another initiative called San Francisco Hepatitis B Quality Improvement Collaborative. This was a city-wide effort, a collaborative effort among healthcare organizations, the IPAs, to systemically improve hepatitis B screening and clinical care. The participating systems included Kaiser Permanente San Francisco and HMO, health physician medical groups, UCSF, and private practice offices throughout the city are part of that group. The San Francisco Chinese Community Healthcare Association, and the Safety Net Healthcare System within San Francisco, part of which is within UCSF, but also involves 21 clinics across the city of San Francisco. When we administered a survey to primary care providers affiliated with these healthcare systems as an initial needs assessment to identify gaps in hepatitis B management within the city, we identified that about 50% performed HPV screening in their at-risk population or vaccination in more than 50% of these at-risk patients, that half of these physicians did not perform hepatocellular carcinoma screening, and that adherence to hepatitis B guideline was overall optimal, and this was irrespective of practice setting, and it was certainly influenced by certain patient, provider, and practice factors. And so this led to implementation of patient and provider HPV education programs, certainly within the safety net population, provider notification measures in other systems, such as Kaiser Permanente. Considering these efforts, the San Francisco Liver Can, or Liver Task Force Initiative, then focused on contributing to several aspects of San Francisco Hep B Free campaign measures. It provided Chinese language websites for San Francisco Hep B Free, and it's provided some support in addressing the patient navigation programs and outreach through events and media for this program. At around the same time, another initiative was occurring. The Health Department in San Francisco had been very much responsive to the issues of opioid epidemics and the rising new cases of hepatitis C within the city, and so a new campaign was launched in 2016 July called End Hep C SF. The vision of this campaign was that it would create a San Francisco where Hep C was no longer a public health threat in this city, and that the HCV-related health inequalities were to be eliminated in this program. And as you can see, there are several branches to this program, but the main core of it is to really identify undiagnosed hepatitis C, treat and enhance access to hepatitis C treatment programs, and to really focus on also prevention of infection and reinfection measures. The program, as I stated, consisted of a core group. This was the Coordinated Committee. It was to interact with our agencies or organization-leading research and surveillance efforts, again, to link with efforts that are ongoing within the city of San Francisco with regards to prevention testing and linkage to care, and to enhance access to therapy. With respect to enhancing screening, an education and prevention campaign was initiated, community-based HCV testing was then implemented, and field-based and peer navigation programs were initiated. The Research and Surveillance Work Group was started, which then reviewed data on HCV burden and identified research agenda for improved understanding of hepatitis C burden within the city of San Francisco, without which we could not necessarily address disparities. And we expanded community-based HCV testing at several sites, and that, in its own, led to other innovative programs with respect to linkage to care. This included expansion to San Francisco City County Jail, single-room residency hotels, syringe programs, methadone residential drug treatment programs, STD clinics, a new initiative called Mobile Van, the Deliver Van, in collaboration with UCSF. I encourage you to look at abstract 594. And a program that we worked with initiating specifically within the homeless shelters in collaboration with the street medicine clinics that provided care to the homeless residents of the city, as well as the San Francisco General Hospital Liver Clinic, which is a safety net specialty clinic to the clinics within the programs in San Francisco. And I encourage you to look at our abstract numbers 633 and 735 for more information about these programs. Now, what happened was while SFDPH initiated this program, that San Francisco Cancer Initiative provided seed funding in 2016 to enhance the efforts of this program. This then also led to additional funding and grants through industry and private funding that is currently supporting this program moving forward. Now, what about gaps in hepatitis C care in the underserved population? Again, being that it's disproportionately represented by the minority population in the city. We had noticed that there had been significant rates of SVR that were similar to that observed within the clinical trials and the real world experiences in other cities. So we were getting rates of more than 90 to 95% cure rates in this population. And with all the efforts that had been put in place prior to even the initiation of NHEPC campaign with regards to provider and patient education program, formal patient education programs, as well as provider education algorithms, we had anticipated that we would see an enhanced screening risk within certain populations. To that effect, one of our exceptional trainees, Dr. Kim, who is actually in the audience, embarked upon an investigation of evaluation of this hepatitis C screening rates within the birth cohort, which was a particular target of ours, as well as linkage to care among these individuals. She identified that there was near universal screening of this population, so we were doing incredibly well, and that where the gaps existed was the consequence, the subsequent evaluation for active HCV confirmation, and then linkage to treatment. And this was influenced by race, as you can see here. She further looked at another population of very significant interest currently in light of, again, higher rates of observed hepatitis C infection in younger populations, as specifically reproductive age women, and the higher rates of HCV within the children born to these women. And we observed that among the 19,000 patients who were between the ages of 15 to 44, about 39% of this population was screened for HCV, again, recognizing this is an underserved population that a lot of risk-based screening are being currently performed. 