July 14, 2017
Hepatocellular carcinoma (HCC) is the most common primary liver cancer in the United States and the leading cause of death in patients with cirrhosis. Hepatitis C infection currently accounts for about 50 percent of cases of HCC. As those numbers decline, the growing burden of obesity, diabetes and nonalcoholic fatty liver disease will likely continue to drive increases in chronic liver disease and liver cancer.
Despite the need for early and effective treatment for HCC, many patients not only lack access to novel cancer therapies but also to basic coordinated care. A survey of primary care physicians published in Clinical Gastroenterology and Hepatology in 2015 found that only half of physicians who saw patients with cirrhosis screened for HCC, and many were unable to identify effective liver cancer therapies.
Lewis R. Roberts, M.B., Ch.B., Ph.D., a researcher and clinician specializing in hepatic and biliary cancers at Mayo Clinic's campus in Minnesota, says another barrier to quality care is a fragmented health care system where patients often wait months for a diagnosis.
"By the time patients come to us, they are quite frustrated because their first imaging study was two or three months ago, and it took that long to get to the point where they are starting to be evaluated," he says. "Here, we can accomplish the evaluation in a week or so by having all the necessary systems and procedures in place."
Mayo Clinic's liver cancer clinic in Phoenix, Arizona, also accommodates patients quickly, according to Thomas J. Byrne, M.D., a hepatologist specializing in liver disease and transplantation.
He explains: "Typically, patients rotate from radiology studies, consultations with hepatologists, subsequent consultations with surgeons or interventional radiologists as well as medical oncologists. It's as if patients have to travel around the perimeter of a large wheel, visiting each spoke in a process that plays out over a fairly lengthy period of time. Our goal is to place the patient at the center of the wheel and have each of the individual specialties involved in care converge in the center on a single day of clinic."
The same efficient, multidisciplinary approach extends to evaluation of indeterminate hepatic lesions, selected neuroendocrine malignancies that have spread to the liver and cholangiocarcinoma, which can present a particular diagnostic challenge, especially in the setting of primary sclerosing cholangitis.
"Our radiologists are highly experienced in imaging liver and biliary tract tumors and are often able to achieve a diagnosis without the need for biopsy," Dr. Roberts says. "When biliary stenosis remains indeterminate after MRI or CT, we may recommend endoscopic retrograde cholangiopancreatography or endoscopic ultrasound followed by fluorescence in situ hybridization, which has been shown to improve tumor detection compared with conventional cytology."
Surgery is the preferred treatment for most resectable primary liver tumors as well as for a small number of colorectal liver metastases (CLM). At Mayo Clinic's campus in Minnesota, about 15 to 20 percent of patients with CLM are eligible for potentially curative surgical resection, including those with multiple bilobar lesions and extrahepatic disease. In such cases, tumors may first be downsized with radiation or chemotherapy.
Patients who are not candidates for resection because of tumor size, location or inadequate liver reserve, are reviewed at a multidisciplinary liver imaging review conference in which a variety of specialists generate a care plan that can usually be executed within one to two weeks, Dr. Byrne says. These patients may be offered locoregional therapies, including transarterial chemoembolization or radiofrequency ablation, which, depending on tumor size and location, may have near-equivalence to surgery.
As a three-site institution, Mayo Clinic has the highest volume of liver transplants in the nation with consistently excellent graft and patient survival outcomes. Waitlist outcomes are also excellent. In 2015, the number of waitlist transplants at Mayo Clinic hospitals in Florida and Arizona was statistically higher than expected, and waitlist mortality was half the national average, according to Scientific Registry of Transplant Recipients data.
"We have a demonstrably unique ability to take care of patients before, during and after transplant, including those with cholangiocarcinoma," says Denise M. Harnois, D.O., a specialist in liver disease, hepatobiliary cancer and liver transplantation at Mayo Clinic's campus in Jacksonville, Florida. "Mayo Clinic in Florida has one of the largest transplant programs in the world, and 20 to 30 percent of our patients are transplanted with a hepatobiliary malignancy. With adherence to a protocol of neoadjuvant chemoradiation originally developed at Mayo Clinic, these patients currently have a 70 percent survival rate of one to three years. Our outcomes are among the best in the southeastern United States as well as nationally."
Dr. Roberts stresses the close collaboration that takes place among the three Mayo transplant programs in clinical care, research and education."There is a great synergy that happens when transplant groups get together on a regular basis and share best practices," he says.
For more information
McGowan CE, et al. Suboptimal surveillance for and knowledge of hepatocellular carcinoma among primary care providers. Clinical Gastroenterology and Hepatology. 2015;13:799.