Hepatocellular carcinoma (HCC) is the fourth most prevalent cause of cancer-related death worldwide, and incidence in the US has tripled in the last 4 decades. Comorbidity with HIV complicates an already difficult clinical picture.
In a previous blog post on HCC care considerations, we described four leading risk factors and causal pathways for the development of HCC. Of these, hepatitis B (HBV) and C (HCV) are also risk factors in HIV. There is, thus, an elevated risk among patients living with HIV to progress toward HCC as a comorbidity.
Figure 1 HIV, HBV, HCV Coinfection Complex (Image creativemeddoses.com).
Although the incidence of HIV/AIDS has dropped in the United States due to more effective prevention and awareness, it is still a significant health risk worldwide, particularly in some African countries, and the comorbidity of HIV and HCC presents additional risks in the US and elsewhere. The clinical picture is that HIV worsens HCC, HCC adds risk to HIV, and both are much more likely when HBV or HCV are present.
Figure 2 HBV/HCV vs HIV Combined attack (Image: creativemeddoses.com)
Saud, et al (2021) found that patients with HCC who also have HBV or HCV comorbidity presented with higher mortality and had tumor diagnosis at a younger age than those without these comorbidities. Although they had a lower rate of underlying cirrhosis, there was a higher frequency of tumoral thrombosis. Berretta, et al (2011) additionally report that HIV infection increased the morbidity and mortality of patients with HCC.
Figure 3 Combined outcome of coinfection (Image: creativemeddoses.com)
On the treatment side, antiviral therapy may reduce the risk of HCC, although not eliminating it, and early detection and treatment of HBV and HCV are desirable. It is important to note that there is often limited access to clinical trials for patients living with HIV. If CD4 count is permissible for entrance to a clinical trial, there is no medical reason for the limited access based on HIV status. Clinicians should consider “carrying the flag” for patients living with HIV and help to overcome the access hurdle by promoting their case for admission.
How to Discuss HCC Staging With Patients
Discussing HCC staging with patients can be difficult. The public literature available to patients often contains misleading information, while the most trustworthy and authoritative information is usually aimed at clinicians and often only available behind paywalls. Blue Faery provides clinically accurate materials that patients will find understandable. These materials are designed to assist physicians in describing the staging and to help patients understand where they are in the spectrum.
These materials include:
- The HCC patient education brochures, written in layman’s terms and intended for patients to read, in English, Spanish, or Chinese.
- The Blue Faery HCC staging discussion pad, which contains anatomical graphics and easily understood text. Each double-sided sheet has space for clinicians to add notes for their patients to use after an appointment.
- The Patient Resource Guide for Liver Cancer is a 20-page booklet with explanations and resources pertinent to patients with HCC and their caregivers.
How to Find HCC Specialists, Treatment Options, & Clinical Trials
The treatment of HCC is best approached with a multidisciplinary team coordinated by a primary care physician. The most effective approach will likely require the expertise of multiple medical professionals and may include an oncologist with experience in HCC, gastroenterologist, hepatologist, interventional radiologist, radiation oncologist, surgical oncologist, and transplant surgeon.
To find all clinical trials, the best option is clinicaltrials.gov, but this website can be confusing and difficult to navigate. To assist clinicians in guiding patients to relevant trials, Blue Faery provides a custom HCC clinical trial navigator.
Community Support for Patients With HCC
Patient communities help provide patients with practical tips for their care journey and are often a source of emotional support from people who understand the experience.
The Blue Faery Liver Cancer Community is a free, HIPAA-compliant online community where patients and caregivers are welcome to join and to seek or exchange information relevant to HCC care. Members ask questions, discuss concerns, and find common ground as they navigate their cancer journeys. The forum moderators include community ambassadors who were former caregivers of patients with HCC.
For one-on-one patient support, Blue Faery has partnered with Imerman Angels, a nonprofit organization that provides peer-to-peer support services for the liver cancer community. Blue Faery and Imerman Angels believe that no one should face cancer alone.
Clinicians should be alert for possible HCC risk or comorbidity in patients living with HIV or who present with AIDS and be aware that HCC may be more aggressive and that these patients may face greater morbidity and mortality as a result of the comorbidity of HIV and HCC. Clinicians should be aware of barriers to enter clinical trials for patients living with HIV and be prepared to push harder for access.