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Global Multidisciplinary Care in HCC

Panelists: Ghassan K. Abou-Alfa, MD, Memorial Sloan Kettering Cancer Center; Richard S. Finn, MD, Geffen School of Medicine at UCLA; Masatoshi Kudo, MD, PhD, Kindai University Faculty of Medicine; Arndt Vogel, MD, Hannover Medical School
Published: Friday, Jul 27, 2018



Transcript: 

Ghassan K. Abou-Alfa, MD: This brings me to another component that I would love to hear also the international perspective on. And, if anything, we always talk about multidisciplinary management of HCC because, at the end of the day, it’s 2 problems: the cancer and the liver disease. Tell us, Dr. Kudo, how does it work in Japan? How do you meet, or how do you interact, in regard to different displays?

Masatoshi Kudo, MD, PhD: Yes. In Japan, it’s a little bit different from other countries because hepatologists—I’m a hepatologist—do radiofrequency ablation and TACE. And, of course, interventional radiologists also perform TACE. And systemic therapy is done by hepatologists because there are a few oncologists in Japan. So, of course, we have a multidisciplinary meeting with the surgeon, the radiologist, and the hepatologist. In my hospital, there is no liver cancer specialist oncologist.

Ghassan K. Abou-Alfa, MD: I have to say, that’s really impressive. If anything, it’s not really Japan. It’s also specifically you. You’re amazing. You really have a lot of expertise in all of those disciplines per se. But let’s see, what about on your part, like how does it go in Germany?

Arndt Vogel, MD: I think if you ask an oncologist or a hepatologist and ask anybody who treats HCC, I think everybody will most likely say that all decisions are made by the multidisciplinary tumor board. So, I think we all agree with it. I think it’s more the question, maybe we have to address more, on the quality of the multidisciplinary tumor board, and I think this is really important and we really need to make the point here that if you discuss a patient, all disciplines that are around the table need to be somehow experienced or experts in their respective fields. If you do not have a good liver surgeon, it’s really difficult to discuss liver surgery. So, I think this is an important point, and this is also one of the reasons why I still think, specifically in the beginning, these patients really need to be discussed in a tumor board where we have very experienced colleagues. And the other point is they should not only be discussed at the beginning of treatment, but also later on. Once you have done a treatment, you need to decide whether you can continue, whether you need to switch treatment and how long you do any specific treatment. So, I think these are 2 important points. First of all, the quality of the tumor board and then that you really need to repeat the discussion while you’re on treatment.

Ghassan K. Abou-Alfa, MD: Actually, you bring a very important point. I’m going to touch it again when we talk a little bit more about staging. But let me talk or ask Rich. I would love to hear about UCLA’s multidisciplinary management of HCC. How does it work?

Richard S. Finn, MD: Well, as Arndt commented, we do have expertise in these areas, and it’s not only biliary surgery; it’s actually having a transplant surgeon, right? Because transplant plays such an important role and it’s important having interventionalists who are experts in their field, whether it’s just percutaneous or TACE. And so, we do get together about every other week. We review the cases. Generally, with the more challenging cases where there’s more doubt as to what the best thing to do is, it’s just not practical to look at every single liver cancer case, especially when there are clear guidelines where there isn’t really that much of a question. The patient is well compensated, has a tumor that can be resected, that patient should be resected. A patient who has extrahepatic spread, that’s clearly an advanced patient and who needs systemic treatment. But we do have lively debate for those gray areas because, in reality in liver cancer and as we’ll probably discuss over the day, there are areas where there aren’t data. When there are data, it’s very easy to make decisions. It’s where we don’t have clean data that expert opinion and resources come into play.

Ghassan K. Abou-Alfa, MD: I hear you loud and clear. If anything, we’re going to talk about staging. And interestingly, in BCLC, if we were to really call it white-and-black in regard to what we’re looking at, the gray zones are really the problem, the in-betweens, and you’re absolutely right in that regard. But if anything, we can see here that maybe yes, we differ across the different countries, different continents in regard to how we do the multidisciplinary team. But I think the spirit is still there. Because as we heard from everybody, understandably, we take the opinions and the views of the different expertise to make sure that all the necessary inputs are given to make sure we deliver the right care for the patients. If anything, I refer here to a beautiful paper that was written by Hashem El-Serag a while ago where he pretty much said that patients who are seen by all disciplines are the ones who do better regardless. And this really will again focus about the need for the multidisciplinary team per se.