2.8% of this population were HCV antibody positive, but only 23% of these women were linked to treatment. So we certainly have work to do. With regards to our work in enhancing hepatitis C screening, access and linkage to care among the homeless residents and population within San Francisco, we embarked upon an initiative whereby we actually engaged another site or center across the nation, always being the question whether the models of care within our city would actually be applicable to other settings. This is in Minnesota, Minneapolis. Minneapolis, Minnesota, sorry. So we, with our partner and with seed funding from industry along with collaboration with the Street Medicine Clinic and the San Francisco Department of Public Health implemented a protocol by which we initially did a needs assessment and understood the barriers and facilitators are implementing such a measure within the homeless shelters, so point-of-care testing. And our information showed that there were, it was significantly important to enhance HCV knowledge and harm reduction within this population, that various barriers were identified and that the provider and shelter clients actually agreed that the homeless individuals really did care about their health and that it was important to scale up HCV services within these shelters. And implementing the HCV point-of-care testing within this population, we then embark upon formal hepatitis C education for the patients, so a patient-centered approach, and then directly link them to treatment on-site or develop the flexible model of referral to primary care providers or providers that they identified as caring for their health or to specialty care if needed. The program outcomes with formulation of the multi-agency partnership effectiveness and efficacy assessment of shelter-based testing and treatment, and to assess impact of patient-centered HCV education program. And the goal was really to eliminate any barriers to HCV testing and treatment in this population. We were very successful initiating screening of the 672 clients that have been screened on-site. About 21% of the patients have been identified as having hepatitis C positivity. 62% of these individuals have had detectable HCV RNA, and remarkably, 45% of these individuals have initiated HCV therapy. In recognizing what were the actual barriers to screening, predominantly this was impacted by lack of testing recommendations by the providers and low perceived risk of HCV, along with lack of awareness of HCV. Recognizing that this population had 75% that identified having a provider, and 90% of this population actually had insurance. A formal patient education led to increased confidence in initiation or partnering in treatment for hepatitis C, acceptance of HCV therapy, and the overall effect of HCV management on improvement in health in this population. So in summary, there are certain accomplishments that the Liver Cancer Task Force has implemented, and certainly their partnership with these initiatives have been critical. There's been funding support to NHEP CSF and SFHEPi-free efforts. There's been enhanced access and participation of patients in liver cancer clinical trials. I didn't specifically highlight this, but to say that we now have monthly email notification, and certainly within the context of Safety Net Program, we do have representations of oncologists, clinical trialists that are sitting at our tumor board that are representing or presenting these individuals with options for these novel therapies to enhance or eliminate limited access. There's been some support of the SFDPH Viral Hepatitis Surveillance Registry, in that they have improved their clinician data forms for detailed levels of patient reporting, again, in impacting or influencing surveillance. And the viral hepatitis quality improvement measures have been implemented in certain institutions that didn't have so in a systemic way. For example, at the UCSF Medical Center, there has been a Hepatitis B and C established cohort led by Dr. Rena Fox, who's also in this audience, for tracking and identifying gaps in care, and then linkage to care and treatment and cancer screening as needed. The future goals of this program is to continue to engage in these efforts to treat more patients with viral hepatitis and prevent disinfection, to continue support the hepatitis surveillance efforts, and to really implement quality improvement measures in other settings or clinical sites that do not have such in place, and to explore policy and advocacy activities for hepatitis B and C screening, vaccination, and treatment. With that, I'd like to acknowledge the members of the Liver Cancer Task Force, and I thank you for your attention. Thank you.

San Francisco Cancer Initiative

community-based interventions

Liver Cancer Task Force

social determinants

hepatitis B and C screening

underserved populations