Management of hepatocellular in the United States
Hepatocellular carcinoma (HCC) is a major cause of cancer burden globally. In the United States, the incidence of HCC is forecast to continue to rise for the next 15 years. Patients with HCC vary markedly owing to heterogeneous tumor characteristics and concomitant liver dysfunction. In the United States and Europe, HCC is staged and managed according to the Barcelona Clinic Liver Cancer (BCLC) system. For very early and early stage HCC, or BCLC 0/A, liver transplant is the optimal treatment option. Liver resection and radiofrequency or microwave ablation are alternative treatment options. For intermediate stage HCC, or BCLC B, transarterial chemoembolization (TACE) is the standard of care. An alternative locoregional therapy, transarterial radioembolization using yttrium-90, has shown comparable outcomes with TACE and may be used in patients for whom TACE is contraindicated. For advanced stage HCC, or BCLC C, systemic chemotherapy with sorafenib, a multikinase inhibitor, is the only evidence-based treatment option available. Another multikinase inhibitor, regorafenib, was recently approved as a second-line therapy for this patient group. Randomized clinical trials investigating other agents in enriched patient groups and novel therapeutics including checkpoint inhibitors are underway. Patient with prohibitive performance status and/or end stage liver dysfunction are classified terminal stage HCC, or BCLC D, and are managed with best supportive care. The future direction for the management of HCC will rely on continuing efforts to uncover molecular pathways and actionable genetic aberrations in HCC.