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Multidisciplinary Care in Hepatocellular Carcinoma

Panelists:Ghassan K. Abou-Alfa, MD, Memorial Sloan Kettering Cancer Center; Richard S. Finn, MD, Geffen School of Medicine; Riccardo Lencioni, MD, Sylvester Comprehensive Cancer Center; Amit Singal, MD, UT Southwestern Medical Center
Published: Friday, Apr 22, 2016



Transcript:

Ghassan K. Abou-Alfa, MD:
Hello, and thank you for joining this OncLive Peer Exchange regarding “Updates on the Treatment of Advanced Liver Cancer.” The disease burden of hepatocellular carcinoma continues to increase, not only because of its aggressive nature, but also because the incidence of cirrhosis is rising. Despite our best efforts to treat HCC, there is a high rate of recurrence. In this OncLive Peer Exchange, we’ll take an in-depth look at how to optimally manage patients with the multidisciplinary approach we currently have available. In addition, we’ll look at which emerging approaches appear most promising.
 
My name is Dr. Ghassan Abou-Alfa, and I’m an associate professor for the Gastrointestinal Oncology Service at Memorial Sloan Kettering Cancer Center. Also participating in this expert-based discussion is Dr. Richard Finn, an associate professor of medicine for the Division of Hematology/Oncology, Geffen School of Medicine at UCLA Medical Center; Dr. Riccardo Lencioni, a professor of clinical radiology at the University of Miami Miller School of Medicine and director of Interventional Oncology Research at Sylvester Comprehensive Cancer Center; and Dr. Amit Singal, medical director of the Liver Tumor Program at UT Southwestern Medical Center. Thank you for joining us. Let’s begin.
 
We’ll start by discussing multidisciplinary care when treating liver cancer, and I’ll start by maybe asking all of you: what is the importance of multidisciplinary care in the HCC population? Richard, thoughts?
 
Richard Finn, MD: Well, unlike most malignancies we treat in medical oncology, liver cancer is almost always occurring in the context of underlying liver disease, unlike with colon cancer, breast cancer where often these are in healthy people. Therefore, it’s going to take this multidisciplinary team to optimally manage patients. And that will often include a cancer specialist, like a medical oncologist; a hepatologist; as well as the fact that operating on a sick liver takes expertise, so usually a hepatobiliary surgeon and probably a transplant surgeon; and then, importantly, interventional radiology—given the importance of that approach.
 
Ghassan K. Abou-Alfa, MD: Great. Amit, interestingly enough, Richard and I will get calls from medical oncologists presenting a case, and presumably the same thing might occur in a setting of a multidisciplinary team discussion. Why should a hepatologist be there?
 
Amit G. Singal, MD: Well, as Richard was saying, I think the key thing is that HCC occurs in a setting of cirrhosis. So, over 90% of HCC in the United States occurs in the setting in cirrhosis. As Richard was saying, I think that oncologists haven’t had the history of dealing with cirrhosis that a hepatologist has, and we haven’t had the history of dealing with cancer like an oncologist has. And so I think that it really involves cross-talk between the two. We know that the degree of liver dysfunction strongly plays, not only in terms of prognosis, but also in treatment selection. Let’s say for surgical resection, you need to have a compensated liver with no portal hypertension, and then liver transplantation often delivers on the other side where you have significant hepatic dysfunction. Not only in the beginning when you’re making the treatment decision, but also longitudinally, as you’re following patients through care, you need to continue to monitor the liver function. And that’s where I think a hepatologist can really add a lot to the care of these patients.
 
Ghassan K. Abou-Alfa, MD: Absolutely. As we just heard, pretty much to reconfirm, liver cancer or HCC is two diseases in one; the cancer itself and, more likely than not, the associated cirrhosis. And the understanding of what could be the potential benefits of therapy or management for the patient would require those two aspects of the disease addressed. With this said, Riccardo, where do you think an interventional radiologist will get their referrals from? Are patients identified by a specialist, any DMT in a management team? Or is it a multidisciplinary team? Or is it some kind of referral from a surgeon? How does this work for you?
 
Riccardo Lencioni, MD: Most of our patients are referred by the multidisciplinary tumor board specialists. So, patients are brought, I would say, by anyone who is sitting at the tumor board. Hepatologists typically follow patients with cirrhosis or often they have patients with small tumors that are under surveillance. Oncologists bring cases that are typically more advanced. Surgeons can discuss the opportunity of resection or transplantation versus interventional therapy, so it’s a mix of different referrals, and we try to figure out on each individual basis what can be crafted for that particular patient.
 
Ghassan K. Abou-Alfa, MD: That’s beautifully said. If anything, the data have shown—and this comes actually from UT Southwestern—that it appears to be that patients who are seen by different disciplines will fare better. So, it’s not really a wishful thinking only, but really the input of the different disciplines would be quite critical. Most importantly, if anything on behalf of my colleagues, I would urge any specialty RN, please attend your multidisciplinary team meetings because this is where really you can contribute to what we call “the gray zones” between the different types of therapy that we might offer, and that we’re going to discuss in a minute.
 
