ASCO guidelines for hepatocellular carcinoma (HCC) are based on nine randomized phase 3 clinical trials of systemic therapy for advanced disease, while NCCN guidelines include information on screening, diagnosis, and staging in addition to treatment. Physician’s Weekly spoke with a panel of experts in hepatology and oncology to discuss the role of these two treatment guidelines in the management HCC, as well as their opinions on the role of a multidisciplinary team in treating this cancer.
PW: In their HCC guideline, ASCO relied on systematic reviews, while NCCN relied on narrative views. What are the benefits of these two approaches?
Amit Singal, MD
Medical Director of Liver Tumor Program
Chief of Hepatology
Professor of Medicine
University of Texas Southwestern Medical Center
Dr. Singal: This is an approach that many societies have taken: Guidelines dependent on systematic reviews, which minimize bias and allow assessments of literature quality, versus guidance documents that are still evidence-based but do not include systematic reviews. The latter allows more leeway for guidance in areas where current data are insufficient. Both are valuable and complementary.
Bassam Estfan, MD
Assistant Professor of Medicine
Case Western Reserve University
Dr. Estfan: All guidelines try to follow evidence-based data. ASCO’s approach serves as a good source for those wanting to learn about available data, major research trials, and how treatments compare to each other. On the other hand, NCCN looks at all the data and formulates it in a way that is useful for clinical practice. An advantage to the NCCN approach is the continuous collective effort to update the guideline yearly. There is value to both approaches.
Robert G. Gish, MD
Robert G. Gish Consultants, LLC
Professor of Medicine
Loma Linda University
University of California
University of Nevada Reno
Adjunct Professor of Medicine
University of Nevada Las Vegas
Dr. Gish: It’s complementary. The systematic reviews include very detailed grades of evidence. The research used in developing guidelines is very strict and often ignores case series and clinical experience, often lagging behind current evidence by 5 years or more. The upside is that they’re very critical and analytical, and once they make a statement, it’s usually a very high-quality statement.
Narrative reviews, like NCCN, tend to be more current and more focused on what happens in a real multidisciplinary team.
Gentry King, MD
Fred Hutchinson Cancer Center
University of Washington
Dr. King: The ASCO guidelines are more descriptive, and they provide more insight into what the consensus of the panel is. That document provides algorithms that say what to do with cancer at this stage, and the level of evidence is indicated in terms of its strength.
The advantage of the NCCN guidelines is that they are updated very regularly to incorporate new treatments and recommendations in real time.
These guidelines serve different purposes. They are more complementary than competitive.
Why is a multidisciplinary approach important in HCC?
Dr. Singal: Patients with advanced HCC have multiple needs that includes management of the cancer as well as underlying liver disease. Further, objective responses have increased, so shifts in the treatment paradigm and downstaging to locoregional or even surgical therapies are increasingly possible and must be considered in a multidisciplinary manner. Multidisciplinary care will also be increasingly important if ongoing trials of combination therapies yield positive results.
Dr. Estfan: Patients with HCC don’t usually have one serious illness only; they often have underlying cirrhosis of varying degrees of compensation. The uniqueness of the liver makes it a target for, potentially, multiple HCC treatment approaches. Thus, a multidisciplinary approach allows for a comprehensive evaluation of the patient and their illnesses, both the underlying liver disease and cancer.
It is also important that these cases are discussed in dedicated multidisciplinary tumor boards. Our multidisciplinary team includes liver surgery, oncology, hepatology, interventional radiology, radiation oncology, transplant coordinators, social work, and radiology. These same specialists, and others, are also part of the tumor board.
Dr. Gish: When a patient receives the diagnosis of liver cancer, I usually note that we have at least 11 treatment options. Treatment might include a liver transplant, and therefore you need a liver transplant hepatologist and surgeon. The next option would be surgical resection. The third option includes a menu of thermal tools from interventional radiologists.
In the oncology space, there are a variety of systemic targeted therapies and checkpoint inhibitors. Many patients are getting combined or sequential therapies.
No one person can be state of the art on everything that I’ve just listed. Each of those skills has to be represented on a multidisciplinary team to get the best outcomes.
Dr. King: The radiologist is a very important part of our multidisciplinary tumor board. HCC is diagnosed with imaging, and their expertise is very valuable because there are some things that are just not straightforward.
We also have radiation oncologists and interventional radiologists. They both deliver the same type of treatment, radiation, but they deliver it in different ways. Because their perspectives vary, though, I learn a lot. Plus, our tools are expanding, not only from the medical oncology perspective but also for radiation oncology; they have proton therapy now.
Multidisciplinary care is optimal for patients with liver cancer. It still surprises me to this day how different the perspective can be based on your expertise.