The EASL–Lancet Liver Commission calls for a paradigm shift in the liver disease response in Europe: prevention and early detection, not end-stage treatment of complications. Liver disease is now the second leading cause of years of working life lost in Europe.
Thursday December 2nd, 2021 (Brussels, Belgium) —The future health of Europeans is inextricably related to a fundamental shift in the way in which liver disease needs to be prevented, diagnosed and treated, an expert panel of health professionals from various medical disciplines, nurses and patients has concluded after a three-year analysis.
The EASL-Lancet Liver Commission: Protecting the next generation of Europeans against liver disease complications and premature mortality (The Commission), today reported on its findings and warned that Europe’s fragmented health policies and health systems need to become more integrated, coordinated and effective to enable earlier detection of disease and to bring common risk factors for liver disease like alcohol and obesity under control.
Liver health is a window to the general health challenges of Europe in the 21st century. We are at the precipice of failure or opportunity. Common risk factors for liver disease reflect behaviours and conditions that are the consequence of both unhealthy environments and social inequities that straddle a wide range of associated medical conditions such as diabetes and cancer,
said Prof. Thomas Berg, Secretary-General of the European Association for the Study of the Liver (EASL) and Head of the Department of Hepatology at the University Hospital in Leipzig, Germany.
The medical profession needs to change its approach to liver disease: instead of focusing on the management of end-stage complications, it needs to shift towards prevention, proactive case-finding, with early identification of progressive liver fibrosis, early diagnosis and early treatment. Therapeutic nihilism for liver diseases belongs to the past.
Each year, almost 300,000 people in Europe die prematurely due to problems of the liver. Many of them could have lived longer and healthier lives. Because today, in most European countries, there is good access to secondary care. And in most cases, liver disease can be prevented. Prevention is the best cure that we have. So together, we need to raise more awareness of the preventable and treatable nature of many chronic illnesses,
said Ursula von der Leyen, President of the European Commission.
This shift must also include a revision of how we converse about liver disease and speak with people with liver disease. Medical nomenclature of liver disease is littered with stigmatising terms, and it is our duty to change these terms and spread awareness and reduce the social stigmatisation associated with liver disease,
said Prof. Patrizia Burra, Co-Chair of the Commission and Head of the Department of Gastroenterology at the University of Padova in Italy.
Non-alcohol fatty liver disease (NAFLD), mainly driven by obesity, is now the fastest growing liver disease in Europe with one in four people now living with the condition. NAFLD is set to become the number one cause of liver cancer in Europe. NAFLD exemplifies the need for conjoined working between medical specialists like hepatologists, diabetologists, cardiologists, primary care providers and patient groups, as well as public health action on noncommunicable disease prevention.
The prevention and treatment of most liver diseases is now possible thanks to significant achievements in modern medicine. The hepatitis B vaccine has become the first vaccine shown to prevent cancer, and within 25 years from discovery, hepatitis C virus infection has become curable in almost every patient. We have to guarantee access to care for all Europeans,
said Michael Manns, a Co-Chair of the Commission and President of Hannover Medical School in Hannover, Germany.
Europe has the highest rates of alcohol consumption per person, the highest prevalence of heavy episodic drinking, and the lowest rates of abstention from alcohol in the world. Alcohol combines synergistically with obesity and other risk factors for liver disease to drive the current high rates of end-stage liver disease and liver cancer. Alcohol causes about 40 per cent of the 287,000 premature liver-related deaths in Europe every year, although the true number might be higher.
Writing in a linked Comment published in The Lancet, Dr Richard Horton, Editor-in-Chief and Dr Sabine Kleinert, Executive Editor, added:
A concerted effort needs to be made to extend services and care to underserved and difficult to reach populations. To achieve protection and promotion of liver health more broadly, wide-reaching public health policies, such as labelling of unhealthy food and minimum alcohol unit pricing, need to be implemented against commercial interests and political inertia or entanglement.
