“It is essential that all patients be evaluated by a multidisciplinary team prior to initiation of treatment,” reads the latest clinical practice guideline on hepatobiliary cancers from the NCCN. “Careful patient selection for treatment and patient engagement are essential.” Similarly, the latest guideline from ASCO on systemic therapy for advanced hepatocellular carcinoma (HCC) recommends “wherever possible, treatment decisions for patients with advanced HCC be made by a multidisciplinary team, including hepatologists, surgeons, radiologists (including interventional radiologists), pathologists, and oncologists.”

We spoke with Cleveland Clinic GI Oncologist Bassam Estfan, MD, about why it’s particularly important to take a multidisciplinary approach to caring for patients with advanced HCC. “Patients with HCC don’t usually have one serious illness, but often have underlying cirrhosis of varying degrees of compensation,” he notes. “The uniqueness of the liver makes it a target for potentially multiple approaches to treat HCC. Thus, a multidisciplinary approach allows for a comprehensive evaluation of the patient and their illnesses, both underlying liver disease and cancer. For instance, two patients with the same size cancer in the liver may be recommended completely different treatment based on age, underlying liver disease status, anatomical location, and other comorbidities. It is also important that these cases are discussed in dedicated multidisciplinary tumor boards.”

Offering a personal perspective on the topic, Dr. Estfan adds that the multidisciplinary team that treats patients with advanced HCC at the Cleveland Clinic includes specialist in liver surgery, oncology, hepatology, interventional radiology, radiation oncology, general radiology, and social work, as well as transplant coordinators. “The management options for HCC include a wide array of treatments and interventions, including resection, transplantation, embolization, radiation, and systemic therapy,” he notes. “Thus, each team member’s role is important in assessing the role they can bring to the management, which may or may not be feasible. Team members interact directly during clinic days through discussion of cases, imaging review, and brainstorming. Sometimes, this leads to having other team members see patients for new consultations. Another forum of interaction is through tumor boards, in which cases that may have been seen previously are discussed, and here the role of an expert radiologist, for instance, is vastly important. We assess patients who have received prior care or work up in other cities, states, or countries, and a critical review of prior imaging can lead to new information that helps the team make appropriate management decisions. For instance, new lesions that were not previously realized may change management from continued observation to liver transplantation.”

The team members at the Cleveland Clinic communicate well, according to Dr. Estfan . “We are fortunate at the Cleveland Clinic to have a dedicated multidisciplinary liver cancer clinic in which all specialists participate,” he adds. “We triage our new patients to make sure they get to see the right providers, we discuss patients’ cases in clinic and make accommodations to meet other specialists, and we have tests or blood work done when needed. These same specialists and more are also part of the tumor board discussing each case.”

Part of that testing includes selecting which patients with advanced HCC at candidates for systemic therapy. “Given that most patients with hepatocellular carcinoma have underlying cirrhosis, assessing the degree of liver health is important for several reasons,” says dr. Estfan. “First, almost all trials of systemic therapy in liver cancer are only done and assessed for safety in those with optimal hepatic function compensation (ie, Child-Pugh Class A cirrhosis). For instance, someone with a high Child-Pugh score is not only at risk for increased side effects and decreased benefit from systemic therapy, they are also at an increased risk for shorter survival from a cirrhosis stand point.”

In such situations, multidisciplinary care becomes even more important in individualizing care, according to Dr. Estfan. “A patient with a high Child-Pugh score, or Na-MELD score (another metric to evaluate patients with cirrhosis) may need to be considered for transplant if possible,” he notes. “The team will investigate ways to safely deliver treatments, which might be locoregional, in order to achieve optimal outcomes. In assessing each individual, we take into account different factors that play into decision making, and no two individuals are the same. These factors include, but are not limited to, specifics such as age, performance status, causes of underlying liver disease, if any, degree of cirrhosis, other comorbidities, personal habits, social support, patient wishes, underlying liver and renal functions, and the location, number, and size of cancerous lesions.