Treatment Options For Liver Cancer: What You Need To Know

Treatment Options for Liver Cancer: What You Need to Know
Presented by: Robert G. Gish, MD
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A dedicated program of the Hepatitis B Foundation
Treatment Options for Liver Cancer

What You Need to Know
[April 27, 2015]
Presented by: Robert G. Gish, MD

Professor Consultant, Stanford University, California
Medical Director, Hepatitis B Foundation
How Liver Cancer Develops
Healthy
Liver
Cirrhotic
Liver
Liver
Cancer
In a healthy liver, chemical signals tell liver cells

when to grow/multiply, and when to stop
In a liver damaged by hepatitis infection, cirrhosis
(scarring), or other diseases, abnormal cells may
grow out of control and become cancerous
o you do not have to have cirrhosis to have
liver cancer
How Liver Cancer Develops

Diabete
s
Fatty
Liver
HBV or
HCV
Alcoh
ol
Iron
Aflatox
ins
Risk factors
Inflammati Cell damage

on
Uncontrolled
cell growth
15
3%5%
Chronic 40 Cirrhosisper year
Liver cancer
hepatitis year
(HCC)
s
Spotlight on Prevention
Liver cancer can be prevented by
eliminating the major risk factors
Prevention of hepatitis B and C
infections
Liver
Cancer
Prevention
The hepatitis B vaccine is the worlds

first anti-cancer vaccine because it
prevents hepatitis B, a leading cause of
liver cancer
There is no vaccine for hepatitis C, but
treatments can eliminate the virus
Prevention of cirrhosis
About 80% of people with liver cancer
also have cirrhosis
Prevent cirrhosis by preventing
hepatitis B and C infections, eliminating
alcohol intake, and maintaining a
Why Are Screening and Surveillance

So Important?
In people with chronic HBV infection, liver cancer
can develop with or without cirrhosis, so regular
screening/surveillance is essential
In people with chronic HCV infection, cirrhosis
occurs before liver cancer develops
Screening/surveillance increases likelihood
of finding liver cancer early
More treatment options for early-stage liver
cancer
Early detection may increase treatment success
Who Needs Liver Cancer Screening?

Screening: first test; Surveillance: all
subsequent testing
American Association for Study of Liver
Diseases recommends:
Men with hepatitis B: start screening/surveillance at
age 40 years
Women with hepatitis B: start screening/surveillance at
age 50 years
People with cirrhosis
Family history of liver cancer (or family history
unknown)
But the following high-risk groups may need
Asian and Pacific Islander immigrants and their children
screening/surveillance earlier and more
African immigrants and their children
frequently:
Co-infection with HIV, HBV and/or HCV
Elevated HCC biomarkers, such as AFP, AFPL3% and or
DCP A dedicated program of the Hepatitis B Foundation
Liver Cancer Screening and Surveillance

The goal is to diagnose liver cancer as early as possible
Screening: the first test
Surveillance: all subsequent testing (regular monitoring)
Common blood tests
- Complete blood count (CBC)
- Alpha-fetoprotein blood test (AFP)
- Additional FDA-cleared blood tests include
AFPL3% and DCP
Imaging studies
- Ultrasound (US)
- Computed tomography (CT or CAT scan)
- Magnetic resonance imaging scans (MRI)
Diagnosing Liver Cancer

Diagnosis of liver cancer is made by
imaging
Liver tumor biopsy is sometimes used to
confirm diagnosis of liver cancer or stage
disease
Most common biopsy type is percutaneous
needle biopsy
o Surgical removal of a small piece of liver to
examine under the microscope
Usually performed as an outpatient
hospital procedure
program of the Hepatitis B Foundation
oA dedicated
Procedure is relatively short with a 6- to 8-
Staging of Liver Cancer

Staging is a medical term to describe
how far the cancer has progressed in a
patient
o Helps health care providers determine the
best course of treatment
o Liver cancer often is diagnosed at more
advanced stages because many people
dont have symptoms in early stages
There are several staging systems for
liver cancer; not all health care providers
use the same system
4 Stages of Liver Cancer

Stage I
The tumor is small
and found in one
part of the liver
Stage II
There are several
small tumors or a
single tumor that
has spread to
nearby blood
vessels
Stage III
There are one or
more tumors that
might have spread
to nearby parts of
the body, such as
the stomach,
blood vessels or
A dedicated program of lymph
the Hepatitis nodes
B Foundation
Stage IV
There are one or
more tumors in
the liver, and
cancer cells have
spread to other
parts of the body
Staging
helps
determine
treatment
options
Managing Liver Cancer
Managing Liver Cancer

