Unmet Needs Identified in the Community Management of Hepatocellular Carcinoma

Unique challenges and opportunities for the treatment and management of patients with hepatocellular carcinoma (HCC) have been identified by the Association of Community Cancer Centers (ACCC) in an analysis, according to a poster presented during the Society of Urologic Oncology 21st Annual Meeting.

Areas in need of continued focus and improvements include increased awareness of and screening recommendations, standardized treatment pathways, access to clinical trials, patient-centered care, and creation and integration of a multidisciplinary team (MDT).

A multidisciplinary approach is needed for the optimized management of patients with HCC, particularly due to the recent advances in diagnostics and therapeutics. Management of this patient population requires in-depth knowledge of liver disease, comorbidities, and available therapies. However, the incidence of HCC is set to rise dramatically within the next few years, and limited information is available for the management of these patients in the community setting.

ACCC sent an online questionnaire to its members in order to identify factors associated with the delivery and coordination of care for this patient population. The aim of this analysis was to gain a better understanding of effective tools, resources, challenges, and educational needs for MDT members in the community oncology setting. Partners and advisors for this project were allowed to invite colleagues at their institutions, as well as referring cancer centers, participate in the survey.

Overall, 31 cancer programs were included in the analysis, and the majority (42%) were non-teaching community hospitals. In addition, 16% were teaching hospitals; 16% were academic medical centers; 10% were research facilities, hospital-based outpatient clinics, or community teaching hospitals; 10% were private practices, and 6% were free-standing cancer centers.

Among respondents to the survey, 61% said their programs did not have a specialized hepatobiliary MDT. Two-thirds of programs with a specialized MDT conduct tumor boards for other programs, while 85% of programs without a specialized MDT consult with a tumor board in their practice.

At 6 in 10 programs, a medical oncologist is the first specialist to see patients with HCC, and about 4 in 10 indicated that > 50% of patients with HCC undergo active treatment within their cancer program.

One-third of respondents indicated that there was a lack of support for screening and psychosocial services for these patients. A quarter of MDTs (25%) have a financial advocate, and 24% have a dedicated nurse navigator for patients with HCC.

In the survey, ACCC asked programs further questions on their communication with patients with HCC regarding specific aspects of care, and 13 to 14 respondents were included for these findings.

Seventy-nine percent of programs asked patients’ preferences for receiving information about their diagnosis/treatment, which included language, inclusion/exclusion of family members, participation in treatment decisions, disease severity, and expected treatment outcomes. The team member roles are explained at 85% of the programs, while 93% explain the diagnosis/next steps according to patient preferences and answer questions, and 86% discuss the HCC stage of disease with the patient. Most centers (93%) discussed prognosis, risks, and benefits for various treatments according to patient preferences.

Quality of life preferences are asked of patients in 86% of the centers in order to make treatment recommendations, and 93% encourage patients to be involved in the treatment decision-making process. Ninety-two percent of programs were proactive in regard to asking patients about distress at every visit, such as depression and anxiety.

The majority of centers explained the benefits of symptom management and encouraged open dialogue, were proactive about asking patients of their symptoms at every visit, were proactive in telling patients how to recognize when an emergency visit is warranted, and encouraged patients to ask questions and make it easy for them to reach a team member (93%, each).

Palliative care was offered at the start of therapy at 57% of centers, and out-of-pocket costs were considered when making treatment decisions in 72%.

More than half (52%) of programs indicated that they discussed clinical trials with all patients with HCC, and 55% conduct HCC trials. Additionally, 24% indicated that they help patients obtain more information on clinical trials when they are specifically asked.

Approximately 52% of the programs adhere to the National Comprehensive Cancer Network (NCCN) HCC Guidelines and have a protocol in place, while 5% were developing a protocol. Overall, 43% of the programs did not have plans to develop a protocol to adhere to the NCCN HCC Guidelines. None of the programs indicated the use of the American Association for the Study of Liver Diseases or American College of Gastroenterology Guidelines.

In terms of improving the management and treatment of patients with HCC in the community, 31%, each, indicated a lack of psychosocial services, lack of screening, and none/limited access to clinical trials; 23%, each, experienced delays in the appropriate treatment and diagnostic test, drug, or treatment reimbursement issues; and 15% reported delays in the diagnosis of HCC.

HCC, the most common primary liver malignancy in the United States, accounted for 42,220 new cases and 30,200 deaths in 2018, and although patients with early-stage disease have effective options available, less than 18% remain alive at 5 years.

_Reference

_{Philip PA, Luca L, Mangir C. Understanding practices and gaps in multidisciplinary hepatocellular carcinoma care within the community oncology setting. Presented at: ACCC National Oncology Conference; September 14-18, 2020; Virtual. Abstract #390.}