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Gradual Gains in Liver Cancer

Refined treatments and targeted drugs signal slow yet significant progress for liver cancer.

BY HEATHER L. VAN EPPS, PHD
PUBLISHED SUNDAY, JUNE 15, 2014
“Every day of my life, I’m thankful for kidney stones,” says 50-year-old Kathy Dayton. It might seem like an odd sentiment until you learn that the imaging scan she received in February 2011 revealed not only a kidney stone but also stage 1 liver cancer. Because it was diagnosed early and her liver was functioning well, Dayton’s tumor could be surgically removed. Although the tumor returned a year later, today she is cancer-free. Primary liver cancer is a complex disease, and progress in treating it has been slow. Nexavar (sorafenib) remains the only approved drug for treating advanced forms of the disease, and its effects on survival are modest. Although it’s unlikely that liver cancer treatments will dramatically improve in the near future, the situation is gradually brightening with recent advances in diagnostics, radiation techniques and chemotherapy.

Hepatocellular carcinoma (HCC), the most common form of primary liver cancer, is a leading cause of cancer-related death worldwide, with more than 700,000 cases diagnosed each year.

Unlike many other types of cancer, its incidence has been rising for decades. Dayton’s road to HCC began in 1984, during her work as a dialysis nurse. She was stuck with a needle from a patient infected with the hepatitis C virus, and 10 years later, a blood test revealed that she had contracted the virus.

Over the years, Dayton hadn’t thought much about her hepatitis status because the levels of the virus in her system were very low and her liver was functioning well. So the HCC diagnosis came as something of a shock.

Unlike Dayton, the vast majority of patients who receive an HCC diagnosis have relatively poor liver function due to underlying disease, most often from viral hepatitis. Other factors thought to cause HCC include cirrhosis (scarring), which is primarily associated with chronic alcohol consumption, and nonalcoholic steatohepatitis (NASH), a condition associated with obesity. In fact, the obesity epidemic may help to explain the rising incidence that has been seen in individuals without hepatitis or a history of alcohol abuse.

With HCC, the best hope for a cure is with surgical removal of the tumor or, in some cases, liver transplantation, a procedure available only to patients who have localized disease and a limited number of small tumors. And because the demand for donor livers far outweighs the supply, patients like Dayton, who has well-preserved liver function, generally must wait behind patients who are critically ill.

Marilyn Townsend’s liver function was starting to decline in the summer of 2009, 18 years after she learned she had hepatitis C, which she most likely acquired after receiving contaminated blood in the era before blood banks routinely screened for the virus. An imaging scan revealed a single small tumor on her liver that was too close to a major blood vessel to be removed surgically, and because she was also in the early stages of cirrhosis, her name was added to the transplantion list. “They laid it on me all at once,” says Townsend, of her HCC diagnosis and the news that she would need a liver transplantation. She received a new liver after a three-month wait, and her scans have since shown no signs of HCC.

"They laid it on me all at once."

When localized to specific segments of the liver, early-stage HCC can also be potentially cured with local tumor ablation, an approach involving the direct delivery of tumor-destroying chemicals or extreme temperatures, although both techniques have approximately a 50 percent rate of recurrence. Dayton’s small tumor was removed a month after her diagnosis, keeping her cancer at bay for a year. Whether the most effective form of local ablation—heat-based radiofrequency ablation—can match the effectiveness of surgery is unclear.

Perhaps the best way to improve the sobering statistics associated with HCC is to catch and treat the disease early in a larger number of patients. This means keeping a close eye on those at high risk, particularly as symptoms of HCC, including pain, fatigue, weight loss and jaundice, often overlap with those of the underlying liver disease. Screening standards for high-risk patients, including those who have cirrhosis or viral hepatitis, now include annual or biannual liver ultrasounds and other routine tests to measure blood levels of alphafetoprotein (AFP), a protein produced by cancer cells that is increased in roughly 70 percent of patients with HCC.

Despite these advances, Mary Maluccio, a surgical oncologist at Indiana University Hospital in Indianapolis, thinks more should be done. “We have largely ignored the fact that if we diagnosed it early, we might have seen a plateau [in HCC incidence] just like we have with the other cancers,” she says.

[Read "Finding the Positives in Negative Results"]

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