Download 2. Follow-up

A Decision Aid for Patients with Chronic Liver
Disease
Westmead, Royal Prince Alfred and
Concord Hospitals
Hepatocellular carcinoma (HCC) or primary liver cancer is the eighth commonest
cancer in the world. The estimated number of new cases globally is 500,000 per year
and there are approximately one million deaths annually. In the past, the survival of
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patients with HCC was very low, however, with newer imaging technologies and
treatments, the survival has improved.
1-What is the liver?
The liver is the largest internal organ
in the body. It lies beneath your ribs
under the right lung and diaphragm. If
you were to poke your fingers under
your right ribs, you would almost be
touching the liver.
The liver is shaped like a pyramid and
is divided into right and left lobes. Unlike most other organs, the liver receives blood
from two sources. The hepatic artery supplies the liver with blood that is rich in
oxygen. The portal vein carries nutrient-rich blood from the intestines to the liver.
2. Liver function
You cannot live without your liver. It
processes and stores many of the nutrients
absorbed from the intestine that are
necessary for life. The liver also produces
some of the clotting factors that keep you
from bleeding too much when you are cut or injured. It secretes bile into the intestine
to help absorb nutrients. The liver additionally removes toxic wastes
from the body.
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3. What is a liver tumour?
You've heard the term "liver cancer" before, but what does it mean? Cancer occurs
when cells in a part of the body begin to grow out of control. Although there are
many kinds of cancer, they all come about because of out-of-control growth of
abnormal cells. Most kinds of cancer are named after the part of the body where the
cancer first arises. Because the liver is made up of several different types of cells,
several types of tumours can form in the liver. Some of these are cancerous
(malignant) and some are not cancerous (benign). These tumours have different
causes and are treated differently. The outlook for your health or recovery depends
on what type of tumour you have.
♣. Benign Tumours
The most common type of benign liver tumour starts in blood
vessels. It is called a haemangioma. Hepatic adenomas and
focal nodular hyperplasia are other types of benign liver tumours. Because most of
these tumours don't cause symptoms, they usually do not need treatment, although
some may bleed and need to be removed by surgery.
♣. Malignant Tumours
The most common form of liver cancer in adults is called
Hepatocellular carcinoma. Liver cancers can present as single
or multiple. Their rate of growth and capacity to spread are
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highly variable. The information to follow will be exclusively related to primary
liver cancer or Hepatocellular carcinoma (HCC).
4. What are the risk factors for developing liver cancer?
A risk factor is anything that increases a person's likelihood of
getting a disease such as cancer. Different cancers have different
risk factors. For example, exposing skin to strong sunlight is a
risk factor for skin cancer. Smoking is a risk factor for cancers of the lung, mouth,
larynx, bladder, kidney, and several other organs. It is however important to
understand that having a risk factor, or even several, does not mean that a person will
get the disease. Scientists have found several risk factors that make a person more
likely to develop Hepatocellular carcinoma.
4.1. Advanced liver disease (Cirrhosis)
Cirrhosis (severe scarring) is the end result of chronic inflammation of the liver.
About 75-90% of all HCCs occur in patient with advanced fibrosis and cirrhosis. In
fact cirrhosis may be a premalignant condition, regardless of the cause of the liver
disease. In Australia, 93% of liver cancers were found in patients with cirrhosis. The
incidence of HCC in patients with cirrhosis is 5 to 10 times greater than in patients
without cirrhosis.
4.2. Viral Hepatitis
Chronic infection with hepatitis B virus (HBV) and hepatitis C
virus (HCV) is a major risk factor for developing liver cancer.
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4.3. Alcohol consumption
In western countries excessive alcohol consumption plays an
important role in the development of HCC.
4.5. Birth Control Pills
Oral contraceptives may slightly increase the risk of HCC. Most
of the studies linking oral contraceptives and liver cancer involve
types of oral contraceptives that are no longer used. Current oral contraceptives are
different and it is not known if the newer oral contraceptives significantly increase
HCC risk.
4.6. Anabolic Steroids
Anabolic steroids are male hormones that are used by some
athletes to increase their strength. Long-term anabolic steroid
use can slightly increase the risk of liver cancer.
5. Survival of patients with HCC:
Without treatment, the survival of patients with HCC is poor. Patients with advanced
HCC only live on average, 1-3 months from the time of diagnosis. Several factors
are related to the prognosis and survival of patients with HCC. These include the
severity of the underlying liver disease, the number and size of tumours and the
presence of metastases (spread of cancer to other areas of the body).
6. Treatment for liver cancer
There are two kind of treatment for liver cancer: Surgical and non surgical therapy.
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6.1. Surgical therapy
This involves either resection (removal) of the tumour or
liver transplantation. Removing the cancer will rid the body
of the cancer and also prevent spread to other regions.
Unfortunately, not all patients are eligible for a liver
resection. Patients with small tumours are the best candidates for surgery or liver
transplantation.
6.2. Non-surgical therapy
Non-surgical therapies mainly involve the direct attacking on the tumour
by injection of alcohol or chemotherapy in to the tumour or
application of ultrasonic waves to the cancerous cells. This
treatment is administered to patients who refuse surgery or who
have severe liver disease that prevents them from having liver
surgery.
7. Prevention of HCC
Prevention of HCC involves both primary (before getting the
disease) and secondary prevention (reducing consequences of the
disease).
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7.1. Primary prevention
Public health methods that reduce exposure to risk factors can
help prevent most liver cancers. These include vaccination
against hepatitis B, avoiding excessive alcohol consumption,
avoiding utilizing used needles and unprotected sexual
intercourse, as well as other risk factors mentioned previously.
