Primary liver cancer, or hepatocellular carcinoma, is a growing problem we face in the care of patients with chronic liver disease, especially hepatitis C. The number of new cases of liver cancer I see each week has grown steadily over the past 15 years. A lot of this has to do with the aging population of patients with hepatitis C. It is well known that the development of liver cancer is a function of time. The longer you liver with hepatitis C, the annual chance of developing cancer increases. The incidence of developing liver cancer is approximately 3-8% per year. Liver cancer is highest in those with cirrhosis; the risk of cancer in hepatitis C patients without cirrhosis is significantly reduced.
Over the years, we have developed a very good strategy to screen for liver cancer in those with hepatitis B and hepatitis C, as well as other causes of cirrhosis. The general strategy is to obtain an ultrasound of the liver along with a blood tumor marker, alphafetoprotein (AFP), every six months. Following these guidelines has shown to reduce death by 37%.
In practices with large numbers of patients with cirrhosis, keeping track of everyone that needs to be screened is a daunting process. Even with the use of electronic medical records, keeping up with everyone is difficult. Despite our best efforts, and alerting patients, they still need to go and have the scan performed, and get their blood work as scheduled. People are human, and they forget to get these tests done in a timely fashion. During tough financial times, patients ask me if they can extend the frequency of testing from every six months to 8-12 months. High deductibles, tuition bills, and other expenses take priority over these necessary scans. As I have said before, all I can do is encourage the patient, educate them on the importance of screening and early detection and cancer, and document it in their medical record. Unfortunately, I have seen cases where skipping required scans have resulted in the development of new, large cancers, that are not amendable to proper treatment.
Routine screening with AFP and ultrasound (or in certain cases MRI or CT scan), small liver cancers are detected. In the setting of cirrhosis, surgical resection is never routinely recommended, due to the high risk of precipitating progressive liver failure and death. Instead, local therapy applied to the tumor is preferred. The two most common therapies we use are radio-frequency ablation (RFA), and transarterial-chemoembolization (TACE). Collectively, these are referred to as loco-regional therapies. A review is available here. In both of these therapies, along with the local delivery of radiation, in the form of yttrium-90, focused treatment can be delivered right to the tumor, instead of a systemic method, which is given by mouth or vein, exposing the entire body to these medicines.
In addition to loco-regional therapy, liver transplantation is at the heart of therapy for hepatocellular carcinoma in patients with cirrhosis. To be considered for transplant, the size and location of the tumor needs to be within specific guidelines.
The Milan criteria state that a patient is selected for transplantation when he or she has:
- one lesion smaller than 5 cm.
- up to 3 lesions smaller than 3 cm.
- no extrahepatic manifestations
- no vascular invasion
With all of this said, we have:
a. Identified those patients with an increased risk of liver cancer (hepatitis C, hepatitis B, alcoholic cirrhosis, all other forms of cirrhosis).
b. Established a screening strategy (ultrasound and AFP every six months).
c. Understand the biology of these tumors, the doubling time and rate of growth.
d. Developed protocols for treatment (loco-regional therapies, sorafenib, liver transplant).
Unfortunately, this always doesn’t work out as planned.
Today, I had the unfortunate job of talking with a long-time patient of mine, and explaining to him that literally out of nowhere, a liver cancer developed, exceeding criteria for transplant, and that there appeared to be invasion of the tumor into his portal vein. This further complicated the options for him. He had always been compliant, getting scans and blood work in a timely fashion. His last MRI was a little less than 6 months ago. On review, no less that five times, with multiple sets of expert eyes, there was no indication that there was a tumor brewing at the last scan, that may have been missed. He had the best of technology scanning his liver.
The lessons here are important. Despite all parties doing their job in a diligent manner, bad things happen to good people. As a physician, I am reminded daily that I have little control in what happens to my patients. All of the science and technology cannot save everyone. The news I shared was devastating to him and his wife. He walked into my office this afternoon thinking that a transplant was needed, but left with the news that most good options had been lost. Keeping emotions at bay, I forged ahead to develop a credible plan “B”. In situations like this, physicians and all healthcare providers need to display empathy, rather than sympathy for our patients. I purposely did not discuss with them “survival”, or “how much time he had left”. Over the many years of listening to patients, the one thing that upsets patients more than anything else is a physician telling them, with authority, what their expected survival will be. In cases of clear-cut terminal illness, I will be more specific. These are cases where an amateur could see that a person was moments from death. Once you define length of survival in these early discussions mortality, more negative comes from it than good.
We did take the time to lay out a plan, one I believe can leave them with a sense that there will be options to try. At each turn, we can readjust our expectations. I do not feel I candy-coated the discussion.
After 25 plus years of delivering bad news to patients, it is never easy, and it pains me and my staff each and every time. We all take the time to get to know our patients, and their families. We become friends, and share laughs when we meet. Days like today suck for all of us.