Liver Transplantation for the Treatment of Liver Cancer

Transcript

00:00 --> 00:01Funding for Yale Cancer Answers
00:01 --> 00:03is provided by Smilow Cancer
00:03 --> 00:05Hospital and AstraZeneca.
00:07 --> 00:09Welcome to Yale Cancer Answers with
00:09 --> 00:11your host doctor Anees Chagpar.
00:11 --> 00:13Yale Cancer Answers features the
00:13 --> 00:15latest information on cancer care by
00:15 --> 00:17welcoming oncologists and specialists
00:17 --> 00:19who are on the forefront of the
00:19 --> 00:21battle to fight cancer. This week,
00:21 --> 00:23it's a conversation about the care of
00:23 --> 00:24patients with liver cancer with doctor
00:24 --> 00:27Ariel Jaffe. Dr. Jaffe is an assistant
00:27 --> 00:29professor of medicine and the section of
00:29 --> 00:31digestive diseases at the Yale School
00:31 --> 00:33of Medicine where Doctor Chagpar is
00:33 --> 00:35a professor of surgical oncology.
00:36 --> 00:38Ariel, maybe we can start off by
00:38 --> 00:40you telling us a little bit about
00:40 --> 00:42yourself and what exactly you do.
00:42 --> 00:44Sure, so basically I specialize
00:44 --> 00:47in the care of patients that have
00:47 --> 00:50advanced liver disease and I work
00:50 --> 00:52both in the transplant program,
00:52 --> 00:54so patients who need to go on
00:54 --> 00:56to have a liver transplant,
00:56 --> 00:58and also patients
00:58 --> 00:59that develop liver cancer,
00:59 --> 01:01which is an extremely common
01:01 --> 01:02complication in patients that
01:02 --> 01:04have chronic liver disease.
01:05 --> 01:07So let's talk a little bit about that.
01:07 --> 01:10So when you're talking about
01:10 --> 01:12patients who require transplant,
01:12 --> 01:14what kinds of conditions
01:14 --> 01:16require liver transplants?
01:16 --> 01:20I mean, are these patients who
01:20 --> 01:23have hepatitis, cirrhosis, tell
01:23 --> 01:25us a little bit more about what
01:25 --> 01:26kinds of conditions will lead
01:26 --> 01:28you down the path of transplant?
01:31 --> 01:33Most commonly, patients that develop
01:33 --> 01:35end stage liver disease, which is
01:35 --> 01:36what we commonly know
01:36 --> 01:39as cirrhosis are the ones that we
01:39 --> 01:40do evaluate for liver transplant,
01:40 --> 01:42and that could be from a variety
01:42 --> 01:43of different causes.
01:43 --> 01:45Some which you alluded to.
01:45 --> 01:47You know patients that
01:47 --> 01:48have chronic viral disease.
01:48 --> 01:51Certain toxins, like alcohol use,
01:51 --> 01:53certain genetic disorders,
01:53 --> 01:55patients with obesity and diabetes which
01:55 --> 01:59can lead to fatty liver and
01:59 --> 02:00go on to develop
02:00 --> 02:01end stage liver disease.
02:01 --> 02:03Once you start to have
02:03 --> 02:04complications from that,
02:04 --> 02:06we generally start to consider
02:06 --> 02:07you for transplant.
02:07 --> 02:10There are a subset of patients who may
02:10 --> 02:11actually have really well preserved
02:11 --> 02:14liver function and look and feel well,
02:14 --> 02:17but in patients that develop liver cancer,
02:17 --> 02:18which sort of as I mentioned,
02:18 --> 02:20is an extremely common complication,
02:20 --> 02:238 to 10% of patients with
02:23 --> 02:25cirrhosis will develop cancer each year.
02:25 --> 02:27That's another indication in which we
02:27 --> 02:30go on to consider them for transplant.
02:30 --> 02:30Because
02:31 --> 02:33transplant will not only cure the cancer,
02:33 --> 02:35but it will actually cure their
02:35 --> 02:36underlying liver disease,
02:36 --> 02:38which is the major risk factor
02:38 --> 02:39for their cancer development.
02:40 --> 02:43So tell us a little bit more
02:43 --> 02:45about that in terms of cancer.
02:45 --> 02:48Are all patients with liver cancer
02:48 --> 02:50candidates for
02:50 --> 02:52transplant or is it only those
02:52 --> 02:54who have that underlying chronic
02:54 --> 02:57liver disease that would make them
02:57 --> 03:00potentially a candidate anyways?
03:01 --> 03:03So not all patients are
03:03 --> 03:05candidates for transplant.
