Compliance to the American Association for the Study of Liver Diseases (AASLD) guidelines and its impact on overall survival in patients with hepatocellular carcinoma.

Abstract

e16609 Background: The Barcelona-Clinic Liver Cancer (BCLC) staging based management proposed by AASLD depends on baseline liver function and performance status of the patient in addition to tumor characteristics. Low adherence to AASLD guidelines, especially in advanced staged tumors, can be ascribed to suboptimal revision/updates of the guidelines reflecting the advancements in hepatocellular carcinoma (HCC) management. Here, in addition to the adherence rate, we explored the overall survival of patients with HCC according to first-line treatment modality compliance to AASLD guidelines. Methods: This is a retrospective study conducted at the University of South Alabama/Mitchell Cancer Institute. Between 2017 and 2019, 148 unique treatment-naïve patients with HCC were identified. Patients were staged according to the BCLC staging system and their compliance with suggested first-line treatment modality according to AASLD guidelines was noted. Overall survival was explored and differences between overall survival rates of compliant and non-complaint patients were compared using the log-rank Wilcoxon test. Results: In our cohort, the median age was 72.5 years (range 38-90). Males represented 80%. Caucasians, African Americans, and other ethnicities (e.g. Asians) represented 68%, 30% and 2% respectively. The overall adherence rate was 83%. The adherence rate according to BCLC stage 0, A, B, C and D was 100%, 97%, 77%, 77% and 38% respectively. Compliance vs. non-compliance to AASLD guidelines showed no significant difference in overall survival of patients with BCLC stage 0-A, B and C. In patients with BCLC stage D (N = 13), compared to patients treated in compliance to AASLD guidelines (N = 5), patients treated in non-compliance (N = 8) had better overall survival (2.2 vs. 5.2 months, p = 0.0012). Conclusions: In our cohort, the adherence rate to AASLD treatment guidelines in patients with BCLC stage D was very low at 38%. Lack of adherence in this group of patients translated into better overall survival. The current AASLD guidelines for the management of HCC have several limitations, especially for advanced stages. In the last few years, the FDA approved several tyrosine kinase inhibitors, immune checkpoint inhibitors and the monoclonal antibody, ramucirumab. This expansion generated the need for periodic updates/revisions of consensus guidelines.

Challenges in the Current Management of Hepatocellular Carcinoma

“…Four out of those seven (4/7) CP C patients were treated with ICI (3 Nivolumab & 1 Pembrolizumab). One had a partial response for close to 10 months while the other had stable disease for 5 months, and none of them experienced grade 3/4 adverse events [38] . There are two takeaways from this limited study, (a) close to 50% of patients had PR or SD for a good 4-5months; (b) ICI is tolerable in CP C patients.…”

Selecting the first line treatment in non-metastatic hepatocellular carcinoma - comparing clinical practice guidelines

“…After retrospectively staging the patients based on their PS, CP score, and pathological features, the overall adherence rate (for all stages of HCC) was 83%; the adherence rate of BCLC stage 0, A, B, C, and D was 100%, 97%, 77%, 77%, and 38% respectively. 36 …”

“…After retrospectively staging the patients based on their PS, CP score, and pathological features, the overall adherence rate (for all stages of HCC) was 83%; the adherence rate of BCLC stage 0, A, B, C, and D was 100%, 97%, 77%, 77%, and 38% respectively. 36 The expertise, as well as the preference of the surgeons, availability of TARE, or TACE, which may, in turn, depend on the financial resources (like insurance) and clinical trials, influence the decision making in an MDTB setup. The scarcity of cadaver livers for transplant and also institutes that run such successful programs virtually removes that option from the table in many practices.…”