Transcript Edited for Clarity 

Brought to you in part by Eisai

 

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Transcript: 

Ghassan K. Abou-Alfa, MD: This brings me to another component that I would love to hear also the international perspective on. And, if anything, we always talk about multidisciplinary management of HCC because, at the end of the day, it’s 2 problems: the cancer and the liver disease. Tell us, Dr. Kudo, how does it work in Japan? How do you meet, or how do you interact, in regard to different displays?

Masatoshi Kudo, MD, PhD: Yes. In Japan, it’s a little bit different from other countries because hepatologists—I’m a hepatologist—do radiofrequency ablation and TACE. And, of course, interventional radiologists also perform TACE. And systemic therapy is done by hepatologists because there are a few oncologists in Japan. So, of course, we have a multidisciplinary meeting with the surgeon, the radiologist, and the hepatologist. In my hospital, there is no liver cancer specialist oncologist.

Ghassan K. Abou-Alfa, MD: I have to say, that’s really impressive. If anything, it’s not really Japan. It’s also specifically you. You’re amazing. You really have a lot of expertise in all of those disciplines per se. But let’s see, what about on your part, like how does it go in Germany?

Arndt Vogel, MD: I think if you ask an oncologist or a hepatologist and ask anybody who treats HCC, I think everybody will most likely say that all decisions are made by the multidisciplinary tumor board. So, I think we all agree with it. I think it’s more the question, maybe we have to address more, on the quality of the multidisciplinary tumor board, and I think this is really important and we really need to make the point here that if you discuss a patient, all disciplines that are around the table need to be somehow experienced or experts in their respective fields. If you do not have a good liver surgeon, it’s really difficult to discuss liver surgery. So, I think this is an important point, and this is also one of the reasons why I still think, specifically in the beginning, these patients really need to be discussed in a tumor board where we have very experienced colleagues. And the other point is they should not only be discussed at the beginning of treatment, but also later on. Once you have done a treatment, you need to decide whether you can continue, whether you need to switch treatment and how long you do any specific treatment. So, I think these are 2 important points. First of all, the quality of the tumor board and then that you really need to repeat the discussion while you’re on treatment.

Ghassan K. Abou-Alfa, MD: Actually, you bring a very important point. I’m going to touch it again when we talk a little bit more about staging. But let me talk or ask Rich. I would love to hear about UCLA’s multidisciplinary management of HCC. How does it work?

Richard S. Finn, MD: Well, as Arndt commented, we do have expertise in these areas, and it’s not only biliary surgery; it’s actually having a transplant surgeon, right? Because transplant plays such an important role and it’s important having interventionalists who are experts in their field, whether it’s just percutaneous or TACE. And so, we do get together about every other week. We review the cases. Generally, with the more challenging cases where there’s more doubt as to what the best thing to do is, it’s just not practical to look at every single liver cancer case, especially when there are clear guidelines where there isn’t really that much of a question. The patient is well compensated, has a tumor that can be resected, that patient should be resected. A patient who has extrahepatic spread, that’s clearly an advanced patient and who needs systemic treatment. But we do have lively debate for those gray areas because, in reality in liver cancer and as we’ll probably discuss over the day, there are areas where there aren’t data. When there are data, it’s very easy to make decisions. It’s where we don’t have clean data that expert opinion and resources come into play.

Ghassan K. Abou-Alfa, MD: I hear you loud and clear. If anything, we’re going to talk about staging. And interestingly, in BCLC, if we were to really call it white-and-black in regard to what we’re looking at, the gray zones are really the problem, the in-betweens, and you’re absolutely right in that regard. But if anything, we can see here that maybe yes, we differ across the different countries, different continents in regard to how we do the multidisciplinary team. But I think the spirit is still there. Because as we heard from everybody, understandably, we take the opinions and the views of the different expertise to make sure that all the necessary inputs are given to make sure we deliver the right care for the patients. If anything, I refer here to a beautiful paper that was written by Hashem El-Serag a while ago where he pretty much said that patients who are seen by all disciplines are the ones who do better regardless. And this really will again focus about the need for the multidisciplinary team per se.

Transcript Edited for Clarity 

Brought to you in part by Eisai

 
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