Tackling a stealthy killer

Dr Jonathan Koea gave up a glamorous career in New York to lead the fight against liver cancer back home. He tells TIM WATKIN how he intends to win.

In the rows of chairs people are waiting, their faces expressionless, as flat and dull as the vinyl they're sitting on. It's a typical hospital waiting room, the walls covered in colourful safety messages and the bustling nurses in stark contrast to the withdrawn patients.

As it does every Tuesday morning, the sign by reception says Liver Clinic. The word cancer isn't used. Although it will affect many who come to this waiting room, the stigma associated with cancer is unwelcome because from these ordinary rooms a dedicated group of doctors is undertaking an extraordinary assault against the most stealthy killer in the country.

The patients are there to see Dr Jonathan Koea, an "outstanding" surgeon who never wanted to do surgery. He left the world's oldest and largest private cancer clinic in New York to help to tackle the unglamorous and undesirable scourge of hepatitis B in his home country.

This morning, Koea will be doing the part of the job he enjoys best - meeting his patients and fashioning a course of treatment. He likes to get to know the people he operates on. In an odd way that makes surgery more enjoyable, he says.

"The other thing I've come to appreciate in dealing with these people, without sounding trite, is that every day is a gift."

Koea's first patient this Tuesday, 69-year-old Charlie Hurihanganui, is also the first patient he treated when he arrived back in the country in September 2000 after two years at the Memorial Sloan-Kettering Cancer Centre in New York.

Hurihanganui had stormed out of his doctor's office in anger when he was first told in 1999, all too casually, that he had hepatitis B. It got worse. Two specialists told him he had cancer, but was too old for surgery. They said his options were few. Depression followed.

"I was getting to the point where I was giving up. Not now."

He heard of Koea through his sister, who interviewed Koea for an iwi newsletter. Koea told him his fitness meant he wasn't too old for surgery and also talked him through a range of other options.

"He's been like an angel just dropped from heaven. He was so positive right from the start."

Surgery in December 2000 found Hurihanganui's tumour was too advanced to be removed. Instead, Koea sealed off the artery feeding blood to the tumour, stopping its growth.

He also placed Hurihanganui on a drug trial, in which a naturally occurring gastro-intestinal hormone that suppresses tumour growth is injected in high doses.

Hurihanganui's health and spirits have improved markedly.

"My workmates reckon I'm having them on because they say I look better than they do," he laughs.

W HILE lacking the shock value of meningitis or tuberculosis, the prevalence of hepatitis B in New Zealand is another, if quieter, matter of national ignominy. Among our Maori, Pacific Island and - in an addition to the usual list of poor-health sufferers - Asian populations, the infection rate is between 5 and 6 per cent.

This is similar to that found in developing countries - and in marked contrast to only 0.4 per cent of the Pakeha population.

At any given time, about 50,000 New Zealanders will have hepatitis B and around 150 will die each year from hepatitis B-related problems - about half from cirrhosis and half from cancer.

What is different about hepatitis B is that it doesn't lead to an all-too-familiar mire of miserable statistics and under-funding where there is little hope and no cure. New Zealand has embarked on a screening programme that has eradication as its goal.

"Hepatitis B is one of the most significant preventable causes of cancer in the world," says Dr Chris Bullen, public health medicine specialist.

Koea elaborates: "With this programme we want to find people with hepatitis B and treat cancer, but our real aim is to eliminate the disease so that our grandchildren won't have to worry about it. Hepatitis B should be like smallpox. We should be able to eliminate it over two or three generations."

And that's not all. "With that we should be able to eliminate liver cancer as well."

Considering the attention given to breast, prostate and lung cancer, it's surprising to learn that primary liver cancer is the most common cancer of internal organs in the world. (Skin cancers are the most common.)

Koea says there is a "direct link between hepatitis B and liver cancer. In countries where hepatitis B is common, usually developing countries, liver cancer is common."

By conquering hepatitis B, you're also well on the way to doing away with liver cancer.

The hepatitis virus is a DNA-containing virus that is spread by close contact and likes to attack liver cells.

No one knows why, but it has made its home in our neighbourhood. More than 90 per cent of the world's hepatitis B is in the Asia-Pacific region.

Elsewhere in the Western world it is commonly transmitted by sexual contact, and the surrounding stigma means carriers can be reluctant to be screened or treated.