An individual treatment plan depends on
several factors
How well the liver is
working when the person is
diagnosed
Stage of cancer, including
number/size of tumors and
whether the cancer has
spread outside the liver
Overall health of the
person being treated
Deciding the Treatment Plan

Liver Cancer
Transplant
Not
Candidate
Resectable
1 tumor < 5cm
2-3 tumors
< 3 cm
>2 cm
Embo/Ablati
< 2 cm
Liver
Liver
on
Surgery
Image
function not
function
OK
Image
every 3
OK
Labs
OK
every 3
months
Labs not OK
<3 cm thermal
months
Palliative
ablate
care
3-8 cm embo/ablate
Hospice
>8 cm radio
care
embolization
Systemic therapy
Sorafenib
Resectabl
e
Team Approach for Treatment

Treating liver cancer requires a
team approach:
Hepatologist (liver specialist)
NP/PA/RN team
Pharmacist
Surgeon
Pathologist
Radiologist (diagnostic and
interventional)
Medical oncologist (cancer
specialist)
Radiation oncologist (radiation
Treatment Options
Liver Transplantation
Surgical replacement of diseased liver with healthy
liver
Transplantation only possible if tumors are small and have
not spread to nearby blood vessels or outside the liver
Orthotopic transplantation: use a healthy liver
from a person who has recently died
Living donor transplantation: use part of a healthy
liver from a living person
Most people needing a new liver are placed on a waiting list

and continue to receive treatment while waiting
Treatment Options
Surgery
Resection: Surgical removal of tumor
Treatment of choice if tumor is small, in one section of
the liver and patient does not have portal hypertension
Possible in persons with good liver function, despite
liver disease (eg, cirrhosis, chronic hepatitis B or C,
fatty liver)
Many patients not eligible (e.g., tumor too large or too
many; reduced liver function caused by cirrhosis)
o Only 30% of tumors are resectable
Treatment Options
Localized
Procedures that damage or eliminate the tumor
locally
for tumors that cannot be surgically removed
to prepare a patient for surgical treatment or
transplant
Radiofrequency ablation (RFA)
Transarterial bead chemoembolization (TABE)
Transarterial chemoembolization (TACE)
Radiotherapy
Radioembolization (TARE)
Treatment Options
Localized
Radiofrequency (or
microwave[MwA]) ablation (RFA):
Target higher concentration
of drugs to
High-frequency
electrical currents
the tumor
with less exposure to other
destroy
tumor
parts of the body
RFA probe
Tumor
Radiofrequency heat
o This can cure small tumors

o Some patients have combination therapy
o Best option for patients who cannot have surgery or transplant if disease is
localized
o Side effects include pain or bleeding: rare
o Very rare events of tumor spreading (seeding or tracking)
Images: Society of Interventional Radiology (SirWeb.org), Johns Hopkins (hopkins-gi.org)
Treatment Options
Chemoembolization (TACE)
Normal liver gets 75% of
Tumor
blood supply from portal

vein; 25% from hepatic
artery
Hepatic
artery
Hepatic
Tumor gets most of its blood

supply from the hepatic
artery
Injection into the hepatic

artery spares most of the
normal liver
Prevents chemotherapy
drugs being absorbed into
circulation and kills the
tumorAby
cutting off its blood
dedicated program of the Hepatitis B Foundation
supply
Catheter placement for

chemoembolization
artery
Liver
Portal vein
Treatment Options
Localized
Transarterial bead chemoembolization
(TABE):
Anticancer drugs delivered directly into tumor
to block blood supply to the tumor
Delivers embolic material to tumor to cut blood

flow
Slowly delivers chemotherapy
Can kill localized tumors that are up to 7-9 cm
Images: Society of Interventional Radiology (SirWeb.org), Johns Hopkins (hopkins-gi.org)
Improving Survival in Liver

Cancer
Precision TACE using beads can
improve survival
% probability of survival at 12
months
o ~98% with TABE; ~82% with TACE
% probability of survival at 24
months
TABE, Transarterial bead chemoembolization
o ~91% with TABE; ~63% with TACE

Treatment Options
Localized
Radiotherapy:
High-energy radiation kills cancer cells

and shrinks tumor
Radioactive beads or external beam
radiation
Transarterial radioembolization (TARE):
Reduces tumor size, but is not a cure

o May make patients eligible for other therapies
(e.g., radiofrequency ablation, surgery,
transplantation)
o One FDA-approved method uses implanted
glass beads or resin to deliver high-dose
radiation directly to tumor; spares healthy liver
cells
oA dedicated
program
the Hepatitis B Foundation
Usually
anof outpatient
procedure
Images: Society of Interventional Radiology (SirWeb.org), CancerHelp UK