03:05 --> 03:06The majority of patients who
03:06 --> 03:09develop liver cancer will have some
03:09 --> 03:10form of chronic liver disease,
03:10 --> 03:12but interestingly, we're actually
03:12 --> 03:14seeing a unique population who don't
03:14 --> 03:16have underlying advanced liver disease
03:16 --> 03:19go on to develop liver cancer and it's
03:19 --> 03:21a little bit of a controversial field
03:21 --> 03:24if those patients should be
03:24 --> 03:26considered for transplant or not.
03:26 --> 03:28But in terms of those that
03:28 --> 03:30may have chronic liver disease
03:30 --> 03:31and develop liver cancer,
03:31 --> 03:33there are certain criteria that need
03:33 --> 03:35to be met for patients to be considered
03:35 --> 03:38for transplant and some of that includes
03:38 --> 03:41how extensive their liver cancer is.
03:41 --> 03:42So for example,
03:42 --> 03:44if it's spread outside of the liver,
03:44 --> 03:46they would not be good
03:46 --> 03:47candidates for transplant,
03:47 --> 03:49or if they have a large amount
03:49 --> 03:51of tumors within the liver,
03:51 --> 03:54they would not be considered
03:54 --> 03:54good candidates.
03:54 --> 03:57We also sometimes like to look at
03:57 --> 03:59patients if they have recurrent cancer.
04:00 --> 04:02We're more likely to consider them
04:02 --> 04:04for transplant or if their underlying
04:04 --> 04:07liver is really very very sick so
04:07 --> 04:09that they have other complications of
04:09 --> 04:11liver disease in addition to cancer,
04:11 --> 04:12then you know,
04:13 --> 04:15we're more likely to want to pursue
04:15 --> 04:16transplant in those patients.
04:17 --> 04:20One of the things that
04:20 --> 04:22people might be thinking about when
04:22 --> 04:24we think about transplant is that
04:24 --> 04:26oftentimes people
04:26 --> 04:29may be under the impression
04:29 --> 04:31that patients who have cancers,
04:31 --> 04:36for example, may not be a potential
04:36 --> 04:39recipient of organs,
04:39 --> 04:41but it sounds like for liver cancer,
04:41 --> 04:43that's not the case, that
04:43 --> 04:45if you have liver cancer,
04:45 --> 04:48even if it's recurrent liver cancer,
04:48 --> 04:52you can still be on the organ
04:52 --> 04:53recipient list.
04:53 --> 04:54Is that right?
04:54 --> 04:56Yes, actually
04:56 --> 04:58it's a really unique cancer and
04:58 --> 05:00you're very spot on with that.
05:00 --> 05:01In that transplant is
05:01 --> 05:04considered one of the curative therapies,
05:05 --> 05:07and it really can't have spread outside
05:07 --> 05:09of the liver or you can't have
05:09 --> 05:10such an extensive tumor burden.
05:10 --> 05:12But because you're really
05:12 --> 05:14replacing the liver,
05:14 --> 05:16you're not only treating the cancer,
05:16 --> 05:18but you're sort of getting rid of
05:18 --> 05:20the damaged organ because we like
05:20 --> 05:22to think of liver cancer in
05:22 --> 05:24particular as sort of a complication
05:24 --> 05:26of a failing organ.
05:26 --> 05:31I think it's an important perspective to have.
05:32 --> 05:33Yeah, it does not mean that
05:33 --> 05:34you're not a candidate.
05:34 --> 05:36It's actually one of the most
05:36 --> 05:37curative therapies and really
05:37 --> 05:39currently in the United States,
05:39 --> 05:39honestly,
05:39 --> 05:41about a quarter of transplants
05:41 --> 05:42are done for the indication
05:42 --> 05:44of having liver cancer.
05:44 --> 05:48Wow, so the other thing that we often
05:48 --> 05:51think about when we think about transplant
05:51 --> 05:54is the universal shortage of organs.
05:54 --> 05:58Liver is one of those nice organs that there
05:58 --> 06:02is a potential for a living related donor.
06:02 --> 06:04How often is that used in
06:04 --> 06:06patients who have liver cancer?
06:06 --> 06:08Can you talk a little bit more about that?
06:09 --> 06:11Definitely so the liver is
06:13 --> 06:15just one of the most remarkable
06:15 --> 06:17organs, and its ability to regenerate.
06:17 --> 06:20So in certain patients who are
06:20 --> 06:22candidates for a living donor organ,
06:22 --> 06:25meaning that a part of the liver is taken
06:25 --> 06:27from a donor and put into the recipient and
06:27 --> 06:30it will actually grow to a normal size,
06:30 --> 06:33usually in about 12 weeks time.
06:34 --> 06:35To determine if someone is
06:35 --> 06:37a candidate for a living donor,
06:37 --> 06:39there's a few factors that we
06:39 --> 06:40have to take into account.
06:40 --> 06:43One is the size of the patient
06:43 --> 06:46because there's a certain sort of
06:46 --> 06:48massive liver that you would need
06:48 --> 06:51to sufficiently
06:51 --> 06:54do its job in a person.
