Hepatocellular Carcinoma Key Statistics, Risks & Treatment Options
In Hepatocellular Carcinoma (HCC)
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By: James Pitt Nov. 21, 2018
Key Statistics on Hepatocellular Carcinoma
Hepatocellular carcinoma (HCC) is the most common liver cancer.
- As of 2016, there were approximately 40,000 cases in the US and over a million worldwide.
- Incidence is three times higher in men than women.
- More than 80% of patients with HCC have preexisting cirrhosis.
- Between 1% and 8% of patients with cirrhosis develop HCC per year, according to the American Association for the Study of Liver Diseases.
The prognosis is notoriously poor.
- Untreated patients in the US have a life expectancy under four months.
- Treated patients have a 2 year-survival rate around 50%.
- HCC mortality is at 4.41 per 100,000 in the US as of 2016
- HCC mortality is projected continue to grow until 2030 (Petrick et. al 2016)
Risk Factors
Chronic liver injuries that cause cirrhosis are associated with HCC.
Why is HCC incidence and mortality increasing in the US? Metabolic syndrome may be part of the picture. Diabetes, obesity, and both alcoholic and non-alcoholic fatty liver disease are associated with HCC.
The opioid epidemic may also be increasing HCC rates. The Department of Health and Human Services also attributes rising liver cancer rates to rising hepatitis virus rates, which it attributes in turn to injection drug use in the opioid epidemic. The US as a whole has low hepatitis rates by international standards, but this does not hold for every community. Appalachia in particular has seen growth in hepatitis virus in recent years. Acute hepatitis C infections increased 364% from 2006 to 2012 in Kentucky, Tennessee, Virginia, and West Virginia; acute hepatitis B infections increased 114% in Kentucky, Tennessee, and West Virginia.
Treatment by Stage (2018 recommendations)
The AASLD 2018 practice guidance uses the Barcelona (BCLC) staging system and GRADE levels of evidence.
Stage 0
Single nodule smaller than 2 cm
Child-Pugh class A
ECOG PS 0 or 1
Stage 0 Treatment options:
Preferred treatment: resection
Alternate: radiofrequency ablation, microwave ablation
Stage A
One to three nodules smaller than 3 cm
Child-Pugh class A or B
ECOG PS 0 or 1
Stage A Treatment options:
Resection
Liver transplant (if patient meets Milan criteria of single tumor ≤5 cm in diameter or no more than three tumors ≤3 cm in diameter)Ablation
Transarterial chemoembolization
Transarterial radioembolization (also known as microbrachytherapy or selective internal radiation therapy)
Stereotactic body radiation therapy
Stage B
Multinodular
Child-Pugh class A or B
ECOG PS 0 or 1
Stage B treatment options
Preferred: transarterial chemoembolization
Alternate:
Transarterial radioembolization
Apply locoregional therapy until patient meets Milan criteria, then liver transplant (“downstaging” or “downsizing”; see Bryce and Tsochatzis 2017)
Stage C
Portal vein invasion, nodal metastasis, or extrahepatic metastasis
Child-Pugh class A or B
ECOG PS 0-2
Stage C treatment options
Sorafenib or lenvatinib as 1st-line drug.
Nivolumab, regorafenib, or cabozantinib as 2nd-line drug.
Alternate: Transarterial radioembolization
Stage D
Child-Pugh class C
ECOG PS 3-4
Stage D treatment options
Liver transplant
Supportive case
Latest developments.
Sorafenib is the first-line chemotherapy for patients with nonresectable HCC. It has remained so since its approval in 2007. However, lenvatinib showed noninferiority in a phase 3 trial, and is approved for first-line use as of August 2018.
The AASLD recommends regorafenib and nivolumab as second-line options. A phase 3 clinical trial of nivolumab as first-line treatment was delayed due to too few patient deaths, and is now expected to conclude in July 2020. Clinical trials of combination therapies as first line treatment are in Phase 1 for regorafenib (NCT03347292) and Phase 2 for nivolumab (NCT03439891, NCT03695250, NCT03071094).
As hepatocellular carcinoma primarily strikes patients in their 60s, Medicare data is a particularly good source for insights into it. Dexur's databases include information on incidence, quality outcomes, and procedure volume for this population.
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