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Challenges in Managing Newly Diagnosed Advanced HCC

Panelists: Ghassan K. Abou-Alfa, MD, Memorial Sloan Kettering Cancer Center; A. Ruth He, MD, PhD, Georgetown University Medical Center; Mark W. Karwal, MD, University of Iowa Health Care; Mark H. OHara, MD, Hospital of the University of Pennsylvania; Manish R. Sharma, MD, University of Chicago; Amit Singal, MD, UT Southwestern Medical Center
Published: Friday, Sep 21, 2018



Transcript:

Ghassan K. Abou-Alfa, MD:
The novel treatments (the protease inhibitors) that we just heard about in hepatitis C are making a big difference. We know that we can now claim that we have a therapy that can cure hepatocellular carcinoma. However, the willingness to provide everybody with access to the therapy is not 100%. In other words, there is still a group of patients with HCC that is related to hepatitis C.

It also appears that the consumption of alcohol, especially heavy liquor use, among the younger population is still on the rise. We are not yet seeing any change in regard to the number of HCC patients that relates to alcohol. Even though it’s not less, it’s not higher. And lastly, of course, nonalcoholic fatty liver disease, or NASH, is definitely on the rise. Sadly, we have morbid obesity and diabetes, which are leading issues among our population at this point in time.

That said, it’s important to discuss the value of the multidisciplinary team in HCC. We already shared a glimpse of the involvement of many people. Here we have several oncologists, and hepatology is also represented. But of course, there are other disciplines that are really critical in that regard. Ruth, do you go to a disease management team, or a conference, to discuss your patients with HCC on a regular basis? What’s the story there?

A. Ruth He, MD, PhD: Yes, we meet weekly. We have a multidisciplinary team.

Ghassan K. Abou-Alfa, MD: OK.

A. Ruth He, MD, PhD: It’s actually led by the transplant team. The team is composed of radiology, with a very good radiologist who knows how to read liver imaging and interventional radiologists who provide liver-targeted therapy for earlier-stage HCC, medical oncology, hepatology, and the transplant team. Sometimes radiation oncology will be there to provide support for radioembolization. Currently, we do not have a pathologist on board because not all the cases have been biopsied. In the future, we might involve a pathologist as part of our team.

Ghassan K. Abou-Alfa, MD: Fair enough. It’s very important. Manish, do you do the same thing? Do you have a multidisciplinary team that meets on a regular basis? Or how regular?

Manish R. Sharma, MD: Yes. We have a liver tumor clinic, so we see the patients in a multidisciplinary fashion. We also meet weekly, on a regular basis. I do make an effort to attend that meeting because I’m the medical oncology representative there. The other same fields, as Ruth was mentioning, are also present. It really is a critical meeting, especially in instances where the major divide is whether a patient is someone who is a resection or transplant candidate versus not. That’s one of the most important decisions that typically gets made at that meeting. If they’re not a resection or transplant candidate, I know they’re headed my way for systemic therapy. It’s critical to make that decision as a group.

Ghassan K. Abou-Alfa, MD: I totally agree with you. One time I was visiting some colleagues at another institution. Out of curiosity, I asked, “When is your multidisciplinary team for HCC?” They said, “It’s this afternoon.” I said, “Oh, great. We’ll go there.” They said, “Oh, we’re busy in clinic.” I insisted that I go. I went on my own. I’m not kidding when I tell you that patients were referred to hospice care because there was no medical oncologist there to offer therapy. Nowadays, we have more therapies. Of course, there is probably more attention. But in those days, when therapy was really limited or probably barely existent, the thought was rather than have a clinical trial to go there.

To all our colleagues who are medical oncologists, you’ve got to be at that meeting. Don’t let it be run only by the transplant surgeons, by the surgeons, by the interventional radiologists, and the hepatologists. You’ve got to be there. You have a voice that needs to be heard. You can also provide a lot of insight in regard to caring for the patients. So, that definitely is important.

Transcript Edited for Clarity.

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Transcript:

Ghassan K. Abou-Alfa, MD:
The novel treatments (the protease inhibitors) that we just heard about in hepatitis C are making a big difference. We know that we can now claim that we have a therapy that can cure hepatocellular carcinoma. However, the willingness to provide everybody with access to the therapy is not 100%. In other words, there is still a group of patients with HCC that is related to hepatitis C.

It also appears that the consumption of alcohol, especially heavy liquor use, among the younger population is still on the rise. We are not yet seeing any change in regard to the number of HCC patients that relates to alcohol. Even though it’s not less, it’s not higher. And lastly, of course, nonalcoholic fatty liver disease, or NASH, is definitely on the rise. Sadly, we have morbid obesity and diabetes, which are leading issues among our population at this point in time.

That said, it’s important to discuss the value of the multidisciplinary team in HCC. We already shared a glimpse of the involvement of many people. Here we have several oncologists, and hepatology is also represented. But of course, there are other disciplines that are really critical in that regard. Ruth, do you go to a disease management team, or a conference, to discuss your patients with HCC on a regular basis? What’s the story there?

A. Ruth He, MD, PhD: Yes, we meet weekly. We have a multidisciplinary team.

Ghassan K. Abou-Alfa, MD: OK.

A. Ruth He, MD, PhD: It’s actually led by the transplant team. The team is composed of radiology, with a very good radiologist who knows how to read liver imaging and interventional radiologists who provide liver-targeted therapy for earlier-stage HCC, medical oncology, hepatology, and the transplant team. Sometimes radiation oncology will be there to provide support for radioembolization. Currently, we do not have a pathologist on board because not all the cases have been biopsied. In the future, we might involve a pathologist as part of our team.

Ghassan K. Abou-Alfa, MD: Fair enough. It’s very important. Manish, do you do the same thing? Do you have a multidisciplinary team that meets on a regular basis? Or how regular?

Manish R. Sharma, MD: Yes. We have a liver tumor clinic, so we see the patients in a multidisciplinary fashion. We also meet weekly, on a regular basis. I do make an effort to attend that meeting because I’m the medical oncology representative there. The other same fields, as Ruth was mentioning, are also present. It really is a critical meeting, especially in instances where the major divide is whether a patient is someone who is a resection or transplant candidate versus not. That’s one of the most important decisions that typically gets made at that meeting. If they’re not a resection or transplant candidate, I know they’re headed my way for systemic therapy. It’s critical to make that decision as a group.

Ghassan K. Abou-Alfa, MD: I totally agree with you. One time I was visiting some colleagues at another institution. Out of curiosity, I asked, “When is your multidisciplinary team for HCC?” They said, “It’s this afternoon.” I said, “Oh, great. We’ll go there.” They said, “Oh, we’re busy in clinic.” I insisted that I go. I went on my own. I’m not kidding when I tell you that patients were referred to hospice care because there was no medical oncologist there to offer therapy. Nowadays, we have more therapies. Of course, there is probably more attention. But in those days, when therapy was really limited or probably barely existent, the thought was rather than have a clinical trial to go there.

To all our colleagues who are medical oncologists, you’ve got to be at that meeting. Don’t let it be run only by the transplant surgeons, by the surgeons, by the interventional radiologists, and the hepatologists. You’ve got to be there. You have a voice that needs to be heard. You can also provide a lot of insight in regard to caring for the patients. So, that definitely is important.

Transcript Edited for Clarity.
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