Tumor boards help ensure that patients with hepatocellular carcinoma receive individualized care, rather than care based on more “black and white” rules.
The latest guidelines from multiple professional societies—including NCCN, ASCO, the Barcelona Clinic, and the American Association for the Study of Liver Diseases—recommend strongly that patients with hepatocellular carcinoma (HCC) be evaluated by a multidisciplinary team. “When you have a hammer, everything is a nail,” explains Nadine Abi-Jaoudeh, MD, FSIR, CCRP. “The multidisciplinary approach allows patients access to all the specialists who might be involved in the management of HCC, therefore optimizing their chances to get the best treatment. This has been shown in published studies.”
Dr. Abi-Jaoudeh notes that tumor board meetings—when treatment plans for new and complex cancer cases are discussed by multidisciplinary teams to decide, as a group, on the best treatment plans for a patient—allow for previously unconsidered solutions to become apparent.
Gathering Input From Every Specialty
“The interactions of multidisciplinary teams vary,” she adds. “However, the best multidisciplinary interactions consist of input from every potentially involved specialty. Medical knowledge is growing at an exponential level, and it is not possible to stay up to date on new developments in other specialty literature to the extent that the specialists themselves know it. This is why having those interactions and discussions is so important. It is a teaching and learning experience as we find out about the latest studies from each other’s specialties. It is also a way to narrow down gaps in the literature.”
As an interventional radiologist, Dr. Abi-Jaoudeh offers the example that “radiology’s review of the imaging can result in changes in management, because they can point to a subtle finding that would change operative risk or disease features that can change risk assessment. For example, an HCC can be well circumscribed or infiltrative, and for the same size lesion, infiltrative—which is not always described in the report—is more aggressive.”
The multidisciplinary team of which Dr. Abi-Jaoudeh is a member communicates well, she says. The collegial environment includes a shared knowledge that all members have a role and that both patients and clinicians will be treated with respect. “The main goal is to provide the patient with the best outcome,” she adds. “We are patient-centric, and things fall into place as a result.”
The Importance of Individualized Care
The role of the multidisciplinary team is of great importance in treating patients with advanced HCC due to the particular importance of individualizing care for this patient population. “There are specific characteristics unique to individuals with advanced HCC that make them better suited for one therapy versus another,” says Dr. Abi-Jaoudeh. “HCC staging is very broad. Intermediate and advanced stages can be divided into multiple categories and several clinical factors come into play. Two patients can be classified as intermediate stage but have different disease burdens. Also, one patient may have underlying portal hypertension or varices that are prone to bleeding and not easily banded. This is why assessing each patient individually and discussing cases at tumor boards are essential.”
It is these discussions at tumor board meetings that help ensure care is individualized as opposed to being based on more “black and white” rules that may leave some patients without care that they could have benefited from, Dr. Abi-Jaoudeh explains. “This is why patients who are not discussed at tumor boards have lower survival,” she adds.
To also help ensure individualized care, Dr. Abi-Jaoudeh utilizes tools that include the Child-Pugh score. She notes that patients with a very high score (ie, 8 or 9) are sometimes placed on immunotherapy alone, whereas those with better functional status and a good Child-Pugh score are often placed on trials, if eligible, or a combination of locoregional and systemic therapies. “The tumor board and I follow the Barcelona Clinic Liver Cancer guidelines and use Child-Pugh and alpha-fetoprotein tumor scores to guide decisions,” Dr. Abi-Jaoudeh says.
- Subtle changes in hepatocellular carcinoma (HCC) can influence operative risk or disease features, which can change risk assessment
- The multidisciplinary team enables attention to these subtle changes, which can result in more individualized care for this patient population
- To further individualize care, clinicians can utilize tools such as the Child-Pugh score and alpha-fetoprotein tumor scores
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