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Raising Awareness Around Liver Cancer and Disease

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CURE spoke with Dr. Marty T. Sellers and Dr. Laura M. Kulik, on behalf of the Blue Faery, about liver cancer and disease – its treatments, causes and areas outside of therapy.

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      Kristie L. Kahl: Can you discuss what the primary types of liver cancers are in adults, and how they differ from one another?

      Dr. Laura M. Kulik: That's an important question because I often hear people say, “Oh my, someone died of liver cancer,” but most cancers in the liver will be metastatic, meaning they're coming from another organ. So, when people have primary liver cancer, that means that the cancer originated in the liver itself, it's not coming from somewhere else.

      And the main type of liver cancer is called hepatocellular carcinoma or HCC. And the way I describe this to patients is I use the analogy of a tree: you have a tree with leaves, branches, the tree trunk and then all the way up to the little, tiny branches. If you have a cancer of the leaves, those are equivalent to the liver cells, and that's called hepatocellular carcinoma. That's a cancer that we see predominantly over 80% of the time and people with underlying liver disease, specifically cirrhosis – which is the in the scarring score that we use if someone has cirrhosis, that's the most scar tissue someone has.

      The other type is called cholangiocarcinoma, and that is cancer anywhere from the twigs to the branches to the main tree trunk, and that is the drainage system of the liver, which is called our bile ducts. We are seeing this type of cancer also increase, especially if it is coming from the little twigs where it's called intrahepatic cholangiocarcinoma, so you can see it on a scan as a mass within the liver.

      And then there are other types of cancer that form more in the larger bile ducts.

      Kristie L. Kahl:How is liver cancer staged, or and how do we define those stages?

      Dr. Laura M. Kulik: So, patients often want to know that. There are different stages that have been used in liver cancer. The most that is used by clinicians within the United States, and I would say in Europe, is called the Barcelona Clinic Liver Cancer staging system. And that breaks it down into five different, separate stages. So there's very early, early, intermediate, advanced and very advanced.

      And the way that these are decided are based on multiple factors: It's how much tumor someone has present. It's how well they are performing, which means are they doing their daily activities? Can they do everything on their own? Are they in bed, and what percentage of the time? And then also how well their liver is actually functioning. And I call this the report card of the liver.

      So, patients are given what's called a Child-Pugh report card. And that's just like in school, it's an A, B or C, with A being the best. So, the worse the liver function, the more risk of dying of liver disease. And unfortunately, this is a competing risk of death related to the cancer itself, as well as the liver failing.

      Kristie L. Kahl:Let's say a patient just received their cancer diagnosis. What are some questions that they should be sure that they ask their health care team?

      Dr. Laura M. Kulik: So I think important questions are what stage, but more importantly, is this something that has the potential to be cured? Am I in the right place? Do I need to be sent somewhere else to get an opinion on the treatment of this liver cancer?

      Kristie L. Kahl:With that, why is it important for a patient to understand the pathology of their disease?

      Dr. Laura M. Kulik: Because, when we start talking about treatments, patients are, and rightfully so, very honed in on this diagnosis of liver cancer. And when you start telling them – and they may have read about it or heard about it from family members – about different types of treatments, if they're not candidates for various reasons, the most common reason is that the liver is not going to tolerate it. (They may not understand) that there are two sides to this. We are trying to ultimately extend life equally with their liver not failing by doing overzealous treatments for the liver cancer, but in the process, hurting their liver so much that they may actually have less life expectancy by not doing the right treatment.

      Kristie L. Kahl:With treatment, we often talk about the multidisciplinary approach in cancer care. Can you talk about how this approach plays a role in liver cancer and its treatment options?

      Dr. Laura M. Kulik: The multidisciplinary approach is becoming the absolute standard paramount, and not only liver cancer, but all other cancers as well. So this is comprised of multiple experts in their area, predominantly in an HCC multidisciplinary conference, this would (include):

      • A hepatologist, who is experienced in the in the liver and in the treatments of liver disease and how to improve potential function and treat the complications.
      • The surgeon, who is involved in doing what's called a resection, which means cutting out that piece of the liver that has the cancer and then the remaining liberal remain. (This) includes the liver that has cirrhosis, because they're at risk of getting cancer again in the future as a result of that.
      • An oncologist. There has been a burst in the number of (Food and Drug Administration) approved medications for liver cancer and, in what we call, the more the advanced disease. And this is generally in patients who have disease that's outside the liver or what's called metastatic. So it's left the organ that it started in, or they have invasion into some of the main vessels within the liver, generally what's called the portal vein or the paddock vein.
      • The interventional radiologist, who does most of the local regional therapies
      • A radiologist, who helps us interpret these films.
      • And, importantly, the nurses. I think the nurses are a key point, because these are the people who are on the phone with the patients that are checking the patients out, will be talking about, “oh, I think we should do this, or we should do that for the patient,” based on all these different things. And then the nurse will say, “I've been talking with them and they don't want to do transplant.” And this is the reason why their input is very important in making those decisions.

      So, a multidisciplinary approach allows the expertise, the experience and the knowledge from all these different people. It's similar to if you had a football team, and instead of having the 11 players on the team, but you only have five players on the field, you're not going to do as well in that game. It's very similar with a multidisciplinary approach, you're going to get everyone to say what they think is the best for that patient.

      And patients really should be asking if there is a multidisciplinary cancer tumor board. And if not, many of these communities are (working) with their local or closest transplant center. And they're allowed to present the cases and then get that input. So we can get that information for the patient, and also potentially save them from a long drive where they may not need to go or encourage them to make that trip because they are candidates for something that would benefit them.

      Kristie L. Kahl:To bring it all together, what is your biggest piece of advice for a patient who has recently received a liver cancer diagnosis?

      Dr. Laura M. Kulik: Well, first and foremost, I would say don't panic. This is a very scary diagnosis. But I would say be your own advocate. And if you don't have that within you because you're overwhelmed or you just don't you know, the other things is to assign someone to be your advocate, because you really want to be asking those questions that we've just covered to the physician that you're seeing: Am I a transplant candidate? Why am I not a transplant candidate? And if I had a donor, am I a living donor transplant candidate?

      I've seen so many patients who have shown up and we start talking about living donor, and things have really changed now. This is a conversation we have very early on when people that have liver cancer. Before we would say “Oh, they're going to get points on the waiting list. They'll get transplanted.” And you know over 15 years ago, patients got transplanted generally within three months after being waitlisted or put on the list for liver cancer. That's not the case anymore. The waiting time is longer and, therefore, the longer you wait, the greater the chance that the cancer may grow to a point that transplant is no longer an option. So now we talk about the living donor much earlier than we used to in the past. And I've seen so many patients when they get to our institution and we talk about it, they say “I was told I wasn't a candidate for living donor.” And many times that may be due to a misunderstanding of how living donor works, specifically in centers that don't do living donor (transplants). So if they don't have the expertise or the experience, it's going to be hard to counsel a patient who may or may not be a living donor candidate.

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