Wednesday, March 21, 2012

Podcast:Hepatitis-Risk For Liver Cancer

Liver Cancer: An Overview

Dr. Melanie Thomas, associate professor of medicine in the division of hematology/oncology and associate director of clinical investigations at Hollings Cancer Center, discusses some of the more common types and causes of liver cancer. Dr. Thomas explains how liver cancer can often be brought on by certain conditions known to damage and stress the liver itself, such as hepatitis B and C, diabetes, obesity and excessive alcohol consumption. She stresses the importance of regular screenings for hepatitis and cirrhosis patients due to the increased risk for developing liver cancer. Dr. Thomas concludes this podcast by discussing the high level of care patients can expect from the specialists who focus on this disease at Hollings Cancer Center.

Liver Cancer: An Overview


Guest:  Dr. Melanie Thomas – Hollings Cancer Center (HCC)
Host:  Dr. Linda Austin – Psychiatry

Dr. Linda Austin:  I’m Dr. Linda Austin.  I’m interviewing Dr. Melanie Thomas who is Associate Professor of Medicine in the division of Hematology/Oncology.  Dr. Thomas is also Associate Director of Clinical Investigations at Hollings Cancer Center here at the Medical University of South Carolina.  Dr. Thomas, your area of specialty is liver cancer.  One thing that’s confusing about that is that sometimes we hear doctors talk about primary liver cancer or secondary.  Can you explain those terms as well as how cancer arises in the liver?

Dr. Melanie Thomas:  Sure.  That’s a really important point.  Many people will say, oh, well, I have liver cancer, but, in fact, they have cancer that began in the breast or the lung, or some other organ, and it has traveled to the liver which is a very common place for cancers to go.  So, that would be, say, lung cancer that’s metastasized to the liver.  Distinguished from that would be a cancer that arose in the liver, and that goes by the name of hepatocellular cancer (HCC) or hepatoma.  Sometimes you hear reference to that cancer. 

So, a hepatoma is not very common relative to the things we hear about more often, breast, lung, colon, etc.  But it’s a cancer that is increasing somewhat dramatically in the U.S.  Most people who acquire liver cancer have some sort of underlying damage to their liver and that can come about from many causes.  The common cause is hepatitis B.  So, there are millions and millions of patients in Asia, Sub-Saharan Africa who have hepatitis B and go on to develop liver cancer.  In the United States, the most common causes are hepatitis C.  After that is excessive alcohol use which can damage the liver.  Then, after than, it’s kind of a larger group of causes, diabetes and obesity are becoming more important.   

Dr. Linda Austin:  So, essentially, then, cancer arises, it sounds like, in a liver that has been stressed in some way.

Dr. Melanie Thomas:  Yes.  In the vast majority of cases, the liver is damaged, and sometimes that’s referred to as cirrhosis.  Cirrhosis, really, simply means that the liver has been scarred.  Now, many people hear the word cirrhosis and they equate that to, oh, alcohol or alcoholic.  But alcohol is only one of many causes associated with liver damage.  So, yes, the liver has been damaged.  We don’t quite know why certain livers go on to develop cancer because less than 30 percent of those patients will actually develop liver cancer. 

Dr. Linda Austin:  But 30 percent is still significant.  That’s a not a small percentage.  What advice do you give a person who has had a history of hepatitis B or hepatitis C or alcoholic cirrhosis in terms of screening?  Proactively, should those patients be doing anything?

Dr. Melanie Thomas:  Absolutely.  Of all the cancers, and we all think about cancer prevention, in my mind, hepatoma or HCC is an absolutely preventable cancer.  So, many patients don’t even know that they’ve been exposed to hepatitis B or C.  So, for those that you mentioned who know they have it, they absolutely need to be under the close care of, preferably, someone who specializes in the liver.  That would be a gastroenterologist or hepatologist.  But even a good primary care physician should be able to screen these patients.  So, they should be seen several times a year, have some blood work done to check their liver function.  If they have active hepatitis B or C, they should also be getting ultrasounds.  Fortunately, there are published guidelines for how frequently those patients should be evaluated.

Dr. Linda Austin:  What about when those diseases are in remission, if they’re no longer in a state of active hepatitis or, let’s say, somebody who has been diagnosed with cirrhosis but they’ve stopped drinking?  They’re still at risk because they have had cirrhosis.  Do you recommend following those patients?

