Overview of Clinical HCC and Its Management

Abstract

HCC is an important cancer worldwide with over 800,000 new annual cases globally but has huge geographic differences in incidence. It is predominantly a cancer of the less developed world, where its burden is heaviest. Its main causes are known and in large part preventable: HBV, HCV, alcoholism, and obesity. Just as widespread neonatal immunization is having a large preventive effect in those regions where it has become policy, a recently appreciated cause is increasing, namely, obesity-associated cirrhosis. As with other solid tumors, best survival rates are achieved when early diagnosis permits aggressive therapy. This in turn highlights the importance of surveillance. Advances in survival have been made in the small subset of patients with limited tumor burden who are eligible for liver transplantation. However, most patients present at too advanced a stage for this. Nevertheless, in the last 3 years, major increases in response rates and survival have been found from new clinical trials that involve immune checkpoint inhibitor agents. Whether these expensive drugs can be made available to the large proportion of patients in less economically advanced countries will be a next challenge. As always in medicine, prevention and early detection are the bedrock for extending survival in HCC patients and potential patients. Given the complexities involved in therapeutic decision-making for each patient who has two diseases – cancer and cirrhosis – a multidisciplinary team is widely regarded as optimal. Wonderful but expensive new HCC therapies are available, but typically for a minority of the patients. Nevertheless, in HCC patients with chronic HBV, nucleoside analog HBV treatments also seem to improve survival and reduce HCC recurrences in resected patients.