06:54 --> 06:56So if you're a really really
06:56 --> 06:58big guy or big girl,
06:58 --> 07:01your candidates might be limited.
07:01 --> 07:03You would really need someone who is
07:03 --> 07:05equally as tall or as large as you.
07:05 --> 07:06The second thing is,
07:06 --> 07:09if you're really incredibly sick and have a
07:09 --> 07:12lot of complications from your liver disease,
07:12 --> 07:14there's concern that you may not be able
07:14 --> 07:16to tolerate just a piece of an organ.
07:16 --> 07:18So it's actually something
07:18 --> 07:20that we use quite often,
07:22 --> 07:23and it varies based on programs and
07:23 --> 07:25how large the programs are,
07:25 --> 07:28but we definitely do a lot of
07:28 --> 07:30living donors in our center here,
07:30 --> 07:33and it's a really a great option
07:33 --> 07:35for a certain subset of patients.
07:36 --> 07:38And tell us a little
07:38 --> 07:40bit more about how that works,
07:40 --> 07:43because I think that for many people
07:43 --> 07:46just the thought of having a relative
07:46 --> 07:49or a loved one being diagnosed with
07:49 --> 07:52a potentially treatable cancer,
07:52 --> 07:53but that you can help with,
07:53 --> 07:57you can help give them a new life,
08:00 --> 08:04is really awesome in terms of the actual
08:04 --> 08:07benefit that you can provide,
08:07 --> 08:09but people may have some
08:09 --> 08:10questions about that.
08:10 --> 08:13Yes, so it's definitely a pretty
08:13 --> 08:15grueling process
08:15 --> 08:18and the way that it works
08:18 --> 08:20is once we determine that someone
08:20 --> 08:23is ineligible as a transplant candidate,
08:23 --> 08:25they're then open to have either relatives
08:25 --> 08:28or even just altruistic
08:28 --> 08:30donors that can call in and be screened
08:30 --> 08:32to see if they're compatible and
08:32 --> 08:34usually it starts with
08:34 --> 08:36just looking at blood typing to
08:36 --> 08:37see if there is a compatibility.
08:37 --> 08:40The rejection is a little bit different
08:40 --> 08:43in the liver compared to other organs,
08:43 --> 08:45so it's nice in that there's not
08:45 --> 08:47so many factors that have to be
08:47 --> 08:50directly matched to be
08:50 --> 08:52considered a compatible donor.
08:52 --> 08:53But once we think that there's
08:53 --> 08:55not going to be overt rejection,
08:55 --> 08:58and that really comes down a lot of
08:58 --> 09:00times to compatibility and blood typing.
09:00 --> 09:03We have a very strict process
09:03 --> 09:05to make sure that the donor itself
09:05 --> 09:07is someone who would do very well
09:07 --> 09:09going to surgery, that they have
09:09 --> 09:10no underlying liver disease,
09:10 --> 09:12and that ultimately we
09:12 --> 09:15feel would essentially come out
09:15 --> 09:18unscathed should they decide to go
09:18 --> 09:20forth with donating their liver.
09:20 --> 09:23It's extremely rare in general to have any
09:23 --> 09:25type of rejection from incompatibility.
09:25 --> 09:27Just because our ability to screen
09:27 --> 09:30and make sure that blood types and
09:30 --> 09:31things match is so great now,
09:31 --> 09:34so that's not generally a major
09:34 --> 09:35major concern,
09:35 --> 09:37but there's a lot of strict processes
09:37 --> 09:40in terms of making sure the size is
09:40 --> 09:42appropriate that the recipient,
09:42 --> 09:44whatever portion was donated,
09:44 --> 09:47that that would be enough for the patient
09:47 --> 09:50not to have what we call post operative
09:50 --> 09:53liver failure or liver insufficiency.
09:53 --> 09:56So I would say technology and our
09:56 --> 09:58screening strategies are just so
09:58 --> 10:00remarkable now that those
10:00 --> 10:03factors are really very well detailed
10:03 --> 10:05before we would proceed with any
10:05 --> 10:07type of living donor liver transplant.
10:08 --> 10:10And then after the transplant,
10:10 --> 10:13does the recipient stay on
10:13 --> 10:15immunosuppressive therapy for life?
10:15 --> 10:16Or how does that work?
10:18 --> 10:20Yeah, so there's variations
10:20 --> 10:23in the quantity of immunosuppression
10:23 --> 10:25in liver transplant recipients.
10:25 --> 10:29Generally within a year after transplant
10:29 --> 10:31you can get patients down to an extremely
10:31 --> 10:33low level of immunosuppression which
10:33 --> 10:35again is slightly different than
10:35 --> 10:37other organs where rejection rates
10:37 --> 10:40are much higher and it's interesting
10:40 --> 10:43because there are certain reports
10:43 --> 10:45of patients being able to completely
10:45 --> 10:47come off of immunosuppression.
