‘Not simply a hand-off’: GIs, hepatologists have critical role in HCC care after diagnosis
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The role of gastroenterologists and hepatologists in the management of patients at risk for or with hepatocellular carcinoma is multifold.
First, many at-risk patients with cirrhosis or chronic hepatitis B virus infection are followed by gastroenterologists. It is important for gastroenterologists to perform semiannual surveillance in these patients to maximize the chance of finding HCC at an early stage when curative therapies are available. Despite professional society guideline recommendations, several studies have demonstrated that many patients with cirrhosis or chronic HBV do not undergo routine surveillance.
GIs Link HCC Patients Into Multidisciplinary Care
The role of the gastroenterologist does not stop when a patient is diagnosed with HCC. It is important that gastroenterologists link patients with HCC into multidisciplinary care, where they can be evaluated for different treatment options. This process is not simply a hand-off, as gastroenterologists should continue to follow patients for treatment of their underlying liver dysfunction.
The prognosis and treatment eligibility for patients with HCC is not only dependent on their tumor burden, but also on continued optimization of the degree of their liver function. Patients with significant liver dysfunction, for example those with Child-Pugh C, are classified as terminal stage and often not eligible for any treatment, outside of liver transplantation.
Transplants May Be ‘Overlooked’ if GIs, Hepatologists Not Part of Care Team
The critical role of the gastroenterologist or hepatologist is underscored by the need to make sure these patients are assessed for LT. Historically, transplant criteria were defined by Milan criteria (defined by one lesion ≤ 5 cm or 2-3 lesions each ≤ 3 cm, without vascular invasion or distant metastases) at time of presentation. However, we have increasing recognition that longitudinal assessments can provide insights into patient selection, so patients who present with larger tumor burden but who are responsive to therapy can be downstaged to Milan criteria and be eligible for transplantation.
Patients within United Network for Organ Sharing-downstaging criteria can receive MELD priority exception points, similar to those who present within Milan criteria. Even those with larger tumor burden, including those with limited vascular invasion, who are downstaged can be considered on a case-by-case basis via living donor LT.
However, this consideration may be overlooked if gastroenterologists and hepatologists are not actively involved and others on the HCC treatment team — such as medical oncologists or interventional radiologists — are not as knowledgeable about transplant eligibility, particularly as that definition evolves.
Although the role of the gastroenterologist was historically small in patients with advanced stage HCC, this is no longer true after the introduction of the immune checkpoint inhibitor combination therapy Tecentriq (atezolizumab, Genentech), a programmed death-ligand 1 inhibitor and Avastin (bevacizumab, Genentech), a VEGF inhibitor. Although this combination significantly prolongs progression-free and overall survival compared with other therapies, such as Nexavar (sorafenib, Bayer), bevacizumab can increase the risk for gastrointestinal bleeding.
Therefore, it is essential that all patients being considered for systemic therapy, particularly those being considered for atezolizumab and bevacizumab, undergo an upper endoscopy to assess their risk for bleeding. Any findings that suggest high risk for GI bleeding, such as those with large varices or severe portal hypertensive gastropathy, should be documented and communicated to a patient’s medical oncologist, as this can affect treatment regimen selection.
Multidisciplinary Care Not Just a ‘Feel-Good Concept’
Overall, gastroenterologists and hepatologists are important members of the HCC multidisciplinary team. A multidisciplinary care model for HCC is not simply a feel-good concept but also is backed by several studies demonstrating that multidisciplinary care significantly improves curative treatment eligibility, as well as overall survival of the patient.
Multidisciplinary care of HCC involves multiple specialties, including but not limited to gastroenterology/hepatology, surgical oncology and transplant surgery, interventional radiology, radiation oncology, and medical oncology. Input from this large team of providers, including gastroenterology/hepatology, is necessary to provide input into the optimal treatment options for each patient with HCC. With this in mind, professional society guidelines recommend multidisciplinary care as being standard of care for patients with HCC.
- For more information:
- Amit Singal, MD, MS, is professor of medicine and chief of hepatology at University of Texas Southwestern Medical Center. He also serves as medical director of UT Southwestern’s Liver Tumor Program. He can be reached at amit.singal@utsouthwestern.edu.
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