Doctors are trying to put across the message that sex is not the issue in New Zealand among the target screening populations. It is mostly contracted at birth or by children living in close quarters with carriers.

As the virus can survive outside the body for 10 days it can be passed on by shared razors and combs, for example, or even in playground scrapes. But it might be years before a carrier shows any symptoms.

"Unlike, say, meningitis, where a person gets sick and dies quickly, a person can get hep B and stay well for 25 or 30 years," says Bullen.

Yet the virus is doing damage, says Koea. While the heart or brain reacts to the slightest distress, "the liver is much more forgiving. You can damage 50, 60, 70 per cent of it before you get an inkling of a symptom. It's a silent disease until it is in its final stages."

For a long time there was little doctors could do to stop or even treat the disease. Then in the 80s, a vaccine was developed and, thanks to the research and lobbying of Dr Sandor Milne, New Zealand became one of the first countries to start using it. It's free from GPs for anyone under 16 and any family member of a carrier. Three shots means 90 per cent protection, probably for life. They can't say for certain until the vaccine has been in use for a lifetime, but so far, so good.

The danger lies in the thousands of adult carriers who are unwittingly passing the disease on to their sexual partners and children. Happily, they can be diagnosed from a simple blood test, so for Koea and his posse it's just a matter of tracking down the carriers.

In an effort to "mop up" these people, two free screening programmes were begun, one in 1999 based on the East Coast and covering most of the North Island, the other last year covering Auckland and Northland.

In Auckland, doctors are breaking down traditional professional barriers to work together to combat the problem. At the hospital, surgeons Koea and John McCall are working with a hepatologist, Dr Ed Gane, and a medical oncologist, Paul Thompson, to offer the increasingly wide range of treatments available.

Simple as this sounds, these initiatives represent the most comprehensive attempt to wipe out hepatitis B anywhere in the world. Given that we have the unique combination of Third World disease rates and a First World health service, Bullen says "there is nowhere else in the world where this is being done on this scale".

For all that, reaching those in need is not easy. Even when the message gets through, it can be hard to convince people to be tested, Bullen says. "People on the margins of our society might not be as concerned about this when their focus is to get food on the table each day."

The screening in the north is done by GPs, who are paid for every person they screen. They have found the most effective argument is to warn people about the damage their ignorance may do to their children and grandchildren rather than the dangers they face themselves. That tends to get their attention.

To get word to Auckland's Pacific Island community, the project team started going to church. They have reached half their targeted total of 50,000 among the Pacific Island community. Maori are proving more elusive, with only 15 per cent of the 70,000 screened, although many were tested at the kapa haka competition at Bastion Pt. So far, 35 per cent of the 50,000 Asians targeted have been screened.

Bullen, who is the project director of the Auckland-based programme, known as "hep B Free", says overall 60,000 people from the high-risk ethnic groups have been tested since last December. Of those, around 4800 have been carriers.

Gane says of those carriers, "somewhere between 10 and 20 per cent will develop life-threatening complications during their life".

The high rate has surprised Bullen and the team. They expected 6 per cent of those screened would be carriers, consistent with the national average among these ethnic groups, "but we have constantly been finding 8 per cent in the north".

He has no idea why but says it appears the percentage of carriers rises the further north you go.

As worrying as that is, Koea is not disheartened, mostly because of the advances in treatment over the past five to seven years. Liver re-section and transplants have become safer. There are even ways of killing a tumour without removing it, by injecting alcohol into the tumour, blocking the arteries to it, or boiling it.

Around 50 per cent of those screened will already be immune - either from vaccination or because their body has fought off the disease earlier in life. In the other half of cases where treatment is needed, it works on three levels to break the cycle, says Ed Gane, clinical director to "hep B Free".

If you're one of the 40 per cent not immune, it's a simple matter of having those three vaccinations. Those with active liver disease who have not yet developed cancer, can be treated effectively with anti-viral agents, while those with cancer can explore the possibility of cutting out the cancer or even undergoing a transplant.

In the past four years, 37 transplants have been listed to attack cancer caused by hepatitis B. Gane says that in assessment, care and recovery, they cost the taxpayer between $120,000 and $140,000 each.

Koea says 30 of the 37 transplants have been carried out. Twenty-six patients are "alive and well", four have developed recurrent tumours and three are waiting for surgery. Most tragically, four had to be de-listed because during the 100-day waiting period their tumours grew too big to allow surgery.

