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Multidisciplinary Approaches in HCC

Panelists: Ghassan K. Abou-Alfa, MD, Memorial Sloan Kettering Cancer Center; Richard S. Finn, MD, UCLA; Laura M. Kulik, MD, Northwestern University Feinberg School of Medicine; R. Kate Kelley, MD, University of California-San Francisco; Riad Salem, MD, Northwestern University Feinberg School of Medicine
Published Online: Tuesday, Feb 14, 2017



Transcript:

Ghassan K. Abou-Alfa, MD:
Hello, and thank you for joining this OncLive Peer Exchange® titled “Optimizing Treatment Selection in Liver Cancer.” Surgery or resection, liver transplantation, and radiofrequency ablation remain the only curative options for patients with hepatocellular carcinoma. However, important advances in systemic therapy as well as locoregional therapy are improving management of this disease. This OncLive Peer Exchange® panel of experts will focus on the evolving treatment landscape, including how the latest evidence interplays with the complexities of the disease to impact clinical decision making.

I am Ghassan Abou-Alfa, and I am a medical oncologist at the Memorial Sloan Kettering Cancer Center in New York. Participating today on our distinguished panel are: Dr. Richard Finn, associate professor of medicine at the Geffen School of Medicine at UCLA and the Division of Hematology-Oncology at the University of California Los Angeles Medical Center; Dr. Katie Kelley, associate professor in the Department of Hematology-Oncology at the University of California-San Francisco; Dr. Laura Kulik, professor of medicine, radiology, and surgery in the Department of Medicine and the Division of Gastroenterology/Hepatology at Northwestern University Feinberg School of Medicine in Chicago, Illinois; and Dr. Riad Salem, vice chair for Image-Guided Therapy and chief of Interventional Radiology (IR) in the Department of Radiology at Northwestern University Feinberg School of Medicine in Chicago, Illinois. Thank you so much for joining us. Let’s begin.

Good evening, everybody. I would like to start with a thought on multidisciplinary approach to therapy. Richard, how does multidisciplinary work at UCLA?

Richard S. Finn, MD: Well, multidisciplinary approaches are important in many of the cancers we treat. And I think, especially in liver cancer, this approach is critical to providing patients with the optimal management, and that really is because it’s 2 diseases. It’s not only the malignancy, but also the underlying liver disease. And because of the critical role of surgeries, especially liver transplant and liver resection—as well as interventional radiology in managing the disease—I think a multidisciplinary tumor board is the ideal way to approach patients. At our center, for example, we meet every other week, and the tumor board consists of hepatologists, liver surgery, medical oncology, both diagnostic and interventional radiology, and even radiation oncology. And we approach patients where typically there is not a clear-cut one right answer. We have an open discussion about what is evidence-based and then individualizing that for each individual patient.

Ghassan K. Abou-Alfa, MD: Great. So, Laura, I have a thought here. Obviously, I can understand if there is a transplant center, a hepatologist would be a very critical part of the team of that nature. But Richard just referred to the 2 diseases in one. How do you see the role of hepatology, not necessarily only in the early stage disease, but rather in the advanced stage as well?

Laura M. Kulik, MD: As a patient’s liver cancer is advancing, they’re often having complications of portal hypertension. They’re more likely to have variceal bleeding and also more likely to die as a result of that, also ascites. So, trying to manage not only from a mortality standpoint but also from a comfort standpoint is very important. A hepatologist will try to treat the underlying disease as well. There are very potent hepatitis C medications that are now available, and it has become a little bit controversial as to when to treat patients who have hepatitis C with HCC, but that’s another role for the hepatologist.

Ghassan K. Abou-Alfa, MD: Great. Katie, it’s interesting. In some interactions here and there, I always hear medical oncologists say, “We’re busy in clinic. We really don’t have time to go to the multidisciplinary team,” inferring that their role is so well defined because systemic therapy is for metastatic disease. What can we tell our friends there?

R. Kate Kelley, MD: I think for liver cancer, more so than many other cancers, we really rely on our colleagues across disciplines in hepatology, IR, and surgery, and across stages of disease, particularly in advanced disease. Even if a patient is receiving systemic therapy or chemotherapy, I’m often consulting my hepatology colleagues to help with encephalopathy, the complications of end-stage liver disease that can evolve as a cancer progresses, or with treatment toxicity, and also with some of the more esoteric issues that can occur with the reactivation hepatitis that can happen on systemic therapy. So, we often are employing antiviral treatments. It’s a multidisciplinary disease from start to finish, from early stage to advanced.

