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The Impact of Underlying Cirrhosis on Managing HCC

Insights From: Richard S. Finn, MD, Geffen School of Medicine;Arndt Vogel, MD, Hannover Medical School
Published: Monday, Nov 07, 2016


Transcript:

Richard Finn, MD:
Liver cancer almost always occurs in the presence of some degree of cirrhosis. Therefore, when we approach a patient, we need to take into account the severity of their liver disease. A staging system like we use in other cancers, like TNM, or tumor nodes metastasis, doesn’t really capture the true outcomes for these patients because it ignores the other competing risk for survival, and that is their underlying liver disease. Commonly, we use the BCLC, or the Barcelona Liver Cancer, staging approach. This staging system takes into account not only the extent of the tumor, but also the underlying liver disease and a patient’s performance status. And by taking all those things into consideration, it stratifies patients to various procedures that have been shown to improve outcome.

For example, someone might have a very sick liver, but a very small tumor, and the prognosis for this patient is very poor based on their liver disease. They may be a candidate for a liver transplant, a curative approach. And, on the other side, a patient may have a very large tumor, but very well preserved liver function, and this patient’s risk of death from their liver cancer is very high. Their liver disease is well preserved, so they would be candidates for approaches that have been shown to improve survival. So, for every patient we see, it’s not only assessing the anatomic staging of their tumor, but also the patient’s physiology and their liver function. And that will come into play as we triage patients to various approaches.

Arndt Vogel, MD: I think the underlying liver cirrhosis is really a big problem. With liver cirrhosis, liver function is impaired, which means patients are not as fit as patients without liver cirrhosis to really tolerate all treatments. And so, we have a significant impact of basically drug-induced toxicity, which really makes it tough to get a successful clinical trial because we can’t have a drug that might have a good anti-tumoral activity. But, on the other hand, if it really impacts the liver and it further deteriorates liver function, it might get out of balance, and we might not see an overall survival benefit for our patients. So, the treatments we use, they need to really not harm the liver too much to be effective and to have long-term benefit for our patients.

Richard Finn, MD: Because liver cancer often occurs in the setting of a sick liver and surgical approaches are often the only curative approaches—and I don’t only mean resection, which is for a minority of patients, but even liver transplant—liver cancer is one of the main indications for patients to have a liver transplant. As it turns out, usually it’s at tertiary centers that these multidisciplinary teams function regularly. All the players that are involved in the management of advanced liver cancer can come together on a regular basis and review cases to come up with an optimal plan. And that means surgery, both hepatobiliary and liver transplant, interventional radiology, hepatology, and medical oncology. In the community, it can be difficult to get these types of teams together, just because everybody is busy with competing demands. In some way, it’s self-serving, but, really, any patient with liver cancer deserves to be evaluated at a tertiary center, and specifically one that probably offers liver transplant. Criteria are changing, and if they’re not a candidate for liver transplant, usually these centers will have the other specialties available with sufficient expertise to manage patients optimally.

Transcript Edited for Clarity
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Transcript:

Richard Finn, MD:
Liver cancer almost always occurs in the presence of some degree of cirrhosis. Therefore, when we approach a patient, we need to take into account the severity of their liver disease. A staging system like we use in other cancers, like TNM, or tumor nodes metastasis, doesn’t really capture the true outcomes for these patients because it ignores the other competing risk for survival, and that is their underlying liver disease. Commonly, we use the BCLC, or the Barcelona Liver Cancer, staging approach. This staging system takes into account not only the extent of the tumor, but also the underlying liver disease and a patient’s performance status. And by taking all those things into consideration, it stratifies patients to various procedures that have been shown to improve outcome.

For example, someone might have a very sick liver, but a very small tumor, and the prognosis for this patient is very poor based on their liver disease. They may be a candidate for a liver transplant, a curative approach. And, on the other side, a patient may have a very large tumor, but very well preserved liver function, and this patient’s risk of death from their liver cancer is very high. Their liver disease is well preserved, so they would be candidates for approaches that have been shown to improve survival. So, for every patient we see, it’s not only assessing the anatomic staging of their tumor, but also the patient’s physiology and their liver function. And that will come into play as we triage patients to various approaches.

Arndt Vogel, MD: I think the underlying liver cirrhosis is really a big problem. With liver cirrhosis, liver function is impaired, which means patients are not as fit as patients without liver cirrhosis to really tolerate all treatments. And so, we have a significant impact of basically drug-induced toxicity, which really makes it tough to get a successful clinical trial because we can’t have a drug that might have a good anti-tumoral activity. But, on the other hand, if it really impacts the liver and it further deteriorates liver function, it might get out of balance, and we might not see an overall survival benefit for our patients. So, the treatments we use, they need to really not harm the liver too much to be effective and to have long-term benefit for our patients.

Richard Finn, MD: Because liver cancer often occurs in the setting of a sick liver and surgical approaches are often the only curative approaches—and I don’t only mean resection, which is for a minority of patients, but even liver transplant—liver cancer is one of the main indications for patients to have a liver transplant. As it turns out, usually it’s at tertiary centers that these multidisciplinary teams function regularly. All the players that are involved in the management of advanced liver cancer can come together on a regular basis and review cases to come up with an optimal plan. And that means surgery, both hepatobiliary and liver transplant, interventional radiology, hepatology, and medical oncology. In the community, it can be difficult to get these types of teams together, just because everybody is busy with competing demands. In some way, it’s self-serving, but, really, any patient with liver cancer deserves to be evaluated at a tertiary center, and specifically one that probably offers liver transplant. Criteria are changing, and if they’re not a candidate for liver transplant, usually these centers will have the other specialties available with sufficient expertise to manage patients optimally.

Transcript Edited for Clarity
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