Said Prof. Nick Sheron, a member of the Commission and Clinical Advisor to Public Health England:
The European Court of Justice and the UK Supreme Court have found that the most effective means to reduce alcohol harm is to set a minimum unit price per centilitre of alcohol.
In Europe, chronic liver disease has a substantial impact on young and middle-aged individuals in their prime working years, with the peak age of death occurring in the late 40s and early 50s. This contrasts with mortality from smoking-related and other obesity-related illnesses, such as lung cancer or type 2 diabetes, for which deaths typically occur in the 60s and 70s. Consequently, data from the World Health Organization shows that liver disease is now second only to ischemic heart disease as the leading cause of years of working life lost in Europe. On average, two-thirds of all potential years of life lost due to mortality from liver diseases are years of working life.
We should utilise the window of opportunity created by the COVID-19 pandemic to overcome fragmentation and the variability of health prevention policies and research across Europe.
said Prof. Maria Buti, Professor of Hepatology and Medicine at the Hospital Universitario Vall d’Hebron in Barcelona, Spain and the EASL EU and Policy Councillor.
A long-term vision for liver health is a long-term vision for the health of future generations of all Europeans. To be successful a considerable focus must be put on underserved and marginalised communities, including our children. To be successful, a considerable focus must be put on underserved and marginalised communities, including our children,
said Prof. Phil Newsome, Professor of Experimental Hepatology at the University of Birmingham in the UK and senior author of the Commission’s report.
On the basis of the data collated in its report, the EASL-Lancet Liver Commission makes 10 key recommendations, approximately half of which are targeted to health professionals, and half of which are oriented to policy-makers.
If these recommendations are acted upon in a uniform way throughout Europe, we would be on the way to driving a paradigm shift in the tackling of liver disease in Europe, and we’ll go a long way towards protecting the general health of future generations of Europeans,
said Prof. Tom Hemming Karlsen, Research Head at the Clinic of Surgery, Inflammatory diseases and Transplantation of the University of Oslo and Oslo University Hospital and a Co-Chair of the EASL-Lancet Liver Commission.
There is a long road ahead to achieve substantive change, but perhaps a combined European effort supported by European medical societies, the WHO Regional Office for Europe, and the European Commission can reverse the alarming trajectories of risk factors for liver diseases. The ultimate long-term goal must be to prevent liver diseases and protect liver health,
wrote Dr Richard Horton and Dr Sabine Kleinert in their comment.
- Implementation of standardised and simplified liver blood tests for earlier detection and prompt care.
- Utilisation of opportunities created by the hepatitis B and C drugs as well as hepatitis B and A vaccines to achieve viral hepatitis elimination in Europe.
- Increase awareness and provide financial incentives for primary care peers and professionals.
- Non-viral liver diseases must be classified along with other non-communicable diseases (NCDs) to engage appropriate care models.
- All forms and sources of stigma towards people at risk of or with liver disease must be opposed – relevant changes to the medical nomenclature should come first.
- Public disclosure of prices for antiviral drugs throughout Europe would reinforce the WHO / World Health Assembly resolution to improve fairness of market prices.
- European governments must introduce uniform policies to reduce the harmful use of alcohol.
- A complete social and digital media ban on the marketing of alcohol and ultra-processed, high-fat and high-sugar foods targeted to children.
- Promote industry-led food reformulation and minimisation of social inequities by subsidising healthy foods.
- EU and European governments should prioritise the harmonisation of critical forms of public health interventions and health-related policies across Europe.
From The Lancet, you can find these supplementary resources:
- A dedicated infographic: A paradigm shift in tackling liver diseases
- Profile: Tom Hemming Karlsen: hepatologist with a public health message, by Geoff Watts
- Comment: Liver disease: at the heart of public health challenges for Europe in the 21st century, by Graham S Cooke and Shevanthi Nayagam
- An urgent challenge for Europe: from tackling liver diseases to protecting liver health, by Sabine Kleinert and Richard Horton