By Annette M. Boyle
CHICAGO — At the Jesse Brown VAMC in Chicago, a multidisciplinary team approach to evaluating and treating veterans with hepatocellular carcinoma (HCC) has reduced wait times for treatment and dramatically improved care to veterans.
Starting about two and half years ago, the team brought together specialists in surgical oncology, interventional radiology and hepatology to ensure patients diagnosed with HCC did not waste time waiting for appointments for treatment.
“Previously, patients would be diagnosed, then sit around a month or two before treatment. In that interval, their tumors would grow or their underlying liver disease would worsen, preventing them from receiving appropriate therapies. Now, the time from diagnosis to treatment has been reduced to just two to three weeks,” Ramona Gupta, MD, chief of interventional radiology at the Jesse Brown VAMC, told U.S. Medicine.
Their “virtual conference” process is very straightforward. When the hepatologists, Sean Koppe, MD, or Anne Henkel, MD, diagnose a patient with HCC, they send an email to Gupta and ask her to review the MRI. She forwards those patients that may be appropriate candidates for resection to David Bentrem, MD, a surgical oncologist. Patients eligible for resection then proceed to surgery.
The team determines the most appropriate treatment for the remainder. Many of them return to Gupta and the interventional radiology (IR) service for transarterial chemoembolization using drug eluting beads (DEB-TACE) or radiofrequency ablation (RFA). For those with the largest tumors or other comorbidities that contraindicate IR treatment, sorafenib may be recommended. Typically, the entire review process takes less than a week.
“Over the last two years, the program has gained a lot of momentum. We now deliver the same quality of care as you would find in the best hospitals around the country, and in a timely fashion. It’s what our veterans deserve,” Gupta said.
Need for Treatment
Streamlining treatment for HCC has implications across the VA. Liver cancer is the fifth most common cause of cancer death for men in the country and the ninth most common for women. The disease occurs primarily among patients with cirrhosis and has increased within the VA as the large cohort of veterans infected with hepatitis C virus (HCV) has aged. Up to 12% of Vietnam-era veterans test seropositive for HCV.
From 2000 to 20007, the number of veterans with cirrhosis in care in the VA system increased by 250%, while the number of cases of HCC rose fivefold. Furthermore, patients with liver cancer have a poor prognosis. The five-year survival rate is only 15%, making it second only to pancreatic cancer (at 6%) in terms of mortality.
Resection and transplantation can cure HCC, but, because the cancer typically develops silently, many patients have tumors that exceed the recommendations for surgery upon diagnosis. Others might have comorbidities or tumor locations that preclude surgery. Only 10% of patients on the transplant list ever receive new livers because of the shortage of donor organs.
TACE offers a relatively appealing option to many patients. “It’s a minimally invasive, targeted treatment. Using angiography, we find the artery feeding the tumor and deliver chemotherapy directly, so patients avoid the terrible systemic effects associated with traditional chemotherapy,” said Gupta. Patients can go home the following day.
DEB-TACE involves injecting microspheres soaked in a cytotoxin such as doxorubicin through the hepatic artery into the tumors. The beads slowly release the chemotherapeutic agent and embolize the tumor’s vessels. Surrounding tissue remains largely unaffected because of the liver’s dual blood supply. While the hepatitis artery supplies 80% to 100% of blood flow to liver tumors, it provides only 20-30% of blood flow to normal liver tissue. The portal vein supplies the balance.
As a result of the focused review and treatment process, many more patients receive the DEB-TACE treatment. According to Gupta, before the team developed the multidisciplinary review, five to eight patients per year received TACE at Jesse Brown. The interventional radiology group projects it will treat 50 patients in 2013.
For patients who fall just outside the guidelines for surgery, TACE may reduce tumor size sufficiently to qualify for resection or transplantation. Gupta estimates that 75% to 80% of patients respond partially or completely to the therapy, although some require multiple treatments. Treatment guidelines recommend as many as four treatments in a six-month period.
“Some tumors respond so well that no further treatment is needed. We review at one month. If we see nothing, we screen at three-month intervals. If clear after two years, we may further increase the screening interval,” Gupta said.
Tumor size largely determines the effectiveness of interarterial treatment. According to the VA’s Provider Review for Hepatitis, studies have found a 100% survival rate at three years following TACE for tumors less than 2 cm in diameter. Recent prospective randomized trials have found a median survival of more than 43 months for HCC patients receiving DEB-TACE treatment.
Replicating the coordinated approach to diagnosis and treatment of HCC adopted at Jesse Brown could make a substantial difference in treatment of the disease across the VA, based on a recent study in Hepatology. That study found that 37% of veterans with HCC were diagnosed during a hospitalization and only 34% received any treatment for the disease. Only 31% of patients diagnosed with HCC were evaluated by a surgeon or oncologist.1
The study used the VA Hepatitis C Clinical Case Registry to identify 1,296 patients who developed HCC from 1998 to 2006 and sought treatment at one of 128 VA healthcare facilities. The researchers manually reviewed all potential HCC cases and determined the Barcelona Clinic Liver Cancer (BCLC) stage at diagnosis.
Of the patients most likely to benefit from therapy (BCLC stages A through C), 40% received treatment. HCC surveillance correlated with diagnosis of cancer at an earlier stage and in an outpatient setting. Patients diagnosed in outpatient clinics, however, were less likely to receive HCC treatment. The authors noted that “this finding indicates a breakdown in the timely identification of HCC diagnosis, patient recall and subsequent referral.”
The authors suggested that “physician bias regarding the perceived ineffectiveness of HCC treatment or lack of knowledge about currently available treatment options” might explain the low rates of referral. They concluded, though, that “given the increasing number of effective HCC-specific treatments now available for patients with HCC, all patients irrespective of stage should be seen by a specialist for formal treatment evaluation.”
1 Davila JA, Kramer JR, Duan Z, Richarson PA, Tyson GL, et al. Receipt of Treatment for Hepatocellular Carcinoma in United States Veterans: Effect of Patient and Nonpatient Factors. Hepatology. 2013. 57(5):1858-1868.