Hepatocellular carcinoma: From clinical practice to evidence-based treatment protocols

Abstract

Hepatocellular carcinoma (HCC) is one of the major malignant diseases in many healthcare systems. The growing number of new cases diagnosed each year is nearly equal to the number of deaths from this cancer. Worldwide, HCC is a leading cause of cancer-related deaths, as it is the fifth most common cancer and the third most important cause of cancer related death in men. Among various risk factors the two are prevailing: viral hepatitis, namely chronic hepatitis C virus is a well-established risk factor contributing to the rising incidence of HCC. The epidemic of obesity and the metabolic syndrome, not only in the United States but also in Asia, tend to become the leading cause of the long-term rise in the HCC incidence. Today, the diagnosis of HCC is established within the national surveillance programs in developed countries while the diagnosis of symptomatic, advanced stage disease still remains the characteristic of underdeveloped countries. Although many different staging systems have been developed and evaluated the Barcelona-Clinic Liver Cancer staging system has emerged as the most useful to guide HCC treatment. Treatment allocation should be decided by a multidisciplinary board involving hepatologists, pathologists, radiologists, liver surgeons and oncologists guided by personalized -based medicine. This approach is important not only to balance between different oncologic treatments strategies but also due to the complexity of the disease (chronic liver disease and the cancer) and due to the large number of potentially efficient therapies. Careful patient selection and a tailored treatment modality for every patient, either potentially curative (surgical treatment and tumor ablation) or palliative (transarterial therapy, radioembolization and medical treatment, i.e., sorafenib) is mandatory to achieve the best treatment outcome.

Keywords: Hepatocellular carcinoma; Evidence-based; Management; Clinical practice; Treatment allocation

Core tip: In response to the hepatocellular carcinoma (HCC) burden marked differences between countries are reflected in providing disparate quality of healthcare considering screening and surveillance programs; available treatment modalities and drugs; reimbursement of specific treatment options by the state-funded health insurance. Since the number of new HCC cases being diagnosed each year is nearly equal to the number of deaths from this cancer it is clear that the international scientific community and healthcare systems worldwide have no efficient answer to this problem. International consensus on the use of any given staging model is lacking. High-quality trials with better patients’ stratification are mandatory. This review article reflects the perspective of liver surgeons working in a developing country.