7.2. Secondary prevention of HCC
This involves the use of measures that delay or halt the further progression of liver
disease or tumour development. These include antiviral therapy in infected patients
with viral hepatitis B and/or C, surgery, liver transplantation and other local therapies.
However, the growth pattern of HCC in the majority of patients is very silent and
once symptomatic, the outlook is not good. Therefore, another approach to secondary
prevention of HCC is the use of imaging techniques and tumour markers to find the
tumour at an early stage in high risk patients (screening). The onset of symptoms
usually signifies advanced cancer that is often not suited to curative therapy.
8. What does screening mean?
Screening for cancer is the examination (or testing) of
people at the early stages in the development of tumours
even though they have no symptoms. Scientists have
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studied patterns of cancer in the population to learn which people are more likely to
get certain types of cancer. They have also studied what things around us and what
things we do in our lives cause cancer. This information sometimes helps doctors
recommend who should be screened for certain types of cancer, what types of
screening tests people should have, and how often these tests should be done. If your
doctor suggests certain cancer screening tests as part of your health care plan, this
does not mean he or she thinks you have cancer. Screening tests are done when
you have no symptoms. Screening for HCC often permits the diagnosis at a stage
when it is small and limited to the liver. Such tumours are frequently amenable to
resection or transplantation or other local therapies resulting in prolonged survival.
If your doctor suspects that you may have cancer, he or she will order certain tests to
confirm this. These are called diagnostic tests.
9. How screening is useful for the early detection of
liver cancer
HCC has a well-known natural history, the majority of the
growth takes place in the asymptomatic phase, which may be years in length.
During this time the tumour releases a chemical substance in to the blood which is
detectable via laboratory tests. Moreover, imaging techniques can be used to locate
the tumour itself when it is small.
10. Does screening improve the survival of patients with HCC?
It is still uncertain whether early diagnosis of
HCC increases the actual survival of patients,
and experts actually disagree on the likely
effectiveness. This is because no study has
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compared the survival of patients subjected to a screening program with those
whose cancer was detected outside of a screening program. However, it is proven
that the rate/frequency of cancer spread increases (metastasis) in proportion to the
size of the tumour. It therefore seems likely, that the identification of small
tumours may increase the survival of patients by decreasing the probability of
spread. Early detection may also increase the chance of resectability (suitability for
surgery) and facilitate longer survival after surgery.
Most studies which have demonstrated the usefulness of screening programs to
improve the survival of patients with HCC come from Asian countries like Japan,
China, Thailand and Taiwan, or southern Europe (Spain, Italy) where liver cancer
is more common. However, not all these studies have produced similar results,
and some show no improvement in survival rate for patients subjected to
surveillance programs, especially in Western patients.
11. What we want to do?
To date there is no information about the usefulness of a liver cancerscreening program in Australia. Investigators at Westmead Hospital
and Royal Prince Alfred Hospital in Sydney are trying to find ways
to increase the survival of patients with liver cancer. They have therefore
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designed a study to compare the survival of patients subjected to a screening program
with that of persons in whom liver cancer is detected out of a screening program. For
this reason, patients with advanced liver scarring (most at risk of liver cancer) will be
requested to enrol in a study that compares screening verus no screening in the
detection of primary liver cancer.
Patients may decide on one of these options, they may
1- Wish to enter a liver cancer screening program.
2- Decline to enter a liver cancer screening program.
3- Be unsure of what to do but are happy to participate.
Patients in group one who elect to be screened will be assessed as follows:
1. Baseline assessment:
a) An interview
At entry the following information may be asked of you:
Demographic data, viral risk factors, ethnicity, substance and
toxin exposure, family history related to liver cancer and
medical history.
b) Laboratory tests:
Blood sample will be drawn for laboratory tests and detection
of tumour marker.
C) Ultrasound:
All patients will be subject to a baseline liver ultrasound.
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2. Follow-up
Patients in the screening program will be assessed every three months. These
assessments will include a physical examination, blood tests and a liver ultrasound
that will be compared to that obtained at the previous visit. If suspicious lesions are
found at any stage of the study (such as an abnormal lab result or a suspicious lesion
on ultrasound) further investigation by MRI and CT scan will be performed and
treatment instituted as appropriate.
Patients who elect not to enrol in the screening program will not be
disadvantaged in any way. They will still have full access to clinic
services and will be monitored as considered appropriate by the
treating physicians.
12. What you should do?
You should decide whether you would like to be on screening
program or would prefer not to be screened. Since decisions about
screening can be difficult, it can be helpful to discuss them with your
family doctor and particularly to ask questions about the potential benefits, risks,
convenience and discomfort from screening tests, and whether they have been
proven to reduce the risk of dying from cancer.
14. What would happen if you are not able to make a decision?
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If you are not able to make a decision about the screening program then investigators
will randomly assign you to screening or no screening group. (equivalent to tossing a
coin).
The potential benefits and disadvantages of
screening
ADVANTAGES
DISADVANTAGES
.
It is uncertain that it can
increase your life
expectancy
It can detect tumours at an
earlier stage
Small tumours are more
likely to be suitable for
surgery
There is no evidence that
screening is cost effective
Inconvenience of clinical
visits, ultrasounds and other
tests every six months
Early detection may
prevent tumour from
spreading
It might increase your life
expectancy
Yes
Anxiety from false positive
result
Unsure
Screening
No
No-Screening
What is your decision?
You should weigh the benefits and disadvantages of this screening program for your
situation then decide to which group to be in. If you are unsure, ask the investigator to
assign you to one group.
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