If the screening programme works, more people will be caught earlier, tax dollars will be saved and fewer will need Koea's surgical skills. In a sense, he's doing himself out of a job. But considering the patients he sees who haven't been screened - those who have been referred to him after turning up at their GP's with liver problems - he doesn't mind.

For three out of four, the cancer is too big and it's too late to operate. They will be dead within a few months of meeting him.

Hurihanganui is one of the lucky ones, but he's still on borrowed time. What is frustrating is that he's staring down the barrel of a disease that he's probably had since infancy.

If he'd known, something could have been done earlier. Instead, buoyant and brave though he is, he's taking seven tablets a day and carrying an inoperable tumour around like a ticking timebomb.

"When you've got experts like Koea around it's better to know, then somebody can actually treat you."

T HAT expertise is on display every Monday morning in an operating theatre on the second floor of Auckland Hospital. Koea, surrounded by a cast and audience, is snipping away at the liver of a 62-year-old man, removing a clearly defined, 4cm tumour.

The scene is recognisable to anyone who has watched a television medical drama. A pump rises and falls, a machine pings gently and regularly, and the staff mumble from behind their masks about terrorism and their children. What TV doesn't prepare you for is the smell of blood and of flesh being seared by the argon torch that staunches bleeding.

Koea looks over and says, "I know this may look like a still-life painting, but there's plenty going on".

The focus of the activity is the liver, prominent in a chest clamped open startlingly wide. Koea's insistence on getting to know his patients suddenly seems important and impressive.

It's all too easy to strip any sense of humanity from the flesh and bones in front of you. The patient's head is hidden behind a sheet and his body is wrapped tightly in what is basically iodised cling film - Koea and his team are working on nothing more than an isolated bundle of flesh. The only signs that this is a human body are the finger and thumb poking out from behind the sheet.

Koea explains the operation. The patient's liver, ridged and splotchy like the surface of a tongue, shouldn't look like that.

"The liver should be like liver in a butcher's shop. It should be soft and flexible, but [this one's] like a block of wood."

Koea didn't intend to end up here, in an operating theatre, hands in another person's chest.

"I never wanted to do surgery because, you know, the yucky stuff," this normally articulate, confident man confesses with a sheepish grin. Then again, he adds, he always did like working with his hands.

Koea grew up in New Plymouth, the only child of two journalists. His father, George, edited the Taranaki Herald before it folded , going the way of so many evening papers. His mother is Shonagh Koea, the award-winning novelist.

It was a stimulating childhood where education was valued, "but still, they were completely stunned when I said I wanted to go to medical school," Koea recalls.

Having just sneaked an A bursary, Koea got into Medical School at Auckland University thanks to the Maori and Polynesian Admissions Scheme. Once he graduated, he was determined to give something back.

After qualifying as a surgeon in 1997, he applied for the international fellowship at Memorial Sloan-Kettering in New York and was accepted in 1999, ahead of 100 other surgeons from around the world. Dr Murray Brennan, an expat New Zealander who is chairman of the centre's surgery department, says Koea is self-effacing, "which is not a New York attribute", but "an outstanding surgeon".

Koea learned liver surgery at Sloan-Kettering, a 20-floor hospital covering three New York city blocks which focuses entirely on cancer.

"It appealed to me as something I could bring back, something we didn't have here, but which there was a clear need for," he says.

"He just soaked up everything," says Brennan. "He was more than competitive and we would have kept him if he didn't have such a strong commitment to New Zealand.

"He's a bright young person who could be competitive anywhere in the world, but who elected to go back to New Zealand where he could make a difference."

Koea admits there was a temptation to stay but says the lure of home was stronger.

"It's part of the New Zealand condition I think - Neil Finn has written that when you're away you think about home and when you're home you think about what's going on in the rest of the world. I did crazy things like hunting out pubs at all hours of the night to watch rugby games. The other issue was the children."

He and his wife, Lisajane, wanted to raise their children as New Zealanders, in a house with a backyard.

So instead of pounding New York streets, he now jogs along North Shore beaches after work and reads bedtime stories to his children.

Hurihanganui is one who's thrilled Koea chose to come home.

"I certainly value the guy," he chuckles. "How else would I have been in this situation where I'm now getting this treatment and all these options? I was so lucky."

nzherald.co.nz/health