Liver Cancer Treatment and Disease Course: What Has Changed in the Last 20 Years?

Changes in hepatocellular cancer over the last 20 years were summarized in a striking article published in “Liver International.” The study examined patients treated between 1986 - 1992 and 2006 – 2012, involving 1318 hepatocellular cancer (HCC) patients. The article discussed the positive effects of innovations in both technology and treatment for patients during these two periods.

Hepatocellular cancer is the most common liver cancer and, by its nature, one of the difficult tumor types to manage. Hepatitis B virus first comes to mind when we discuss hepatocellular cancer. Looking broadly at the factors causing hepatocellular cancers worldwide, nearly % 66 are associated with Hepatitis B.

First of all, since % 66 of hepatocellular cancer is associated with Hepatitis B, this shows that we face a preventable cancer. In other words, if Hepatitis B vaccination is properly followed from birth, nearly %70 of hepatocellular cancers worldwide could be eliminated. Looking at the last 20 years, surgical treatments extending as far as liver transplantation have become readily applicable worldwide. Adding local ablative treatments such as alcohol injection, radiofrequency ablation (destroying the tumor by burning), or cryoablation (destroying the tumor by freezing) has provided substantial advantages. In addition, arterial treatments combined with chemotherapy, particularly the successful use of occluding or embolizing agents and radioactive substances, are important treatment changes for this patient group over the last 20 years. As is known, targeted therapies have increased survival in almost all tumors over the last 10 years. In hepatocellular cancer too, sorafenib , a targeted drug, made a survival difference. Until 2017, patients with advanced or surgically unresectable liver cancer had no effective second-line treatment option. In 2017, first regorafeniband then the cancer immunotherapy nivolumab received FDA approval, creating new treatment opportunities for patients after sorafenib.

Let Us Now Summarize What Has Changed in Hepatocellular Cancer Treatment Over the Last 20 Years and What Needs to Change:

1) We see that Hepatitis B virus was the most important cause of hepatocellular cancer from 1986 to 2012 (1986 – 1992: % 66.2, 2006 – 2012: % 66). Although this cancer type is preventable, the incidence of Hepatitis B-related hepatocellular cancer did not change between 1986 - 1992 and 2006 - 2012. This shows that countries lack sufficient awareness of a regional prevention strategy and that no change has therefore occurred.

2) Looking at 2006 - 2012, the rate of cancer diagnosis at an early stage was higher.

3) There appears to be no clear change in surgical resection rates. However, while transarterial chemoembolization treatments were more frequent between 1986 - 1992, local ablative treatments were used more often between 2006 – 2012. Whereas treatments blocking tumor vessels were more common previously, technological progress has markedly increased the use of radiofrequency ablation, a burning method performed by inserting a needle through the skin into the liver. The rate of arterial chemoembolization was %40.6, while subsequently local ablative treatment use was %55. This can be summarized as a positive use of technology. Transarterial treatments were more difficult and risky for both patient and practitioner, whereas radiofrequency ablation is now much more practical. Interventional radiology can readily select and perform it. This shows how local ablative therapies have developed.

4) One very important point, considering all these advances, is that patients with hepatocellular cancer treated between 2006 and 2012 lived markedly longer than those treated in 1986 - 1992 (average survival 1986 – 1992: 7.9 months, 2006 – 2012: 65 months). This shows that one of the most important changes came from detecting cancer at an early stage, one of the most fundamental determinants of long survival.

Looking at the 20-year period, longer survival results from early liver cancer detection and advances in treatment. However, the unchanged role of Hepatitis B virus in causing % 66 of these cancers disappoints us. Considering that over these 20 years the public and physicians have become more aware, information has become more accessible, and people have increasingly questioned their medical conditions, the absence of change in the Hepatitis B rate is disappointing. This reveals a new goal for us: should we emphasize treatment or prevention? I think we must strike this balance well. Over the last 20 years, we seem to have focused on treatment rather than preventive approaches. Yet for a disease that could be eliminated at a rate of %66, more successful outcomes could be achieved if every country's strategy invested as much as, or perhaps more than, its treatment research investment in prevention.