Liver Cancer

DIAGNOSIS

Hepatocellular carcinoma (HCC) is usually diagnosed through screening program to detect early HCC using ultrasounds every 6 months in people with cirrhosis. Once a lesion has been identified, the diagnosis of HCC is made on the presence of characteristic features of an HCC using dynamic imaging tests such as CT and MRI with contrast that should confirm the diagnosis in a patient deemed to be at risk of the disease.

Patients diagnosed with HCC should be managed by a multidisciplinary team involving hepatologists, surgeons, radiologists (including interventional radiologists), pathologists, and oncologists. Multidisciplinary expert care can improve outcomes for patients with HCC.

PREVENTION

Primary prevention focus on risk factors for HCC and their treatments. To prevent the complications of chronic HBV infection, the World Health Organization (WHO) recommends to include hepatitis B vaccination in routine immunization services in all countries. Another essential strategy to prevent HCC related to chronic viral hepatitis is testing blood products for HBV and HCV, as well as adoption of universal precautions to avoid transmission of blood-born viruses in healthcare settings. Chronic Alcoholic Liver Disease (ALD) has become one of the leading risk factors for HCC with the special challenge as these patients are frequently missed by surveillance programs, resulting in advanced tumor stages at the time of diagnosis. Early diagnosis of ALD is important to encourage alcohol abstinence to minimize the progression of liver fibrosis, and manage cirrhosis-related complications including HCC. NAFLD/NASH are considered to be caused by the “western” lifestyle, such as unhealthy diet and sedentary culture. To reduce risk of non-alcoholic fatty liver disease it is advised to adopt a healthy diet rich in fruits, vegetables, whole grains and healthy fats, exercise regularly and maintain a healthy weight. This lifestyle intervention may serve as HCC prevention. HCC surveillance enables early detection and increases the chance of potentially curative treatment; therefore, broad implementation of HCC surveillance in high-risk patients is essential to reduce the high mortality from HCC.

Hepatocellular carcinoma (HCC)

Hepatocellular carcinoma (HCC) is one of and also the most common type of liver cancer. Other types of liver cancer – intrahepatic cholangiocarcinoma and hepatoblastoma, are much less common. HCC is considered to be one of the leading causes of cancer-related deaths worldwide. It is associated with liver cirrhosis in western populations, but can occur in non-cirrhotic liver tissue, especially in eastern populations with hepatitis B virus (HBV) infection.

POSSIBLE SYMPTOMS

Most people don’t exhibit symptoms in the early stages of HCC. However, when signs and symptoms do appear, they might be related to cancer or to chronic liver disease.

RISK FACTORS

The risk of hepatocellular carcinoma is higher in people with cirrhosis caused by infection with HBV, HCV, alcohol abuse or accumulation of fat in the liver (NAFLD/NASH). Chronic liver disease due to HBV or HCV or alcohol accounts for the majority of HCC cases, whilst the incidence of non-alcoholic fatty liver disease, has been rising and it is also associated with the development of HCC.

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SURVEILLANCE

The decision to enter a patient into a surveillance programme is determined by: The risk of having HCC Always considering different factors in each case (age, co-morbidities etc.) Surveillance is recommended for: Patients with cirrhosis (irrespective of the etiology) Patients with hepatitis B but no cirrhosis, in whom the annual incidence of HCC is more than 0,2% Preferred test for surveillance is ultrasonography and screening of patients is recommended every 6 months.

PROGNOSTIC MODELS AND HCC STRATIFICATION

Barcelona Clinic Liver Cancer (BCLC) is the most used prognostic model of HCC. This classification categorizes prognosis of HCC in 5 groups and guide the management of hepatocellular carcinoma. Barcelona-Clinic Liver Cancer (BCLC) staging, risk assessment classification and treatment schedule. Five stages are considered: Stage 0, A: Patients with early HCC are suitable for curative therapies: resection, liver transplantation, or percutaneous treatments (such as RFA) Stage B: patients at intermediate HCC stage, may benefit from TACE, Transarterial chemo-embolization Stage C: patients at advanced HCC stage, may receive new systemic agents recently approved or drugs in the setting of RCT Stage D: patients with end-stage disease will receive symptomatic treatment