10:47 --> 10:49And we've actually had a few patients
10:49 --> 10:52within our center that we've done that on.
10:52 --> 10:53It's a little bit higher risk,
10:53 --> 10:56and it requires some more close monitoring,
10:56 --> 10:58but I would say the vast majority of
10:58 --> 11:01patients are usually on at least one
11:01 --> 11:04medication for the duration of their life,
11:04 --> 11:07but it's again incredibly low
11:07 --> 11:09dose compared to the majority of
11:09 --> 11:11other organ transplant recipients.
11:12 --> 11:14And they quote cured?
11:16 --> 11:17Yeah, so that's
11:17 --> 11:20exactly the hope is
11:20 --> 11:22that from liver transplant,
11:22 --> 11:24you're essentially replacing the
11:24 --> 11:27entire organ, and so whatever the
11:27 --> 11:29etiology of that patients,
11:29 --> 11:32liver diseases is essentially cured.
11:32 --> 11:35Of course, there's a risk if
11:35 --> 11:37patients redevelop viral infections,
11:37 --> 11:40or if some of the risk factors
11:40 --> 11:41that led initially to their
11:41 --> 11:43liver disease are still present.
11:43 --> 11:46And I think a lot in our population
11:46 --> 11:48the common things are patients
11:48 --> 11:50who develop fatty liver disease
11:50 --> 11:52in the post transplant setting,
11:52 --> 11:54if they continue to
11:54 --> 11:56have diabetes or obesity,
11:56 --> 11:57you can develop recurrent
11:57 --> 11:59disease in the organ.
11:59 --> 12:02But if patients mitigate their risk
12:02 --> 12:06factors and go on to live a healthy life,
12:06 --> 12:07then yes, liver transplant is
12:07 --> 12:09curative not only for the cancer,
12:09 --> 12:11but again for the initial
12:11 --> 12:13cause of their cirrhosis.
12:14 --> 12:17And so for patients who have liver cancer
12:17 --> 12:19is transplant one of the things that
12:19 --> 12:22you think of first or do people have
12:22 --> 12:25to kind of go through chemotherapy?
12:25 --> 12:27At least in assessment of
12:27 --> 12:29surgical resection and so on?
12:29 --> 12:31Kind of the more commonplace
12:31 --> 12:33cancer therapies before you think
12:33 --> 12:35about transplant or is transplant
12:35 --> 12:37something that is now first line?
12:38 --> 12:41So it definitely is extremely
12:41 --> 12:43independent on each patient's case.
12:43 --> 12:48If we see a patient who has a single tumor,
12:48 --> 12:50that's very small in size,
12:50 --> 12:52and we think that we can cure them
12:52 --> 12:54with a local resection, meaning,
12:54 --> 12:56just cutting out a portion of that liver,
12:56 --> 12:58that's generally the first line
12:58 --> 13:01therapy that we would actually go to.
13:01 --> 13:03In patients that have more
13:03 --> 13:04advanced liver disease and other
13:05 --> 13:06complications from their liver,
13:06 --> 13:07if they develop a cancer
13:07 --> 13:10on top of that, we know that a transplant
13:10 --> 13:12would cure both of those aspects,
13:12 --> 13:15so I would not say it's often firstline,
13:15 --> 13:17but it's a curative approach that we
13:17 --> 13:19definitely have in the back of our heads
13:19 --> 13:21for a subset of patients that
13:21 --> 13:22would be good candidates.
13:23 --> 13:25Terrific, we're going to learn
13:25 --> 13:27a lot more about liver cancer and
13:27 --> 13:29transplant hepatology right after we
13:29 --> 13:32take a short break for a medical minute.
13:32 --> 13:34Please stay tuned to learn more
13:34 --> 13:36with my guest doctor Ariel Jaffe.
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14:01 --> 14:03and family history or risk assessment and
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14:15 --> 14:17or family history that includes
14:17 --> 14:19cancer at unusually early ages,
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14:20 --> 14:22on the same side of the family
14:22 --> 14:24with the same cancer,
14:24 --> 14:25more than one diagnosis of
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14:52 --> 14:53Welcome
14:53 --> 14:55back to Yale Cancer Answers.
14:55 --> 14:58This is doctor Anees Chagpar and I'm joined
14:58 --> 15:00tonight by my guest doctor Ariel Jaffe.
