How to Treat Hepatocellular Carcinoma in Elderly Patients

Abstract

Hepatocellular carcinoma (HCC) is the primary tumour of the liver with the greatest incidence, particularly in the elderly. Additionally, improvements in the treatments for chronic liver diseases have increased the number of elderly patients who might be affected by HCC. Little evidence exists regarding HCC in old patients, and the elderly are still underrepresented and undertreated in clinical trials. In fact, this population represents a complex subgroup of patients who are hard to manage, especially due to the presence of multiple comorbidities. Therefore, the choice of treatment is mainly decided by the physician in the clinical practice, who often tend not to treat elderly patients in order to avoid the possibility of adverse events, which may alter their unstable equilibrium. In this context, the clarification of the optimal treatment strategy for elderly patients affected by HCC has become an urgent necessity. The aim of this review is to provide an overview of the available data regarding the treatment of HCC in elderly patients, starting from the definition of “elderly” and the geriatric assessment and scales. We explain the possible treatment choices according to the Barcelona Clinic Liver Cancer (BCLC) scale and their feasibility in the elderly population.

Outcomes in elderly patients undergoing hepatic resection compared to ablative therapy for hepatocellular carcinoma

“…Surgical outcomes in elderly patients undergoing liver resection are well‐studied in the literature 13‐18 . Cho et al concluded that liver resection could be performed safely in patients aged ≥70 years as in younger patients 19 .…”

“…It is challenging to estimate the risk‐benefit ratio of various treatment options in the elderly population, which has a limited life expectancy and a reduced ability to adapt to physical and psychological stress. This evaluation could be difficult; therefore, we recommend the use of standard performance status scales, which are used daily in clinical practice (such as Karnofsky performance status or Eastern Cooperative Oncology Group performance status) to evaluate surgical candidacy in these patients 14 . Frailty is another parameter that is being extensively utilized in the surgical literature 15,16 .…”

Hepatocellular cancer and colorectal liver metastasis treatment in the older population

“…A systematic review and meta-analysis, published in 2019, showed no significant difference in terms of blood loss, transfusions, liver failure, Clavien-Dindo III/IV complications, postoperative mortality, hospital stay, R0 resection, and operative time between younger and older patients undergoing laparoscopic hepatectomy [29]. Moreover, the minimal invasive approach in HCC cirrhotic patients has also the potential to reduce risk of post-operative liver decompensation and morbidities [30,31]. However, most of the studied patients were evaluated based on chronological age, comorbidities, and physical function -not on the comprehensive geriatric assessment.…”

“…Thanks to improvements in radiological staging, anesthesia, surgical technique (understanding of segmental liver anatomy, parenchymal preserving surgery, bleeding control), and perioperative care it was possible to offer complex liver surgery to older patients. This is particularly important because, more than 60% of patients with primary and secondary liver tumors are older than 65 years at the moment of diagnosis [2].…”

“…The main reason for this situation is still the underrepresentation of older patients in trials regarding liver resection. In the majority of the published studies, only 15-20% of patients were older than 70 years [2]. Therefore, the extrapolation of such results on the geriatric population can lead to inappropriate treatment decisions.…”