Dr. Melanie Thomas:  Yes, definitely.  Cirrhosis is really an end point.  There’s something called fibrosis which, you know, means the liver is damaged but it’s not a final, sort of, end.  Cirrhosis cannot be reversed.  If you think of it as, you know, you got sunburned many times when you were young and now you’ve got patches of skin that are very damaged, and there’s nothing you can do to change that.  It’s essentially the same thing in the liver.  So, it’s an end point.  You can’t reverse cirrhosis, but it can continue to get worse and a person can go into liver failure. 

So, the example you gave of someone who knows they have cirrhosis, was actively drinking and they stopped, first of all, they should be very happy about that because that’s a tremendous thing that they can do.  They still should be followed by, again, a gastroenterologist, primary care physician, because once the liver is damaged, we think what takes place is that the liver attracts a lot of inflammatory cells and that the damage can continue because of that attraction of inflammatory cells.  Cessation of drinking can slow their progression to liver failure, but once someone has a damaged liver, they are still at risk for a lot of problems related to cirrhosis.

Dr. Linda Austin:  So, then, how should that patient be followed?  Should they get some sort of ultrasound periodically?  What do you recommend?

Dr. Melanie Thomas:  A person with cirrhosis, really, from any cause, hepatitis B, hepatitis C, alcohol would be the biggest, should have some blood work and an ultrasound done of the liver every six months.  That’s kind of the current published recommendation.  The hepatitis C patients have the highest risk of going on to develop cancer.  So, for a patient such as that, I would really double that recommendation.  It should be more like every three months or four times a year that they’re followed.  So, again, for a person who has known hepatitis C, particularly if there’s alcohol involved, that can accelerate their progression to liver cancer.  I would follow a patient like that about every three months.

Dr. Linda Austin:  What are the earliest symptoms, the first symptoms, of liver cancer?

Dr. Melanie Thomas:  This is one of the problems with this disease.  Hepatocellular cancer stays very silent, usually, until it’s very advanced.  That’s for several reasons.  Cancers that begin in the liver tend to stay in the liver.  They can metastasize elsewhere, but he majority of them just become bigger and bigger within the liver.  The problem is that the inside of the liver doesn’t have pain nerves like other parts of the body do.  So, patients can develop very large masses, you know, grapefruit, almost football size, and not be aware of them.  That’s why screening is so important, with the blood work and the ultrasounds, so you can pick up small tumors earlier. 

So, symptoms to watch for would be unusual weight loss, a decrease in appetite, distended abdomen, fatigue.  The skin turning yellow, really, would be a very advanced sign.  All of these would be very advanced signs.  So, unfortunately, by the time a patient would notice symptoms, they generally have quite advanced disease, which, again, brings us back to the importance of screening.

Dr. Linda Austin:  Is there chemotherapy for this form of cancer?

Dr. Melanie Thomas:  In the last year, one oral drug has been approved in the treatment of advanced hepatocellular cancer.  It was one of the few tumors that, again, until a year ago had no drugs approved for it.  One of the things that’s unique about liver cancer, and this is important, is that it’s very much a multi-disciplinary disease.  To take the best care of patients, you need to have a surgeon involved, hepatologist, medical oncologist, interventional radiologist.  For the smaller tumors, there are a lot of things that can be done with those.  But, because it’s an uncommon disease, it’s really good that patients find a place that specializes in it and has all of those areas of expertise.  

Dr. Linda Austin:  Such as we have here, especially with your arrival here at Hollings Cancer Center.

Dr. Melanie Thomas:  That was actually one of the things that really attracted me here.  I have been doing this disease full-time for about six years and, again, you really need other collaborators.  When I came here, I was fortunate to find that there’s a liver transplant program here, which many people don’t know is extremely well-ranked nationally in terms of the quality of their outcomes.  If the same surgeons are very good liver surgeons, I have at my disposal three full-time hepatologists, which is just terrific.  They also have very strong interventional radiology.  So, I think I bring sort of the fourth leg of the table.  We really are, now, positioned to provide full service for these patients. 

Dr. Linda Austin:  Dr. Thomas, we are so fortunate to have you join our faculty.  Welcome to Charleston and to the medical university and to Hollings Cancer Center.

Dr. Melanie Thomas:  Thank you.

Liver Cancer
2012-New guidelines on the management of hepatocellular carcinoma (HCC).
These guidelines result from a joint collaboration between the European Association for the Study of the Liver (EASL) and the European Organization for Research and Treatment of Cancer (EORTC).

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