15:00 --> 15:03We're talking about patients with liver
15:03 --> 15:06cancer, and before the break we talked
15:06 --> 15:08about the whole aspect of transplant
15:08 --> 15:11as a potential curative modality for
15:11 --> 15:14patients with liver cancer. But Ariel,
15:14 --> 15:16just as we were heading to the break,
15:16 --> 15:18you mentioned that there are a
15:18 --> 15:20lot of other things that go into
15:20 --> 15:21thinking about liver cancer as well,
15:21 --> 15:23so I wanted to take a step back
15:23 --> 15:26and talk a little bit about
15:26 --> 15:28how common is liver cancer?
15:29 --> 15:32Primary liver cancer is actually
15:32 --> 15:34a quite significant global burden.
15:34 --> 15:37There's over 800,000 new
15:37 --> 15:39cases diagnosed each year,
15:39 --> 15:41and actually in the US in particular,
15:41 --> 15:43it's the fastest increasing cause
15:43 --> 15:45of cancer and the fastest increasing
15:45 --> 15:47cause of cancer related death.
15:47 --> 15:49When we talk about
15:49 --> 15:52primary liver cancer we mean cancer
15:52 --> 15:53that has originated and developed
15:53 --> 15:56in the liver from the beginning.
15:56 --> 15:58There are two main types that we think about,
15:58 --> 16:00so hepatocellular carcinoma,
16:00 --> 16:03probably accounts for 80 to
16:03 --> 16:0590% of primary liver cancer,
16:05 --> 16:08but another common type that we see
16:08 --> 16:10that often develops in patients with
16:10 --> 16:12chronic liver disease is something
16:12 --> 16:13called cholangiocarcinoma and
16:13 --> 16:16that arises in the biliary cells,
16:16 --> 16:17and these are the cells that line
16:17 --> 16:19the little lakes
16:19 --> 16:21and channels within the liver
16:21 --> 16:23that sort of drain and modify the
16:23 --> 16:25substance that the liver makes,
16:25 --> 16:26called bile.
16:26 --> 16:28When you think about
16:28 --> 16:29secondary liver cancer,
16:29 --> 16:31a lot of times what we're talking
16:31 --> 16:32about is metastatic disease,
16:32 --> 16:35so cancer that may have spread to the liver,
16:35 --> 16:37but that's really treated and
16:37 --> 16:39managed extremely differently
16:39 --> 16:40than primary liver cancer.
16:41 --> 16:43And so that's really fascinating.
16:43 --> 16:45I didn't realize that liver
16:45 --> 16:47cancer in the United States was the
16:47 --> 16:50the fastest growing in terms of
16:50 --> 16:52incidence and mortality. Why is that?
16:52 --> 16:55What are the risk factors that
16:55 --> 16:58predispose to liver cancer that
16:58 --> 17:00are factoring into this equation?
17:00 --> 17:02Or is it the risk factors?
17:02 --> 17:04Yes, so there's definitely been a shift
17:04 --> 17:07sort of in the risk factors globally where
17:07 --> 17:10prior the major causes of liver disease
17:10 --> 17:12used to really be chronic viral disease.
17:12 --> 17:15And mainly we're talking about
17:15 --> 17:17chronic hepatitis B and hepatitis C,
17:17 --> 17:20but with the ability to treat
17:20 --> 17:22hepatitis C and control hepatitis B,
17:22 --> 17:26and even prevent that with vaccinations
17:26 --> 17:28really in the Western world,
17:28 --> 17:30what we're seeing as the major cause of
17:30 --> 17:33liver disease is definitely what we call
17:33 --> 17:35Fatty liver disease or non-alcoholic
17:35 --> 17:38fatty liver disease, and
17:38 --> 17:42as we see a rise in the obesity epidemic,
17:42 --> 17:45we're seeing more and more patients that
17:45 --> 17:47develop complications such as diabetes,
17:47 --> 17:50high cholesterol,
17:50 --> 17:51central adiposity,
17:51 --> 17:53meaning
17:53 --> 17:55a lot of belly fat, which is inflammatory
17:55 --> 17:58bad fat that the body does not like,
17:58 --> 18:00and high blood pressure.
18:01 --> 18:03As we're seeing more patients
18:03 --> 18:04develop those complications,
18:04 --> 18:05we're seeing a rise in the
18:05 --> 18:07incidence of fatty liver disease.
18:07 --> 18:10It is certainly true that there's just
18:10 --> 18:13this exponential rise in obesity in
18:13 --> 18:16America and in the world quite frankly.
18:16 --> 18:21So let me ask you this, is it possible
18:21 --> 18:24to reverse that, if you lose weight,
18:24 --> 18:26do you reduce your risk of fatty
18:26 --> 18:29liver and therefore reduce your
18:29 --> 18:31risk of hepatocellular carcinoma?
