Ghassan K. Abou-Alfa, MD
The incidence of liver cancer in the United States has risen sharply since 1980, with the American Cancer Association reporting an approximate annual increase of 3% in women and 4% in men from 2004 to 2013.1
Liver cancer remains difficult to cure, and the mortality rate from liver cancer has increased an estimated 3% each year between 2010 and 2014. The 5-year survival rate for early-stage liver cancer is only 31%, which decreases to 3% for liver cancer with distant metastases.2
Limited options are available to treat advanced disease. A panel of experts discussed standard treatments for early-stage and advanced liver cancer during a recent OncLive
program moderated by Ghassan K. Abou-Alfa, MD. They also reviewed investigational second-line therapies and expressed optimism that some of these therapies may one day improve outcomes for patients.
Early-Stage Liver Cancer
The treatment of liver cancer requires a multidisciplinary approach. “More so than many other cancers, we really rely on our colleagues across disciplines in hepatology, radiation, [and] surgery,” R. Kate Kelley, MD, said. Standard treatment for early-stage liver cancer is typically surgical resection or liver transplantation.3
Richard S. Finn, MD, said that resection should be considered before transplant, which he described as a last resort, adding that the presence of underlying liver disease may be a deciding factor when choosing between resection or transplant.
“Practicing in the United States, we see a lot of patients who have hepatitis C. Unfortunately, by the time they develop liver cancer, many of them have less compensated cirrhosis, in which case transplant is a better option,” Finn said. In contrast, patients with hepatitis B typically have better liver function at diagnosis and may not need a transplant.
Laura M. Kulik, MD, noted that for many patients, “[transplantation] is the only potentially curative option.” She said when the patient’s tumor is too large (>5 cm) or the patient has too many tumors for transplant, she attempts to downstage the disease. Kulik explained down-staging involves using arterial-directed therapies, such as transarterial chemoembolization or transarterial radioembolization with yttrium-90 (Y-90) microspheres, to shrink the tumor to <5 cm. Arterial-directed therapies are generally contraindicated for patients with main portal vein thrombosis and Child-Pugh Class C liver function.3
Kulik said 5 cm is the cutoff for transplant because “once you start reaching a tumor burden of 5 cm, there’s about a 50% chance that you’re going to have vascular invasion present and explant, which has the highest chance of recurrence,” Kulik said.
“Transplant is really aimed at the sick liver...a sick liver means that you can’t resect it,” Abou-Alfa said. He highlighted the controversy over whether to pursue resection or transplant for resectable patients with Child-Pugh Class A liver function.3
“Some people will argue that transplant should be a first indication, as well,” he noted.
Riad Salem, MD, the panel’s only radiologist, noted that radiofrequency ablation (RFA) is increasingly being recognized as a potentially curative option. Radiofrequency ablation is a low-risk, minimally invasive treatment that used to be reserved for patients whose liver cancer was unresectable or who were unable to receive a transplant.4
However, Salem said that because RFA allows for ablation of a small area of the liver without the risks associated with surgical resection, “ablation has now been moved way ahead of resection for small lesions in the guidelines.”