Skip to main content

Advertisement

Advertisement

Improving the odds for liver cancer patients

He walked resolutely into my consultation room — tall, tanned, fit-looking and in his 40s. He sat up abruptly and said almost breathlessly: “My GP (general practitioner) says I have liver cancer.”

The National Cancer Centre Singapore holds clinical trials of novel therapies that liver cancer patients can participate in. Photo: NCCS

The National Cancer Centre Singapore holds clinical trials of novel therapies that liver cancer patients can participate in. Photo: NCCS

He walked resolutely into my consultation room — tall, tanned, fit-looking and in his 40s. He sat up abruptly and said almost breathlessly: “My GP (general practitioner) says I have liver cancer.”

A successful professional in the prime of life, he had a lovely family with children in their early teens. While serving his National Service, he was diagnosed with chronic hepatitis B, but as he had always been fit, he had not thought much about it. He loved sports and, even with his busy life, he put in a game of tennis every week.

But during the last game, he felt a sudden pain on his right flank and could not continue. Alarmed, his friends had sat him down and later took him to his GP when he felt better.

Dr Tan had an ultrasound machine in his practice, which he used to scan his patient’s abdomen. He was grim as he broke the news. The scan revealed a tumour in the right lobe of his liver which looked like it may have bled a little. The patient was reluctant to be sent to the Accident & Emergency Department as he had felt better after the initial pain. Dr Tan thus had his nurse arrange for the patient to be seen at the Liver Cancer Clinic at the National Cancer Centre Singapore (NCCS) the next morning. He had made a diagnosis of hepatocellular carcinoma (HCC).

At the NCCS, I ordered a multi-phasic CT scan which confirmed a large tumour and four smaller ones. The patient had multi-focal HCC. Fortunately for him, the cancer had remained within the liver and metastases were not found in the lungs or elsewhere, and the cancer had not invaded the veins. While the blood test showed good liver function — he was what is known as Child-Pugh A — he had locally advanced HCC. In oncology terms, he had stage IIIa liver cancer. Such presentation at diagnosis in previously-well patients is, by no means, uncommon.

Different types of cancer with the same cancer stage can have different outcomes. A patient with stage IIIa colon cancer can expect a more than 70 per cent chance of living for more than five years with treatment, while a patient with stage IIIa breast cancer can expect a more than 65 per cent chance of making it to the five-year mark. Such are the advances of science and successful multidisciplinary cancer care, which combines surgery, chemotherapy and radiation therapy when required. But a patient with stage IIIa HCC can expect a less than 30 per cent chance of making it to five years with current conventional treatment — although some of the newer therapies available may offer better outcomes.

Why the disparity? While every cancer is different and HCC is an inherently more challenging cancer to treat, one of the historical reasons behind this is that there has been very much less research carried out on liver cancer than on, say, colorectal or breast cancer. HCC has traditionally been a cancer of people from underdeveloped countries in the Third World. The main cause of HCC is chronic hepatitis B. The Asia-Pacific region carries at least 70 per cent of the world’s burden of HCC because of the high prevalence of chronic hepatitis B as well as the high population density in this region. But HCC is simply not an important cancer in most parts of the industrialised world which, until recently, were the only ones with both the financial resources and scientific capability for biomedical research.

At the multidisciplinary liver cancer clinic at the NCCS, we discussed available treatment options with the patient and his sombre family. The last decade had seen significant developments that have led to more efficacious therapies with better outcomes than the past, although the results are not quite near those for colorectal or breast cancer. While a combination of surgical resection and intraoperative radiofrequency ablation is technically feasible in him, cancer recurrence will be rapid and inevitable.

Transplantation is similarly contraindicated. A therapy known as trans-arterial chemoembolization may buy him time. An alternative would be newer therapies. Selective internal radiation therapy with the radionuclide yttrium-90 has demonstrated good efficacy in clinical studies. Similarly sorafenib, an oral anti-cancer has increased survival in patients whose cancer has spread outside of the liver.

There are also clinical trials of novel therapies that the patient could participate in at the NCCS. With careful choice of therapy, his chances of making it to five years will hopefully be better than 30 per cent. He hopes to see at least his elder daughter graduate from university. And perhaps, he muses, science can deliver more efficacious therapies which can benefit him in the interim.

Does life need to end in mid-track because cancer comes calling unexpectedly? This is currently the case for liver cancer except when it is diagnosed at the very early stage. Only advances in science and clinical therapeutics can change this course. The experience of the last 10 years has shown that this is possible. But this will require the dedication of determined scientists and clinician-scientists and adequate support for research. At Duke-NUS, we study the genomic heterogeneity of HCC to help us select the most efficacious therapies for different subsets of patients. And at our hospitals, we carry out clinical trials. The patient is hopeful. He wants to see his daughter graduate. Perhaps there may be a way that his odds may be improved.

 

*The patient described in this commentary is not an actual patient, but a composite of many patients.

 

ABOUT THE AUTHOR:

Pierce Chow is Professor in the Office of Clinical Sciences at the Duke-NUS Graduate Medical School Singapore and Senior Consultant Surgeon at the National Cancer Centre Singapore and the Singapore General Hospital. He has led five multi-centre clinical trials of the Asia-Pacific Hepatocellular Carcinoma trials group, that have involved more than 30 centres in 14 countries.

Read more of the latest in

Advertisement

Advertisement

Stay in the know. Anytime. Anywhere.

Subscribe to get daily news updates, insights and must reads delivered straight to your inbox.

By clicking subscribe, I agree for my personal data to be used to send me TODAY newsletters, promotional offers and for research and analysis.