CURRENT TREATMENT MODALITIES

Treatments of hepatocellular carcinoma include, in early stages 0 or A: Resection (removing the cancer and a part of healthy tissue that surrounds it) Liver transplant surgery (remove the entire liver and replace it with a liver from a donor, cadaveric or living donor) Destroying cancer cells with heat or cold (ablation) If the HCC is classified as intermediate stage, treatment is named loco-regional and include: Delivering chemotherapy or radiation directly to cancer cells (TACE, Trans arterial chemo-embolization or similar) In more advanced HCC stages, treatment will be systemic such as: Targeted drug therapy. Targeted drugs, such as sorafenib, regorafenib, nivolumab etc. may help slow the progression of the disease in people with advanced liver cancer. In addition, psychological burden of end-stage HCC should not be neglected or underestimated! Due to the HCC characteristics, patient has two diseases, cirrhosis and cancer and the treatment usually will be escalating through the stages. Patients care would consist of a multidisciplinary team, to improve management, assess and optimize risks. HCC FROM PATIENTS’ AND FAMILIES’ PERSPECTIVE Liver cancer is often associated with drug or alcohol abuse, which creates a stigma, although that is no longer the case for a large percentage of people, who develop HCC. Patients’ and families’ experiences with HCC are connected to 4 major themes: Theme 1: Illness perceptions. The perceptions of HCC covered a broad spectrum, highlighted by a lack of information to prepare them for “the journey ahead,” feelings of isolation, and unrealistic hopes. In addition, the feeling of lack of control over HCC, and the treatment of HCC in particular, impacts patients and family lives. Theme 2: Uncertainty about treatments over time, struggle with symptoms management, and questioned or regretting receiving, or not receiving the treatment. Theme 3: Quality of life. Symptoms are affecting everyday life and many patients believe that their quality of life was compromised by the side effects. Theme 4: Coping strategies. Patients experienced a range of reactions to their diagnosis and develop their own ways of coping.


THE ROLE OF LIVER PATIENTS' ASSOCIATIONS

The role of Liver Patients´ Associations in HCC, is crucial and it is based on updated and scientific information especially focused on prevention, since nobody would be better than another patient to inform his peers. Patients´ associations are a key element in this field, informing in a closer way, with the language that patients understand better. The message has to be clear, saying that we cannot play with health and we cannot rely on messages that can be found on the Internet or hear from neighbour ... Patients´ associations have to be involved in training patients, in making them see that it is not free to make these types of decisions, to use indiscriminately which are based on information from doubtful sources and that is a very important task for patients´ representatives to do. Based on ELPA’s experience we are aware of the importance of social media to expand medical information. Patients are actively seeking medical knowledge in social media and are exposed to health-related content through these platforms. Social media present an opportunity for patient education. The intersection of social media and health is unique, given its influence potential on public health. Considering patients´ perspective, social media may provide adequate context to disseminate updated information. Health education on social media could influence public health by improving health literacy, dispelling misconceptions and disinformation from inaccurate sources.
References: Bruix. Gastroenterology. 2016;150:835. Living with hepatocellular carcinoma from the patient perspective: a longitudinal study, Hansen L, Vaccaro GM, Rosenkranz SJ, et al., J Clin Oncol. 2014;32(suppl 3). Abstract 373. Presented at: 2014 Gastrointestinal Cancers Symposium; January 16-18, 2014; San Francisco, California. Prevention of Hepatocellular Carcinoma, Kerstin Schütte b Fathi Balbisi a Peter Malfertheiner, Gastrointest Tumors 2016;3:37–43. Review of hepatocellular carcinoma: Epidemiology, etiology, and carcinogenesis, Yezaz Ahmed Ghouri, Idrees Mian, and Julie H. Rowe, MD, Journal of Carcinogenesis 2017; 16: 1. Risk factors and prevention of hepatocellular carcinoma in the era of precision medicine, Naoto Fujiwara, Scott L. Friedman, Nicolas Goossens, Yujin Hoshida, Journal of Hepatology 2018 vol. 68 j 526–549 Serper. Gastroenterology. 2017;152:1954. Social media and medicine, Austin L. Chiang, Jama 2020;17:256-257