Multidisciplinary Treatment a Growing Need in Liver Cancer

Michael Choti, MD

The treatment of patients with liver cancer requires a multidisciplinary approach, explains Michael Choti, MD, professor and chair of the Department of Surgery at UT Southwestern Medical Center.

“Cancer of the liver, often metastatic to the liver, is often an area that is associated with more complex management,” says Choti. “Liver cancer often involves working with the medical oncologist, surgeon, radiation oncologist, and experts in imaging, gastroenterology, and interventional radiology in order to provide the patient with the best treatment.”

There have been significant advancements in liver cancer, especially involving personalized medicine, biomarkers, and imaging, Choti adds. Treatment options have also expanded as new systemic therapies and surgical techniques are introduced.

OncLive: What advancements are occurring in the management of liver cancer?

In an interview with OncLive at the 1st Annual School of Gastrointestinal Oncology, hosted by Physicians’ Education Resource (PER) on April 23, 2016, in New York City, Choti explained the impact of these advancements and how building on them will require all oncology professionals to work as a team.Choti: Globally, we have a better understanding of personalized medicine and biomarkers to identify which patients may be better candidates for therapy that is directed at one specific organ, such as the liver. If we can understand prognostic biomarkers, we can define which patients may benefit from, for example, surgical therapy of liver metastasis. That could be very advantageous.

We are clearly making advances in that area. We are on our way to identifying better predictive biomarkers, which could tell us which patients may do better or worse with liver-directed therapy.

Significant changes are happening in how we treat patients with liver cancer. As a surgical oncologist, we are certainly increasing and improving therapies, techniques, minimally invasive surgery, and other approaches to treat patients safely and more aggressively for local or metastatic liver cancer.

What role could PD-1 agents play in the treatment landscape of liver cancer?

How do you decide which patients should receive specific therapies?

We are also seeing advancements in the area of imaging, liver-directed therapies and, of course, the systemic therapies are improving. These, along with immunotherapy, not only offer better long-term outcomes for patients, but they also increase the opportunity to reduce residual disease in the liver.This is a new class of agents that may offer the ability to treat patients who, in the past, have not been candidates for systemic therapies.The biology of GI cancer can vary not just based on the site of origin, but also based on genetics and other patterns that will predict how patients will respond. The decision of how which patients will receive which therapy is often multifactorial. It is based on a team decision, multidisciplinary tumor boards, and looking at the biology of patterns.

We do this to determine not only which type of chemotherapy a patient should receive, but also whether to offer local therapy or surgical therapy for metastatic disease. With localized GI cancer, surgical therapy is still the mainstay of curative therapy for patients. Even with the development of new agents and new therapies, these agents are largely used in patients with advanced, incurable forms of cancer.

How is it determined whether patients have resectable versus nonresectable disease?

Additionally, surgical therapy for patients with local disease is still the standard. There is an increasing ability to offer local or surgical therapies—even in patients with more advanced disease who are responding better to new systemic therapies.This is a very important topic. The reason it is an important topic is because it’s complicated—it’s not just something that is easy to define. It requires sophisticated quality of imaging, sophisticated discussion, and expertise in the surgeon and the radiologist.

There was a study that surveyed medical oncologists on whether they could determine resectable versus nonresectable disease. It is very clear that there is a major discordance between a community medical oncologist’s ability to look at either the radiologic report or the scan itself to determine if their patient is a candidate for surgery or not.

In conclusion, it is difficult for medical oncologists to determine if a patient has resectable disease; often, it requires a multidisciplinary team and their expertise in order to offer patients the best treatment.

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