Along with the latest guidelines from the NCCN and ASCO, the American Association for the Study of Liver Diseases—in a guidance document due for publication in 2023—strongly recommends multidisciplinary evaluation of patients with hepatocellular carcinoma (HCC), according to Amit Singal, MD, MS, FAASLD, who worked on the guidance. Having also recently helped complete a systematic review/meta-analysis of the literature that examines multidisciplinary care for HCC, currently in press with Hepatology Communications, Dr. Singal is well versed on the importance of taking a multidisciplinary approach to caring for patients with advanced HCC.

“Patients with advanced HCC have multiple needs, including management of their cancer, as well as their underlying liver disease,” he notes. “Further, objective responses have increased, so shifts in the treatment paradigm and downstaging to locoregional, or even surgical, therapies are increasingly possible and must be considered in a multidisciplinary manner. Multidisciplinary care will also be increasingly important if ongoing trials of combination therapies yield positive results.”

Multidisciplinary discussions come into play when imaging provides inconclusive information, note the NCCN guidelines, for example if it’s not clear whether the patient has as benign tumor or HCC. Then, “multidisciplinary discussion and individualized workup may be pursued, including additional imaging or biopsy,” read the guidelines. “Multidisciplinary team management has been associated with improved outcomes in HCC, including higher rates of treatment, higher rates of curative treatments in early stages, and prolonged survival in advanced disease.” Team discussions are also important when considering liver transplantation, as well as with the various “surgical, liver-directed, and systemic therapy options available for patients.”

Multidisciplinary care can range from tumor boards, in which various specialists review imaging and discuss treatment plans, to co-located clinics, where multiple specialists are available to see patients in a “one-stop shop,” says Dr. Singal. “Multidisciplinary approaches are important, given that different providers offer different treatments and perspectives to care, including surgeons offering resection or transplantation, interventional radiologists and radiation oncologists offering local therapies to liver-localized disease, and medical oncologists offering systemic therapies, including immunotherapy. Hepatologists are often regarded as the ‘quarterback’ of the team, helping patient navigate different treatment options, particularly given that most HCC develops in the setting of chronic liver disease, so treatment options have to consider both cancer- and liver-related factors. Multidisciplinary care has become increasingly important, given adoption of quick sequential or combination therapies across stages of disease.”

Dr. Singal points to the format used at UT Southwestern as a prime example allowing for ideal multidisciplinary care for advanced HCC. The team there utilizes a multidisciplinary conference and co-located clinic in which “all specialties are present.” This format, he says, allows “seamless transitions in care between specialties and continuous communication between providers involved in the care of each patient with HCC,” both of which are increasingly important with disease progression.

To that end, as liver function worsens, “there is increasing risk of liver-related mortality and decreased benefit of treating HCC with systemic therapies,” says Dr. Singal. “There also may be increased risk of adverse events or deterioration of QOL in some cases. Therefore, assessment of liver function (for example, using the Child Pugh scoring system) is always important when considering HCC treatment, including systemic therapies.” He adds that “all systemic therapy trials have been evaluated in patients with compensated liver disease (ie, Child Pugh A).”

In regard to ensuring that care is individualized for patients with advanced HCC—as opposed to following “black and white rules” that may leave some patients without care from which they could have benefited, Dr. Singal explains that while guidance offers a starting point for HCC therapy, “decisions in clinical practice can deviate from that guidance, as care should be individualized to each patient. Studies have shown that receiving care at centers with high HCC volume and multidisciplinary formats are associated with better outcomes, likely related to increased expertise allowing individualized care.”

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