Best Treatment Approach Controversial in HCC



ORLANDO – Treatment centers and surgeons tend to play to their strengths when choosing therapy for patients with well-compensated cirrhosis of the liver and early hepatocellular carcinoma, investigators reported at a symposium sponsored by the Society of Surgical Oncology.

Therapy for early HCC with well-compensated cirrhosis is controversial; there is little agreement on when resection, transplantation, or radiofrequency ablation becomes the best approach. Choice of therapy for early HCC often depends on the surgeon’s repertoire of techniques and the therapeutic services the hospital offers, based on the findings of a web-based survey of centers that had at least five HCC cases per year.

"This study demonstrates that nonclinical factors have an important effect of therapy for early HCC, and in particular the choice of therapy depends in part on the surgeon’s portfolio of techniques, as well as the availability of transplantation services," said Dr. Hari Nathan of the department of surgery at Johns Hopkins Hospital in Baltimore.

In a previous analysis of the data from their web-based survey, Dr. Nathan and colleagues found that surgeon specialty was more important than certain patient-specific factors when determining treatment choice (J. Clin. Oncol. 2011;29:619-25).

"Differences in choice of therapy for nontransplant and transplant surgeons were not the result of an across-the-board preference for one therapy vs. another. Rather, some clinical factors impacted surgeons differently, depending on their specialty," he said.

In the new analysis, the authors used the survey data to assess the effect of surgeon and hospital factors on the choice of therapy for early, well-compensated HCC, and the effect of regional liver transplantation services on the surgeon’s choice of therapy.

They defined early HCC according to the Milan criteria as a single tumor less than 5 cm in its largest dimension, or two to three tumors less than 3 cm. Cirrhosis was considered to be well compensated if it was Child-Pugh class A, with no varices, ascites, or encephalopathy.

They presented respondents with case scenarios factoring in age, tumor number and size, type of resection required, etiology of cirrhosis (hepatitis B or C, or alcoholic), biological MELD (Model for End-Stage Liver Disease) score, platelet count, and anticipated transplantation waiting time.

Of the 1,032 invitations they extended, 336 surgeons (33%) responded. Of the respondents, 284 (85%) were in academic practices and 52 (15%) were in community practices for a median of 10 years (range, 4-17 years). About two-thirds (65%) were trained in liver transplantation. Procedures performed for HCC included transplantation and radiofrequency ablation (41% of responders), transplantation alone (14%), or liver resection but not transplantation (45%). Asked which procedures were available at their primary hospital (regardless of whether the respondent performed them personally), 100% said that resections were available, and 99% said that ablations were available. In contrast, transplantations were available at 71% of respondents’ hospitals.

The authors found that neither years in practice, surgical oncology training, nor liver transplantation training had a significant effect on treatment choice. Similarly, regional transplantation variables – such as number of procedures, percentage of transplant recipients with HCC, 30th percentile of liver transplantation wait time, and severity of illness by median MELD score – did not significantly predict treatment choice.

There was, however, significant variation in therapeutic choice based on practice type, adjusted for case presentation, with surgeons in academic practices favoring transplantation 57% of the time, compared with 47% for those in community practice. Community-based surgeons were more likely to favor liver resection (45% vs. 38% for academic surgeons), and radiofrequency ablation (9% vs. 4%).

In regression analysis that controlled for clinical factors, they found that surgeons in academic setting were significantly less likely than community-based surgeons to recommend ablation over liver transplantation (relative risk ratio [RRR], 0.41; P = .01). When they looked at the effect of practice types’ controlling for surgeons’ specialties, however, the significance of the practice type on treatment choice disappeared.

Regression analysis also showed that "higher volume surgeons prefer transplantation over resection more strongly than lower-volume surgeons," Dr. Nathan said.

High-volume surgeons (defined as those performing 30 or more cases annually) were overwhelmingly transplantation surgeons; when the authors adjusted for whether the surgeon performed transplantations, the preference for transplantation disappeared.

Additionally, nontransplantation surgeons who worked at hospitals where transplantations were available were more likely to recommend transplantation over ablation, compared with surgeons working at nontransplantation hospitals.

"Interestingly, they also favored resection over radiofrequency ablation more strongly. This appeared to be a separate phenomenon than the one that we observed for the portfolio – that’s personally performed by each surgeon – and in regression analyses these effects were independent," he said.


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