18:32 --> 18:34Absolutely,
18:34 --> 18:36generally when patients have
18:36 --> 18:38developed cirrhosis which is really
18:38 --> 18:40advanced scarring within the liver,
18:40 --> 18:42we do say that you can't
18:42 --> 18:44reverse completely to having
18:44 --> 18:45a normal healthy liver,
18:45 --> 18:47but for a lot of patients who
18:47 --> 18:48are not quite yet cirrhotic,
18:48 --> 18:51or who may be cirrhotic but have active,
18:51 --> 18:54ongoing inflammation, which is a
18:54 --> 18:55big risk factor for
18:55 --> 18:57the development of cancer,
18:57 --> 19:00you can absolutely reduce the risk of
19:00 --> 19:02developing complications from liver disease,
19:02 --> 19:04and the development of liver cancer.
19:04 --> 19:08So in particular for fatty liver disease,
19:08 --> 19:10really the only kind of approved
19:10 --> 19:13therapy at this time is the
19:13 --> 19:15recommendation to lose weight.
19:15 --> 19:18And generally we say 5 to 10% of
19:18 --> 19:20weight loss has been associated
19:20 --> 19:22with reduction in inflammation
19:22 --> 19:24reduction in scarring of the liver,
19:24 --> 19:26and even reduction in the
19:26 --> 19:28potential to develop liver cancer.
19:28 --> 19:30And it's why we like to really tell
19:30 --> 19:32patients that a lot of the risk factors
19:32 --> 19:34to develop liver disease and liver
19:34 --> 19:36cancer are really preventable.
19:36 --> 19:39And you see and
19:39 --> 19:43treat patients with liver disease who may
19:43 --> 19:46be at risk of developing liver cancer,
19:46 --> 19:49and you also see patients who
19:49 --> 19:50have developed liver cancer.
19:50 --> 19:52You know if you tell them to lose weight,
19:52 --> 19:56that's often easier said than done.
19:56 --> 19:58Are there any specific recommendations
19:58 --> 20:00that you give patients?
20:00 --> 20:02I'm just thinking that our listeners
20:02 --> 20:04might be thinking, yeah,
20:04 --> 20:07I'd love to lose 5 to 10% of my body weight.
20:07 --> 20:09How exactly do I do that?
20:10 --> 20:12Yeah, so it is definitely
20:12 --> 20:13easier said than done,
20:13 --> 20:15and I think especially in the COVID era
20:15 --> 20:18where a lot of people were really
20:18 --> 20:19confined to their home,
20:19 --> 20:21it's been an even bigger challenge,
20:21 --> 20:24so oftentimes what I say to patients is,
20:24 --> 20:26we kind of go through what
20:26 --> 20:28they're eating and their physical activity.
20:28 --> 20:30And sometimes their food choices.
20:30 --> 20:31They may think that they're eating healthy,
20:31 --> 20:34but when we actually breakdown the calories
20:34 --> 20:36or the amount of sugar they're eating,
20:36 --> 20:39it's a lot more than they're aware of so
20:39 --> 20:40off the bat,
20:40 --> 20:42I always offer patients to speak with
20:42 --> 20:45nutrition because I think to have someone
20:45 --> 20:48hold you accountable and really go through
20:48 --> 20:51the target of each food
20:51 --> 20:53group and macro and micro nutrients
20:53 --> 20:55you should be hitting is very helpful.
20:55 --> 20:57We also have specific fatty liver
20:57 --> 21:00clinics and weight loss clinics here,
21:00 --> 21:02so there are definitely patients
21:02 --> 21:04even if they're dieting or exercising,
21:04 --> 21:06they're just really stuck in this
21:06 --> 21:08challenging place and they can't
21:08 --> 21:10get to an ideal body weight.
21:10 --> 21:12And in that situation there are
21:12 --> 21:14medications that are available to
21:14 --> 21:15sort of assist in weight loss.
21:15 --> 21:17So we have a lot of programs
21:17 --> 21:19and a lot of
21:19 --> 21:21ancillary help for patients that
21:21 --> 21:22really struggle.
21:22 --> 21:24Alright, so the news flash
21:24 --> 21:26there is talk to your doctor,
21:26 --> 21:28because there likely is
21:28 --> 21:31help available and we can
21:31 --> 21:33all get through this
21:33 --> 21:34and hopefully reduce our risk.
21:34 --> 21:36But Ariel, I want to just kind
21:36 --> 21:38of switch gears a little bit.
21:38 --> 21:40Let's suppose it's a little too late.
21:40 --> 21:44And we develop liver cancer.
21:44 --> 21:47How do you know that you
21:47 --> 21:48have developed liver cancer?
21:48 --> 21:50So how is that diagnosis made?
21:50 --> 21:53Are you going to have signs and symptoms?
21:53 --> 21:56Are you going to go yellow or is this
21:56 --> 21:58something that is picked up
21:58 --> 21:59incidentally?
21:59 --> 22:01That's a great question.
22:01 --> 22:03You know, the majority of patients
22:03 --> 22:06that develop liver cancer are really
22:06 --> 22:08asymptomatic until it becomes very advanced.