Transcript Edited for Clarity
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Transcript:

Ghassan K. Abou-Alfa, MD:
Hello, and thank you for joining this OncLive Peer Exchange regarding “Updates on the Treatment of Advanced Liver Cancer.” The disease burden of hepatocellular carcinoma continues to increase, not only because of its aggressive nature, but also because the incidence of cirrhosis is rising. Despite our best efforts to treat HCC, there is a high rate of recurrence. In this OncLive Peer Exchange, we’ll take an in-depth look at how to optimally manage patients with the multidisciplinary approach we currently have available. In addition, we’ll look at which emerging approaches appear most promising.
 
My name is Dr. Ghassan Abou-Alfa, and I’m an associate professor for the Gastrointestinal Oncology Service at Memorial Sloan Kettering Cancer Center. Also participating in this expert-based discussion is Dr. Richard Finn, an associate professor of medicine for the Division of Hematology/Oncology, Geffen School of Medicine at UCLA Medical Center; Dr. Riccardo Lencioni, a professor of clinical radiology at the University of Miami Miller School of Medicine and director of Interventional Oncology Research at Sylvester Comprehensive Cancer Center; and Dr. Amit Singal, medical director of the Liver Tumor Program at UT Southwestern Medical Center. Thank you for joining us. Let’s begin.
 
We’ll start by discussing multidisciplinary care when treating liver cancer, and I’ll start by maybe asking all of you: what is the importance of multidisciplinary care in the HCC population? Richard, thoughts?
 
Richard Finn, MD: Well, unlike most malignancies we treat in medical oncology, liver cancer is almost always occurring in the context of underlying liver disease, unlike with colon cancer, breast cancer where often these are in healthy people. Therefore, it’s going to take this multidisciplinary team to optimally manage patients. And that will often include a cancer specialist, like a medical oncologist; a hepatologist; as well as the fact that operating on a sick liver takes expertise, so usually a hepatobiliary surgeon and probably a transplant surgeon; and then, importantly, interventional radiology—given the importance of that approach.
 
Ghassan K. Abou-Alfa, MD: Great. Amit, interestingly enough, Richard and I will get calls from medical oncologists presenting a case, and presumably the same thing might occur in a setting of a multidisciplinary team discussion. Why should a hepatologist be there?
 
Amit G. Singal, MD: Well, as Richard was saying, I think the key thing is that HCC occurs in a setting of cirrhosis. So, over 90% of HCC in the United States occurs in the setting in cirrhosis. As Richard was saying, I think that oncologists haven’t had the history of dealing with cirrhosis that a hepatologist has, and we haven’t had the history of dealing with cancer like an oncologist has. And so I think that it really involves cross-talk between the two. We know that the degree of liver dysfunction strongly plays, not only in terms of prognosis, but also in treatment selection. Let’s say for surgical resection, you need to have a compensated liver with no portal hypertension, and then liver transplantation often delivers on the other side where you have significant hepatic dysfunction. Not only in the beginning when you’re making the treatment decision, but also longitudinally, as you’re following patients through care, you need to continue to monitor the liver function. And that’s where I think a hepatologist can really add a lot to the care of these patients.
 
Ghassan K. Abou-Alfa, MD: Absolutely. As we just heard, pretty much to reconfirm, liver cancer or HCC is two diseases in one; the cancer itself and, more likely than not, the associated cirrhosis. And the understanding of what could be the potential benefits of therapy or management for the patient would require those two aspects of the disease addressed. With this said, Riccardo, where do you think an interventional radiologist will get their referrals from? Are patients identified by a specialist, any DMT in a management team? Or is it a multidisciplinary team? Or is it some kind of referral from a surgeon? How does this work for you?
 
Riccardo Lencioni, MD: Most of our patients are referred by the multidisciplinary tumor board specialists. So, patients are brought, I would say, by anyone who is sitting at the tumor board. Hepatologists typically follow patients with cirrhosis or often they have patients with small tumors that are under surveillance. Oncologists bring cases that are typically more advanced. Surgeons can discuss the opportunity of resection or transplantation versus interventional therapy, so it’s a mix of different referrals, and we try to figure out on each individual basis what can be crafted for that particular patient.
 
Ghassan K. Abou-Alfa, MD: That’s beautifully said. If anything, the data have shown—and this comes actually from UT Southwestern—that it appears to be that patients who are seen by different disciplines will fare better. So, it’s not really a wishful thinking only, but really the input of the different disciplines would be quite critical. Most importantly, if anything on behalf of my colleagues, I would urge any specialty RN, please attend your multidisciplinary team meetings because this is where really you can contribute to what we call “the gray zones” between the different types of therapy that we might offer, and that we’re going to discuss in a minute.
 
Transcript Edited for Clarity
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