Patterns of presentation, referral, and treatment of hepatocellular carcinoma in a pre-sorafenib era: experience of a Canadian provincial cancer agency

Abstract

Background: Systemic treatment options in hepatocellular carcinoma (hcc) are limited. Sorafenib, a multikinase inhibitor, has been shown to improve survival in patients with advanced hcc and adequate hepatic reserve. Currently, the proportion of referred patients with hcc that would be eligible for sorafenib therapy is unclear. We reviewed patterns in the presentation and management of referred patients with hcc at the BC Cancer Agency (bcca) before the availability of sorafenib.

Methods: Records of patients with hcc referred to the bcca from January 1, 2003, to December 31, 2007, were reviewed. Distributions were analyzed using frequency statistics.

Results: Of 518 patients reviewed, 77% were men and 45% were of Asian ethnicity; median age was 64 years. Histology confirmation was available in only 34% of the patients; 64% had an elevated level of alpha-fetoprotein at diagnosis. The Child-Pugh score at presentation could not be determined in 56%; the most common missing variable was albumin (44%). Among the 226 evaluable patients, the Child-Pugh classification was A in 140 (62%), B in 64 (28%), and C in 22 (10%). Eastern Cooperative Oncology Group performance status was not documented in 40% of patients. The TNM staging was recorded per agency protocol; however, it was incompletely documented in most patients. Distant metastases were recorded in 12% of patients, and 75 patients (15%) underwent hepatic resection before referral. After bcca referral, no further therapy was offered to 287 patients (54%), regional therapy was offered to 170 (33%), and chemotherapy was offered to 67 (13%).

Conclusions: In this era of targeted therapies, characterizing the proportion of patients with hcc that would be eligible for such therapies is important. In our experience, referred patients are commonly Asian men with an acceptable hepatic reserve by Child-Pugh score, who have been diagnosed by clinical criteria alone. Most patients were offered no further therapy. Moving forward, accurate and systematic documentation of staging, performance status, and Child-Pugh score per the Barcelona Clinic Liver Cancer staging protocol will be imperative to best identify patients who may benefit most from sorafenib or available clinical trials, and to subsequently evaluate the population-based impact of the introduction of such therapies in patients with advanced hcc.

Keywords: Sorafenib; hcc; targeted therapy.

FIGURE 1

Kaplan–Meier outcome data of overall survival against time (years).

FIGURE 2

Barcelona Clinic Liver Cancer staging system and treatment options . hcc = hepatocellular carcinoma; pst = performance status; rfa = radiofrequency ablation; pei = percutaneous ethanol ablation. * Cadaveric or from a living donor.