The
EASL liver cancer guidelines panel answer questions at The International Liver
Congress, 2018. Photo by Liz Highleyman.
EASL
also issued new guidelines on the treatment of hepatocellular carcinoma (HCC)
at the conference.
Liver cancer is the fifth most common cancer and the second
leading cause of cancer-related death, with about 854,000 new cases and 810,000
deaths per year, according to the guidelines. About 85% of all cases occur in
East Asia and sub-Saharan Africa. HCC accounts for around 90% of primary liver
cancers, meaning they originate in the liver.
The panel recommended enhanced screening programmes to
identify people at risk for HCC. Regular surveillance is strongly advised for
people with liver cirrhosis, with a weaker recommendation for those with
advanced (stage F3) liver fibrosis. Abdominal ultrasound every six months is
recommended.
Liver resection and liver transplantation are the first
options for people with early tumours, according to the guidelines.
Radiofrequency thermal ablation is the standard of care for
people with early HCC not suitable for surgery, and it can replace surgery as
first-line treatment for those with very early cancer. Ethanol injection is
another option, and microwave ablation shows some promise, but there is little
evidence to support external beam radiation therapy.
Recurrence is common after surgery and follow-up is
recommended every 3 to 4 months for the first year.
Systemic therapies, or drugs that affect the whole body,
have seen the most evolution since the previous guidelines in 2012.
Sorafenib (Nexavar)
is the standard-of-care first-line systemic therapy for people with advanced
HCC or those with early tumours who are either considered unsuitable for or who
experience disease progression on loco-regional therapies.
The
guidelines also recommend lenvatinib (Lenvima), which has been found to
be non-inferior to sorafenib, as an alternative first-line therapy for people
with advanced HCC and good liver function.
Regorafenib
(Stivarga) is recommended as a second-line treatment for people who
experience disease progression on sorafenib. Studies have also shown that
cabozantinib (Cabometyx tablet formulation and Cometriq capsule
formulation) improved survival in this patient group.
EASL does
not yet recommend immunotherapy for liver cancer. Last September the US Food
and Drug Administration approved nivolumab (Opdivo) as second-line
therapy for people with HCC who were previously treated with sorafenib, but it
is not yet approved for this indication in Europe.
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