22:08 --> 22:11So at the time that someone may have
22:11 --> 22:14pain or start to have
22:14 --> 22:16some vague symptoms like weight
22:16 --> 22:18loss or significant fatigue or even
22:18 --> 22:20jaundice or yellowing of the eyes,
22:20 --> 22:23which suggests that there's either a
22:23 --> 22:25blockage in the liver or that the tumor
22:25 --> 22:28has spread so much in the liver that it's
22:28 --> 22:30just kind of taken over any remaining
22:30 --> 22:32normal tissue, that's often too late.
22:32 --> 22:35So really, what's incredibly important is
22:35 --> 22:38to identify patients that have chronic liver
22:38 --> 22:41disease or risk factors for liver cancer.
22:41 --> 22:43Some which include
22:43 --> 22:45poorly controlled diabetes,
22:45 --> 22:47heavy alcohol use, obesity,
22:47 --> 22:49and make sure that we're
22:49 --> 22:51screening those patients.
22:51 --> 22:53So really all major societies recommend
22:53 --> 22:55in patients with chronic liver disease
22:55 --> 22:58that every six months you're actually
22:58 --> 23:00screened for liver cancer with the
23:00 --> 23:02hopes that if you develop a cancer,
23:02 --> 23:04you can actually pick it up early.
23:04 --> 23:06And it's interesting because liver
23:06 --> 23:09cancer is the only solid organ tumor
23:09 --> 23:11that could actually be diagnosed
23:11 --> 23:14based on imaging alone,
23:14 --> 23:17so it has very unique features when we
23:17 --> 23:20do a CAT scan or an MRI that basically
23:20 --> 23:22allow us to definitively tell if this
23:22 --> 23:24is a hepatocellular carcinoma and
23:24 --> 23:27oftentimes we don't even have to do
23:27 --> 23:30a biopsy to confirm the diagnosis.
23:30 --> 23:33So people who have those risk factors
23:33 --> 23:36should have a CT or MRI every six months.
23:37 --> 23:40So we always recommend an ultrasound.
23:40 --> 23:41That's the first
23:41 --> 23:44step for screening,
23:44 --> 23:46and that's really just based
23:46 --> 23:47on sort of cost effectiveness,
23:47 --> 23:49and you know the fact that it is
23:49 --> 23:52fairly sensitive, but in some patients,
23:52 --> 23:54if their liver is very scarred down,
23:54 --> 23:57so you can't get a good look at that tissue,
23:57 --> 23:59or if there's a lot of obesity, because
23:59 --> 24:02a lot of fat in the belly can limit how
24:02 --> 24:04good of a look you can get.
24:04 --> 24:05In those cases,
24:05 --> 24:07you may then need to do more advanced
24:07 --> 24:10imaging, but generally once we see
24:10 --> 24:12something abnormal on an ultrasound,
24:12 --> 24:15the next step is to do a cross sectional
24:15 --> 24:18scan with either a CT or an MRI.
24:19 --> 24:21And so it's interesting
24:21 --> 24:23that liver cancers are one of
24:23 --> 24:25the few where you don't need a
24:25 --> 24:27biopsy to make that diagnosis.
24:27 --> 24:30So let's suppose you see that,
24:30 --> 24:32tell us about some of
24:32 --> 24:33the medical management,
24:33 --> 24:35some of the things that are coming
24:35 --> 24:37down the Pike short of transplant
24:37 --> 24:39that might be helpful in these patients.
24:41 --> 24:43Whenever someone has a new
24:43 --> 24:45diagnosis of liver cancer,
24:45 --> 24:46we always want to make sure that
24:46 --> 24:48it hasn't spread outside the liver.
24:48 --> 24:49So that's a big step,
24:49 --> 24:51because once it has spread,
24:51 --> 24:53your treatment is a little bit different,
24:53 --> 24:56and it's very important to look at a
24:56 --> 24:57patient's underlying liver function,
24:57 --> 25:00because that plays a major role in
25:00 --> 25:02understanding if they're eligible or
25:02 --> 25:03would tolerate certain treatments.
