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

Abstract

Primary malignancy of the liver or hepatocellular carcinoma (HCC) is unique in its presentation, disease process, and management. Unlike breast or colon cancer, the staging of HCC depends on performance status and baseline liver function along with pathological characteristics. Apart from traditional options like surgery and systemic therapy, effective management can be achieved in selected cases with liver transplant and locoregional therapy (LRT) like transarterial chemoembolization (TACE), transarterial radioembolization (TARE), and ablation. Liver study societies and cancer groups across the globe proposed guidelines to aid the treating physicians in choosing first-line treatment for liver cancer. It is tough to compare these guidelines as they differ not only in treatment recommendations but also in risk assessment (and staging). The approach to the same patient may be different in the country he or she is managed. In clinical practice, decisions are usually taken on the consensus of multidisciplinary tumor boards and do not necessarily adhere to any guidelines. In the early (and very early) stage HCC, curative options like surgery, transplant, and ablation are recommended. In intermediate stage HCC, LRT (TACE and TARE) is preferred in the first line and systemic therapy for treatment failure or residual disease. Systemic therapy, including the atezolizumab/bevacizumab combination and tyrosine kinase inhibitors (TKI) like sorafenib and lenvatinib, is used for advanced stages. Supportive care is advised for terminal stage HCC.

Chemoembolization with Degradable Starch Microspheres (DSM-TACE): expanding indications in HCC multidisciplinary tumor board

“…The adherence of MDTB treatment decisions to guidelines recommendations has been shown to be suboptimal mainly in the case of advanced age, severe comorbidities and strategic tumor localization [77] , but also in relation to differences in the availability of the therapeutic options in every center [78] . The overall rate of guidelines violations may reach 40% [77] and, interestingly, the adherence rate drops with the increasing disease stages to less than 50% in the intermediate and advanced stages, according to an Italian study [79] . Our MDTB, for example, is "non-compliant" with guidelines offering stereotactic body radiotherapy (SBRT) or proton beam therapy (PT) [80] for local HCC ablation in case of contraindications to surgical resection or thermal ablation.…”

Real‐world evidence in hepatocellular carcinoma

“…Clinical guidelines recommend the use of locoregional therapies and surgical resection for the management of early or moderately advanced HCC 28,29 . Numerous real‐world cohort studies have examined the impact of locoregional therapies and/or surgical resection on early stage HCC, and several examples are discussed below 30‐32 .…”

“…Clinical guidelines recommend the use of locoregional therapies and surgical resection for the management of early or moderately advanced HCC. 28,29 Numerous real-world cohort studies have examined the impact of locoregional therapies and/or surgical resection on early stage HCC, and several examples are discussed below. [30][31][32] In a retrospective Australian study of patients with BCLC-0/A, those treated with curative intent had better overall survival and recurrence-free survival than patients receiving transarterial chemoembolization (TACE).…”

Nurses' comfort care of transarterial chemoembolization patients based on their perceptions around postembolization syndrome and symptom interference

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Transarterial chemoembolization (TACE) is a first-line method for treating intermediate-stage hepatocellular carcinoma, wherein a chemotherapeutic drug is injected into a branch of the patient's hepatic artery (Jogi et al, 2020). It also acts as a bridging treatment and is provided to patients who are waiting for a liver transplantation (Coletta et al, 2017).

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