Community-based hepatologists can improve patient care by creating their own liver cancer treatment programs. Patients who are eligible for liver transplant must be referred, but only about 8% of hepatocellular carcinoma (HCC) patients actually receive a new liver. The remaining 92% can be managed in the community setting.
“Liver cancer is, and is going to be, a huge problem because we don’t have good therapies,” said Mitchell L. Shiffman, MD, FAASLD, Director, Liver Institute of Virginia (LIV), part of the Bon Secours Health System, during yesterday’s Clinical Practice SIG program. “We talk a lot about referring patients for transplantation, but the reality is that the bulk of care falls on you, the hepatologist, because the bulk of HCC patients will never get a liver transplant.”
Dr. Shiffman opened a community-based liver cancer program in Richmond and Newport News, VA in 2010. In 2017, the practice expects to diagnose 81 new cases of HCC. The most appropriate patients will be referred for transplantation, but most will be managed locally.
The key to creating a successful liver cancer program is to educate, and sometimes reeducate, local providers in appropriate HCC care and to build relationships with nearby transplantation centers, he noted. The entire operation must focus on the goals of therapy for HCC based on tumor stage (T1-4).
Patients with T1 cancer are typically good candidates for surgery or ablation, he explained, while some patients may be allowed to progress to T2 and considered for transplantation. Patients with T2 should be referred for transplantation if they appear to meet eligibility criteria.
Patients with T3 are usually candidates for surgery and/or chemotherapy. There is potential for some patients to be downstaged to T2 using ablation to reduce the tumor burden, but only a minority of downstaging attempts are successful, he said.
Patients with T4 have more limited choices, either chemotherapy or palliative care.
In seven years, LIV has treated 329 HCCs. More than half of patients are diagnosed at a stage that is too advanced for transplant referral.
“The problem is early diagnosis,” Dr. Shiffman said. “The only way to diagnose early is to routinely screen all high risk patients, which is anyone with cirrhosis. Nonhepatologists are generally not familiar with HCC risk factors and need your help. You have to educate the community because many do not handle these issues properly.”
Radiologists, for example, may not realize that biopsy is not needed to diagnose HCC. MRI and CT are sufficient in more than 90% of patients. Surgeons may not realize T2 patients are preferred candidates for transplant and should not have their tumors removed. Surgical efforts are most effective for patients with T1, T3 and T4 tumors. He said oncologists may rush to chemotherapy for T3 patients who might be downstaged to T2 using ablation, which could make them eligible for transplant. But once it become clear that downstaging will not work, chemo can begin immediately.
“You’ve got to educate the players and get them on your ship,” Dr. Shiffman said. “It is clearly appropriate to operate or deliver chemo to some patients, but not to those who are good candidates for transplant.”
He likened an HCC program to a ship. The hepatologist is the captain, who depends on the services and consults from radiologists, oncologists, surgeons and liver transplant programs. The entire operation is coordinated by a navigator, typically a nurse, who coordinates communication and referrals.
It is also essential to establish relationships with nearby transplant centers before you need them.
“The optimal and only curative therapy for HCC is transplant,” he added. “You want to do treatment locally, but you can’t do transplants locally.”