Ghassan K. Abou-Alfa, MD: I totally agree. And, if anything, obviously for the patients as we evolve in the therapy, we always understood it to be categorized as being resectable, curative, then to locally advanced and metastatic disease. But, obviously, there’s a lot of discussion back-and-forth as we see those different categories coalescing together in many aspects.

Transcript Edited for Clarity

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Transcript:

Ghassan K. Abou-Alfa, MD:
Hello, and thank you for joining this OncLive Peer Exchange® titled “Optimizing Treatment Selection in Liver Cancer.” Surgery or resection, liver transplantation, and radiofrequency ablation remain the only curative options for patients with hepatocellular carcinoma. However, important advances in systemic therapy as well as locoregional therapy are improving management of this disease. This OncLive Peer Exchange® panel of experts will focus on the evolving treatment landscape, including how the latest evidence interplays with the complexities of the disease to impact clinical decision making.

I am Ghassan Abou-Alfa, and I am a medical oncologist at the Memorial Sloan Kettering Cancer Center in New York. Participating today on our distinguished panel are: Dr. Richard Finn, associate professor of medicine at the Geffen School of Medicine at UCLA and the Division of Hematology-Oncology at the University of California Los Angeles Medical Center; Dr. Katie Kelley, associate professor in the Department of Hematology-Oncology at the University of California-San Francisco; Dr. Laura Kulik, professor of medicine, radiology, and surgery in the Department of Medicine and the Division of Gastroenterology/Hepatology at Northwestern University Feinberg School of Medicine in Chicago, Illinois; and Dr. Riad Salem, vice chair for Image-Guided Therapy and chief of Interventional Radiology (IR) in the Department of Radiology at Northwestern University Feinberg School of Medicine in Chicago, Illinois. Thank you so much for joining us. Let’s begin.

Good evening, everybody. I would like to start with a thought on multidisciplinary approach to therapy. Richard, how does multidisciplinary work at UCLA?

Richard S. Finn, MD: Well, multidisciplinary approaches are important in many of the cancers we treat. And I think, especially in liver cancer, this approach is critical to providing patients with the optimal management, and that really is because it’s 2 diseases. It’s not only the malignancy, but also the underlying liver disease. And because of the critical role of surgeries, especially liver transplant and liver resection—as well as interventional radiology in managing the disease—I think a multidisciplinary tumor board is the ideal way to approach patients. At our center, for example, we meet every other week, and the tumor board consists of hepatologists, liver surgery, medical oncology, both diagnostic and interventional radiology, and even radiation oncology. And we approach patients where typically there is not a clear-cut one right answer. We have an open discussion about what is evidence-based and then individualizing that for each individual patient.

Ghassan K. Abou-Alfa, MD: Great. So, Laura, I have a thought here. Obviously, I can understand if there is a transplant center, a hepatologist would be a very critical part of the team of that nature. But Richard just referred to the 2 diseases in one. How do you see the role of hepatology, not necessarily only in the early stage disease, but rather in the advanced stage as well?

Laura M. Kulik, MD: As a patient’s liver cancer is advancing, they’re often having complications of portal hypertension. They’re more likely to have variceal bleeding and also more likely to die as a result of that, also ascites. So, trying to manage not only from a mortality standpoint but also from a comfort standpoint is very important. A hepatologist will try to treat the underlying disease as well. There are very potent hepatitis C medications that are now available, and it has become a little bit controversial as to when to treat patients who have hepatitis C with HCC, but that’s another role for the hepatologist.

Ghassan K. Abou-Alfa, MD: Great. Katie, it’s interesting. In some interactions here and there, I always hear medical oncologists say, “We’re busy in clinic. We really don’t have time to go to the multidisciplinary team,” inferring that their role is so well defined because systemic therapy is for metastatic disease. What can we tell our friends there?

R. Kate Kelley, MD: I think for liver cancer, more so than many other cancers, we really rely on our colleagues across disciplines in hepatology, IR, and surgery, and across stages of disease, particularly in advanced disease. Even if a patient is receiving systemic therapy or chemotherapy, I’m often consulting my hepatology colleagues to help with encephalopathy, the complications of end-stage liver disease that can evolve as a cancer progresses, or with treatment toxicity, and also with some of the more esoteric issues that can occur with the reactivation hepatitis that can happen on systemic therapy. So, we often are employing antiviral treatments. It’s a multidisciplinary disease from start to finish, from early stage to advanced.

Ghassan K. Abou-Alfa, MD: I totally agree. And, if anything, obviously for the patients as we evolve in the therapy, we always understood it to be categorized as being resectable, curative, then to locally advanced and metastatic disease. But, obviously, there’s a lot of discussion back-and-forth as we see those different categories coalescing together in many aspects.

Transcript Edited for Clarity
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