Multidisciplinary Care Tied to Improved Liver Cancer Survival

03/24/17

By Marilynn Larkin

NEW YORK (Reuters Health) - Curative therapies are more likely to be prescribed when liver cancer patients are evaluated by a multidisciplinary team of specialists such as hepatologists, oncologists or surgeons, rather than general gastroenterologists, researchers say.

Dr. David Kaplan of the Hospital of the University of Pennsylvania in Philadelphia told Reuters Health that because the study findings were derived from non-registry data, they “likely better reflect the general care of liver cancer in the broader community than those derived from academic centers, as patients received care at high- and low-volume centers with variable access to liver cancer expertise.”

“The data confirmed previous findings that nearly 24% of hepatocellular carcinoma (HCC) patients received no cancer-specific treatments, largely due to significant hepatic dysfunction, severe comorbidity, or highly advanced stage at diagnosis,” he said by email.

“A key novel finding was that process of care - which specialists the patient accesses and the number of specialists seen - strongly impacted whether or not therapy was administered,” Dr. Kaplan continued. “For instance, patients managed primarily by general gastroenterology practitioners rather than hepatologists were less likely to be actively treated than those seen by an oncologist or surgeon, after adjusting for liver disease and tumor-related factors.”

“Management of cases by general gastroenterology practitioners tends to cluster at low-volume, non-academically affiliated centers with less access to liver cancer expertise,” he noted. “These data therefore support regionalization of care to increase access of patients from low-volume centers to expertise present at high-volume centers.”

“A second key finding was that specific components of the management team strongly impact survival outcomes,” Dr. Kaplan observed. “Seeing a surgeon increased the likelihood of curative therapy and reduced mortality compared to patients who did not see a surgeon.”

“While patients seen by a hepatologist were not more likely to receive active therapy for their cancer, their risk of mortality was 30% lower than patients not managed by a hepatologist,” he added. “Multidisciplinary tumor board discussion of case was associated with a 17% reduction in mortality.”

Dr. Kaplan’s team analyzed data from 3,988 HCC patients (99% male) treated at 128 Veterans Administration centers from 2008 to 2010 and followed through 2014.

They found that receiving care at an academically affiliated VA hospital (odds ratio, 1.97) or a multi-specialist evaluation (OR, 1.60), but not review by a multi-disciplinary tumor board (OR, 1.19; 95%), was associated with a higher likelihood of receiving HCC therapy.

Liver transplantation (hazard ratio, 0.22), liver resection (HR, 0.38), ablative therapy (HR, 0.63), and transarterial therapy (HR, 0.83; 95%) were associated with reduced mortality during followup, the team reports in Gastroenterology, online March 7.

Mortality was reduced when patients were seen within a month of diagnosis by hepatologists (HR, 0.70), medical oncologists (HR, 0.82), or surgeons (HR, 0.79), and when their case was reviewed by a multi-disciplinary tumor board (HR, 0.83).

Dr. Kaplan concluded, “These data strongly suggest that multi-specialist involvement that focuses on identifying patients potentially curable by resection or transplantation, and aggressive management of liver-related comorbidity, are critical for optimizing outcomes for patients with HCC.”

Dr. Scott L. Friedman, Dean for Therapeutic Discovery and Chief, Division of Liver Diseases at the Icahn School of Medicine at Mount Sinai in New York City, commented, “The incidence of HCC is rising faster than any cancer in the U.S. and Europe, and this tumor is already the second leading cause of cancer mortality worldwide. This study underscores the unique challenges of caring for this neoplasm, which typically occurs in the setting of advanced underlying liver disease.”

“More importantly,” he told Reuters Health by email, “it reinforces the value of a multidisciplinary team to expeditiously harness the most appropriate, advanced therapies to improve patient outcomes.”

Dr. Friedman concluded, “Although the study’s findings are somewhat limited by its retrospective, observational design and its restriction to VA hospitals - i.e., only male patients in a single national system - the report nonetheless solidifies the importance of specialized, integrated care for optimal management of complex diseases.”

The study was funded in part by Bayer Healthcare Pharmaceuticals.

SOURCE: bit.ly/2mZDHKk

Gastroenterology 2017.

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