(cancerhelp.org.uk)
Treatment Options
Targeted Therapies
Therapies that enter the bloodstream and reach
the whole body (systemic)
Newer biologic therapies that specifically target
the tumor
Unlike chemotherapy, which kills both tumor
cells and healthy cells, targeted therapies block
specific pathways in the tumor
o may have different or less severe side effects
than chemotherapy
Targeted therapies may be oral (pills, tablets)
Treatment Options
Targeted Oral Drug
Nexavar (sorafenib) is the first FDA-approved
oral drug to treat liver tumors that cannot be
surgically removed
A targeted oral therapy approved for primary

liver cancer in more than 70 countries
Blocks tumor cell signals so tumor cells cant

grow or multiply
Reduces formation of new blood vessels that
provide oxygen and nutrients to the tumor cells

What to Ask Your Health Care Team

What are my treatment options and how will
they help?
If I have hepatitis B or C, do I need antiviral
treatment?
There are all oral therapies that can cure HCV or
suppress HBV
Can you explain my blood test or imaging

results to me?
Do I need more tests before we decide on my
treatment?
Do I need to see any other doctors before I
start treatment?
What to Ask Your Health Care Team

What will the treatment involve?
What are the possible side effects of
treatment?
What are the chances that the cancer will
come back?
Can I get a copy of all of the results?
Life After Treatment

Take time to recover, heal and discover your
new normal
May still feel the effects of treatment

May experience changes in food, activities,
support
Make sure you keep all medical follow-up

visits
Talk to your health care team about a
wellness plan
Talk to your health care provider about your
familys
cancer risk
For Amore
information
dedicated program of the Hepatitis B Foundation
Read Facing Forward from the National Cancer
Follow-Up Care: What Is Involved?

Medical follow-up visits are very important
To check that the cancer has not spread or
returned
To manage any side effects that might occur
Regular imaging and blood tests will be

required for several years after surgery and/or
a liver transplant
Maintain your health insurance since you will
have follow-up visits for many years
Keep records of all blood test results, imaging
studies,
surgery and discharge reports, and list
of medications
Treatment Options
Whats in the Pipeline?
Treatments being developed
o Combination therapies
o New ways to deliver
chemotherapy/radiation directly into
tumor
o Immunotherapy (use patients immune
system to kill tumor)
o Many therapies being studied in clinical
trials
Why Immunotherapy?
Spontaneous immune responses

frequently observed
Strategy does not depend on
liver function
Can be combined with ablation
Currently this is for research
programs only
Types of Immunotherapy
Checkpoint inhibitors
o Target molecules that regulate immune
response to cancer cells
Cancer vaccines
o Encourage immune system to attack
cancer cells
Adoptive T-cell therapy

o Genetically/chemically modify patients
immune cells (T cells) to specifically
attack cancer cells
Types of Immunotherapy
Monoclonal antibodies
o Attack specific targets on cancer cells
Cytokines
o Messenger cells help control immune
system
Cancer-killing virus therapy

o Modified virus causes tumor to selfdestruct; stimulates immune response
to cancer
Tremelimumab with
Chemoembolization or
Ablation
Cancer drug that helps immune
system recognize and kill cancer
cells
Can it be used to treat advanced
liver cancer?
Used in combination with:
o TACE: inject chemotherapy into tumor
through arterial blood vessel
o RFA: heated probe destroys tumor tissue
Clinical Trials
Study whether a drug is safe and
effective in people
May not get study treatment, but
will get standard treatment
Learn more about clinical trials
o Join our webinar on Wed May 27, 1:30
pm EST
o Register at
www.livercancerconnect.org
Patient Resource on Liver Cancer
www.LiverCancerConnect.org
A Dedicated Program of the Hepatitis B

Foundation
Drug watch
Liver cancer centers
Clinical trials
Information for
newly diagnosed
Talking to your
health care team
Treatment options
Liver Cancer Connect Drug Watch
Key Messages
Know your risk - Family history, hepatitis, cirrhosis...

Get screened and regular monitoring
(surveillance) Early diagnosis saves
lives
Know the symptoms - Get checked
immediately if you have any signs or
symptoms of liver cancer
Get informed - Talk to your health care
provider about treatment options and clinical
trials for liver cancer
Question and Answer Time

Use the chat box on your screen to type and
send your questions to the presenter
Your questions will be seen only by the
presenter
Please note, the presenter cannot give
treatment recommendations or advice on a
persons personal medical condition

Treatment Options For Liver Cancer: What You Need To Know

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Treatment Options for Liver Cancer: What You Need to Know

Presented by: Robert G. Gish, MD

Joining the webinar

A dedicated program of the Hepatitis B Foundation