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Researchers suggest HCC guidelines be adjusted in developing countries
In a retrospective cohort study, researchers found that Peruvian patients with advanced-stage hepatocellular carcinoma could undergo liver resection and maintain good outcomes, despite current management guidelines. The researchers suggest that clinicians in developing countries reconsider the guidelines to avoid section bias for treatment.
“Far too often, practitioners from developing countries have a tendency to rely on the medical flowcharts created in developed countries,” Eloy Ruiz, MD, of the National Cancer Institute of Peru, said in a press release. “We hope our findings help cancer care professionals in developing countries rethink their approach to liver cancer management.”
Eloy Ruiz
Ruiz and colleagues, including Stéphane Bertani, PhD, of the Institut de Recherche pour le Développement and Université de Toulouse, France, sought to better understand HCC and its management in Peru compared with other countries. In doing so, they used molecular and epidemiology techniques when studying 253 patients with HCC without extrahepatic metastases who underwent a hepatectomy between 1991 and 2001 at the National Cancer Institute of Peru.
Among the patients, average tumor size was more than 14 cm in diameter, with 73% of the patients presenting with a tumor greater than 10 cm. Fifteen-percent of the resections were performed on livers with cirrhosis and 76.3% of all resections were major hepatectomies.
During follow-up, 59% of patients experienced recurrence, of which 15.5% underwent re-resection.
The 5- and 10-year survival probability rates were 37.5% and 26.2%. The 5- and 10-year recurrence-free survival probability rates were 22.9% and 16.2%.
According to classification of Barcelona-Clinic Liver Cancer (BCLC) stage disease, eight (3.2%) patients with BCLC stage A disease, 214 (84.6%) with BCLC stage B, and 31 (12.3%) with BCLC stage C survived 20 years postoperatively. The 5-year survival probability estimates for patients with BCLC stages A and B were 50% and 36.8% compared with 10-year survival probability estimates of 25% and 22.1% (P = .48). The 5-year survival probability estimate for patients with BCLC stage C was 3.2% and was different from BCLC stage A (P = 0.0026) and BCLC stage B (P < .0001).
The 5-year survival probability rate among patients with cirrhosis was 11.4% compared with the 5- survival probability rate among patients without cirrhosis (40.1%). The 10-year probability survival rate was 27.9% in patients without cirrhosis.
According to a press release, this staging system was created based on data from developed countries and is used by the European Association for the Study of the Liver and the American Association for the Study of Liver Disease for the diagnosis and management of HCC.
However, patients in many developing countries are poorly documented and their cases are not considered when clinicians develop these guidelines for HCC.
“Our fear is that the situation in Peru is not an isolated one,” Bertani said in the release.
Many of the patients included in this study had advanced disease and have not qualified for the operation according to standard HCC guidelines, according to the release. However, a number of patients survived which could suggest that the guidelines are possibly not adequate for use in Peru and other developing countries.
“Guidelines should always be evidence-based, and that evidence needs to be built up in developing countries,” Pascal Pineau, MD, of the Institut Pasteur, France, said in the release. “Peruvian liver specialists should re-examine the situation and, if necessary, develop new and more appropriate therapeutic guidelines providing a better chance of survival to local patients."
The researchers concluded: “We hypothesize that in developing countries, a strict adherence to these therapeutic algorithms might create a selection bias resulting in the dismissal of patients who could eventually be treated.” – by Melinda Stevens
Disclosure: The researchers report no relevant financial disclosures.