25:04 --> 25:05And outside of transplant,
25:05 --> 25:07we really do think of
25:07 --> 25:09liver cancer treatment in either
25:09 --> 25:11a curative approach or what's
25:11 --> 25:14called a palliative approach, and
25:14 --> 25:17transplant is one of the curative therapies,
25:17 --> 25:19but other curative therapies include
25:19 --> 25:22local resection and that's
25:22 --> 25:24when we cut out a small
25:24 --> 25:26piece where that tumor is
25:26 --> 25:26and of course,
25:26 --> 25:28someone has to be a good candidate
25:28 --> 25:30to undergo surgery and so if
25:30 --> 25:32they have really advanced liver
25:32 --> 25:34disease that would not be
25:34 --> 25:36an ideal treatment choice,
25:36 --> 25:39but other curative therapies
25:39 --> 25:41include something called ablation which
25:41 --> 25:45is really where you destroy the tumor and
25:45 --> 25:47that can be either through
25:47 --> 25:48thermal techniques,
25:48 --> 25:49radiation techniques,
25:49 --> 25:50electrical injury,
25:50 --> 25:54and then we think of some of our
25:54 --> 25:57palliative treatments which include
25:57 --> 26:00what we call local regional
26:00 --> 26:02therapies or transarterial therapies,
26:02 --> 26:04and that's basically where you can
26:04 --> 26:06either induce radiation damage
26:06 --> 26:09or locally give chemotherapy to
26:09 --> 26:12the tumor to kind of cut off the
26:12 --> 26:14blood supply and kill that tumor,
26:14 --> 26:16and then for patients
26:16 --> 26:18that either are just not responding
26:18 --> 26:19to those or where the cancer has
26:19 --> 26:21spread outside of the liver,
26:21 --> 26:24we start to think about systemic
26:24 --> 26:25therapy or chemotherapy.
26:26 --> 26:28And so you know,
26:28 --> 26:30I can imagine that no patient wants
26:30 --> 26:33to go through chemotherapy and
26:33 --> 26:35everybody has heard horror stories
26:35 --> 26:38about what chemotherapy is like.
26:38 --> 26:40But very often on this show we've been
26:40 --> 26:43talking about some of the newer advances,
26:43 --> 26:45especially in systemic therapy,
26:45 --> 26:47where we really are looking
26:47 --> 26:50towards personalized medicine,
26:50 --> 26:51sometimes immunotherapies.
26:51 --> 26:53Is there anything like that
26:53 --> 26:56going on in primary liver cancer?
26:56 --> 26:59Absolutely, so I think probably the
26:59 --> 27:02management for patients with liver cancer
27:02 --> 27:05that's more advanced has been one of the
27:05 --> 27:07most innovative
27:07 --> 27:09fields within liver cancer.
27:09 --> 27:12And that's because there have been so many
27:12 --> 27:14new advancements in systemic therapies.
27:14 --> 27:17Just a few years ago,
27:17 --> 27:20we just had one or two medications,
27:20 --> 27:23and now we have 10 FDA approved therapies.
27:23 --> 27:26And as of May 2020, so just a
27:26 --> 27:28little over a year ago,
27:28 --> 27:30a new combination therapy.
27:31 --> 27:33One of the components
27:33 --> 27:35was an immune checkpoint inhibitor,
27:35 --> 27:38which is one of our immunotherapy
27:38 --> 27:40medications that actually proved to
27:40 --> 27:42be the best first line therapy,
27:42 --> 27:45so it had improvement in overall
27:45 --> 27:46survival and disease
27:46 --> 27:48free progression compared to what our
27:48 --> 27:51prior first line was and is actually
27:51 --> 27:54now what we try to use for our patients.
27:54 --> 27:58And I think it's also important to know that
27:58 --> 27:58oftentimes,
27:58 --> 28:00when our patients hear that they're going
28:00 --> 28:03to go on systemic therapy or chemotherapy,
28:03 --> 28:05they kind of think of
28:06 --> 28:08the movies or loved ones that they've
28:08 --> 28:10seen have gotten really very sick.
28:10 --> 28:13Or their hair has fallen out or their
28:13 --> 28:15immune system is completely wiped out,
28:15 --> 28:18and the medications that we use to
28:18 --> 28:19treat liver cancer are definitely
28:19 --> 28:20much more tolerable
28:22 --> 28:23with significantly reduced side
28:23 --> 28:25effects compared to
28:25 --> 28:27what a lot of patients think about
28:27 --> 28:29for sort of standard chemotherapy
28:29 --> 28:30for other tumors.
28:31 --> 28:33Doctor Ariel Jaffe is an assistant
28:33 --> 28:34professor of medicine in the
28:34 --> 28:36section of digestive diseases
28:36 --> 28:38at the Yale School of Medicine.
28:38 --> 28:39If you have questions,
28:39 --> 28:41the address is cancer answers at
28:41 --> 28:44yale.edu and past editions of the
28:44 --> 28:46program are available in audio and
28:46 --> 28:48written form at yalecancercenter.org.
28:48 --> 28:50We hope you'll join us next week to
28:50 --> 28:52learn more about the fight against
28:52 --> 28:54cancer here on Connecticut Public Radio.
28:54 --> 28:55Funding for Yale Cancer
28:55 --> 28:57Answers is provided by Smilow
28:57 --> 29:00Cancer Hospital and AstraZeneca.

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November 28, 2021

Yale Cancer Center

visit: http://www.yalecancercenter.org

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