Multidisciplinary Treatment Strategies for Hepatocellular Carcinoma - Episode 1
Transcript:Ghassan K. Abou-Alfa, MD: We’ve entered a new era in the field of gastrointestinal oncology, particularly in treating advanced hepatocellular carcinoma [HCC] for which we have several new treatment options. Along with this exciting progress that we’ve experienced for treating HCC comes increased complexity surrounding the optimal use of available agents.
The goal of this OncLive® Peer Exchange® discussion, with a panel of multidisciplinary experts, is to provide clarity and perspective on the latest clinical data, and practical advice on how new information applies to the clinic.
I am Dr. Ghassan Abou-Alfa, medical oncologist at Memorial Sloan Kettering Cancer Center, and professor of medicine at Weill Medical College of Cornell University in New York, New York.
Today I am joined by my colleagues Dr. Farshid Dayyani, associate professor in the Division of Hematology and Oncology, Department of Medicine, at the University of California Irvine School of Medicine in Orange, California.
Dr. Katie Kelley, associate professor of clinical medicine in the Division of Hematology and Oncology, Department of Medicine at the University of California San Francisco and Helen Diller Family Comprehensive Cancer Center in San Francisco, California.
And Dr. Amit Singal, medical director of the Liver Tumor Program and clinical chief of hepatology at the University of Texas Southwestern Medical Center in Dallas, Texas.
Thank you for joining us, and let’s begin.
This is an incredible time for HCC. We say it’s an incredible time because we have so many drugs—we’re going to talk about all of them. It’s also an incredible time because it appears to be that the understanding of liver cancer is not really as we thought it might be. So, Amit, I’ll start with you. How common is liver cancer in the United States?
Amit Singal, MD: When you think about HCC, it’s really a global problem. This is the fourth leading cause of cancer-related death. In the United States, it’s about the ninth leading cause right now. When you take a look over the last 10-year period assessed by SEER [Surveillance, Epidemiology, and End Results Program], HCC has the largest rise in all solid tumors in terms of incidence and mortality.
Ghassan K. Abou-Alfa, MD: Incredible. And, of course, the question is why? Can you tell us why people get liver cancer?
Amit Singal, MD: The most common risk factor in the United States is actually the presence of cirrhosis. Cirrhosis is the end stage result of any chronic liver injury. So the most common causes that we see are chronic hepatitis C [HCV], alcohol, and the not-so-new kid on the block any more, nonalcoholic fatty liver disease—the liver manifestation of the metabolic syndrome; this goes along with obesity and diabetes. So as you have chronic liver disease, you develop scar tissue, which is cirrhosis at the end stage, and then once you develop cirrhosis, you have about a 2% to 3% annual risk of developing HCC.
Ghassan K. Abou-Alfa, MD: Farshid, along the lines of what Amit told us about the risk factors to develop HCC, from your perspective as an oncologist, what do your patients have as a risk factor in regards to ACC [acetyl-CoA carboxylase] that you’ve seen?
Farshid Dayyani, MD: I think what we see, what Amit properly said, is that globally it’s a huge issue. In terms of etiology, hepatitis B [HBV] is more of a global problem in Eastern Asia and Southern Africa, and here in the United States more HCV and non-alcoholic liver disease. Where I practice in Orange County, California, we have a very large Asian and Hispanic population, and those are 2 of the populations with the highest rates of HCC incidence. So for us, the problem is very acute. We have a large population of HCV-related cancers and liver cancers, and I think if you look at the projections over the next 10 years in the United States with the baby boomers and high rates of HCV, that’s one of the reasons I think that HCC will continue to be on the rise.
Ghassan K. Abou-Alfa, MD: Fair enough. Katie, is liver cancer from hepatitis B, versus hepatitis C, versus alcohol, versus NASH [Non-Alcoholic SteatoHepatitis] a different disease? In other words, do you really recommend to our colleagues who are listening to us that they need to understand the risk factors for a specific patient?
Katie Kelley, MD: That’s a great question. I think there are certainly biological differences in how these cancers arise. We don’t fully understand the genetic underpinnings of how one virus causes liver cancer compared to another. But I think there are some key differences that relate to the underlying liver disease itself. One of the points that Amit already touched upon is that cirrhosis, or fibrosis, is usually an underpinning of most liver cancers, but there are a couple of exceptions, including viral hepatitis B, where the virus itself can directly integrate into a hepatocyte, and in turn cause cancer without any precursor fibrosis or cirrhosis.
I believe that we’ve also seen this happen in some NASH cases as well as in non-alcoholic fatty liver disease, where one can go straight from a metabolic insult without appreciable fibrosis or fibrosis, or cirrhosis, and get cancer. I think this tells us that we really need to understand the health of the liver underlying the cancer. One of the directions in the next decade of research will be to really understand how these tumors are different.
Transcript Edited for Clarity