Evidence Illustrates Multidisciplinary Care Is Standard in HCC

Amit G. Singal, MD

Amit G. Singal, MD

Multidisciplinary care for hepatocellular carcinoma (HCC) is more than just a good idea, Amit G. Singal, MD, MS, said during a presentation at the 2020 HCC-TAC Conference. Clinical evidence shows that patients who receive care that incorporates multiple providers from a variety disciplines leads to better results.

“Multidisciplinary care is not only something that makes us feel good, but it actually improves outcomes,” said Singal, medical director of the Liver Tumor Program at The University of Texas Southwestern (UTSW) Medical Center. “I would argue that the evidence is strong enough that we can go out there and say, ‘This is the standard of care for HCC.’”

While Singal acknowledged that both incidence and mortality of HCC are increasing, he said “this is an exciting time” to work in the field because survival is “clearly” going to improve. Patients are going to have better outcomes, and there will be see increases in bidirectional transitions between therapies, he added.

Moreover, optimal timing of appropriate therapy is key in HCC management. Prior research has demonstrated that the underuse or delays of optimal HCC treatment are associated with worse survival outcomes. In a retrospective cohort study, investigators identified 267 treatment-eligible patients, 62% of which received treatment. The median time to treatment was 1.7 months; 31% of patients experienced delays in treatment.¹

Delayed treatment was associated with the presence of ascites (HR, 2.8; 95% CI, 1.3-6.1) and current therapy with transarterial chemoembolization (HR, 4.8; 95% CI, 1.8-12.5). When adjusting for tumor stage and Child-Pugh class, treatment underuse (HR, 0.33; 95% CI, 0.24-0.46) and delayed treatment (HR, 0.50; 95% CI, 0.30-0.84) were both associated with significantly worse overall survival (OS).

Singal, who is also the David Bruton Jr Professor in Clinical Cancer Care, and associate professor of medicine at UTSW Medical Center, said most providers engage in multidisciplinary care, but there are several potential formats available, including:

• Same day, single visit: Patients see multiple providers from multiple specialties at co-located clinics;
• Multidisciplinary conference: Providers discuss care in conference, then refer the patient to the appropriate provider;
• Virtual: Physicians discuss care via teleconference, particularly areas with limited subspecialty availability.

These different formats are used in different centers,” Singal said, adding that virtual conferencing is going to be increasingly important as patients are being treated in the community, and not just in academic centers. “I think that there’s no study that has compared these different formats, but we do know, in general, some form of multidisciplinary care is good.”

He pointed to results published in 2013 showing how multidisciplinary care can affect the course of treatment. In an analysis, researchers evaluated demographic and clinicopathologic data of 343 patients presented before a multidisciplinary liver tumor board at Johns Hopkins Liver Tumor Center from 2009 to 2012. Investigators compared imaging and pathology interpretation, diagnosis, and management plans between an outside provider and physicians at the tumor center.

Of 269 patients with malignant lesions, 95 were diagnosed with HCC.

Tumor board discussions resulted in a change in imaging interpretation in 18.4% of patients, a change in pathology interpretation in 10.9%, a change in diagnosis in 8.4%, and a change in management plan for 41.7%.2 Eleven patients were deemed eligible for treatment rather than palliative care, 14 were deemed eligible for resection or transplant, and 43 were deemed eligible for systemic therapy or transarterial chemoembolization.

“There are patients who otherwise were not thought to be eligible for curative therapies and the presentation before the multidisciplinary conference changed that,” Singal said. “These are nice data in terms of how multidisciplinary conferences or multidisciplinary care can actually change management.”

Singal cited 5 trials showing that multidisciplinary care increased receipt of treatment, improved early detection, and/or changed therapy plans. The most recent data, published by Dong Hyun Sinn, MD, PhD, and colleagues in 2019, showed that multidisciplinary care improved OS in patients with HCC.

Researchers performed a retrospective cohort study of all patients diagnosed with HCC from 2005 to 2013 at Samsung Medical Center in Seoul, South Korea (n = 6619). OS rates for patients who were and were not managed via multidisciplinary care were compared with the entire cohort and with an exactly matched cohort (n = 1396).

At 5 years, the OS rate was significantly higher in the patients who received multidisciplinary care compared with those who were not at 71.2% vs 49.4%, respectively (HR, 0.47; 95% CI, 0.41-0.53; P <.001).³ The same was true in the exactly matched cohort, at 71.4% vs 58.7%, respectively (HR, 0.67; 95% CI, 0.56-0.80; P <.001).

Investigators observed a survival benefit associated with multidisciplinary management in most pre-defined subgroups, and found the effect was especially significant in patients who were Albumin-Bilirubin grade 2 or 3, Barcelona Clinic Liver Cancer stage B or C, or who had alpha-fetoprotein levels ≥200 ng/mL.

“There have been several studies now that have shown that [multidisciplinary care] improves the most important outcome for both providers and patients—it improves survival,” Singal said. “What we can say is this likely improves outcomes for all patients, but particularly these patients who require more communication and the potential for different management strategies.”

References

1. Singal AG, Waljee AK, Patel N, et al. Therapeutic delays lead to worse survival among patients with hepatocellular carcinoma. J Natl Compr Canc Netw. 2013;11(9):1101-1108. doi:10.6004/jnccn.2013.0131.
2. Zhang J, Mavros MN, Cosgrove D, et al. Impact of a single-day multidisciplinary clinic on the management of patients with liver tumours. Curr Oncol. 2013;20(2):e123—e131. doi:10.3747/co.20.1297.
3. Sinn DH, Choi GS, Park HC, et al. Multidisciplinary approach is associated with improved survival of hepatocellular carcinoma patients. PLoS One. 2019;14(1):e0210730. doi:10.1371/journal.pone.0210730.

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