STEP 4: Treatment

Step 4 describes the optimal treatments for HCC, the training and experience required of the treating clinicians and the health service characteristics required for optimal cancer care.

All health services must have clinical governance systems that meet the following integral requirements:

  • identifying safety and quality measures
  • monitoring and reporting on performance and outcomes
  • identifying areas for improvement in safety and quality (ACSQHC 2020).

Step 4 outlines the treatment options for HCC. For detailed clinical information on treatment options refer to these resources:

The intent of treatment can be defined as one of the following:

  • curative
  • anti-cancer therapy to improve quality of life or longevity (or both) without expectation of cure
  • symptom palliation.

The treatment intent should be established in a multidisciplinary setting, documented in the patient’s medical record and conveyed to the patient and carer as appropriate.

The potential benefits need to be balanced against the morbidity and risks of treatment.

In many cases severity of the co-existing liver disease affects treatment options and needs to be treated appropriately.

The lead clinician should discuss the advantages and disadvantages of each treatment and associated potential side effects with the patient and their carer or family before treatment consent is obtained and begins so the patient can make an informed decision. Supportive care services should also be considered during this decision-making process. Patients should be asked about their use of (current or intended) complementary therapies (see Appendix D).

Timeframes for starting treatment should be informed by evidence-based guidelines where they exist. The treatment team should recognise that shorter timeframes for appropriate consultations and treatment can promote a better experience for patients.

Initiate advance care planning discussions with patients before treatment begins (this could include appointing a substitute decision-maker and completing an advance care directive). Formally involving a palliative care team/service may benefit any patient, so it is important to know and respect each person’s preference (AHMAC 2011).

HCC treatments that improve survival include:

  • surgery – resection or transplant
  • local ablative therapies
  • regional therapies
  • localised therapies.

Surgery – resection or transplant

Only a small number of cases are suited to surgery. Established criteria for surgical intervention depend on the severity of liver disease and the presence of clinically significant portal hypertension. The size, number and position of the tumours, and residual liver volume, all need to be considered.

A resection may benefit patients with compensated liver disease. Laparoscopic surgical techniques produce better patient outcomes.

A liver transplant may benefit patients who also have cirrhosis, including those with decompensation, and patients with a tumour volume that is within accepted international guidelines.

Timeframe for starting treatment

Surgery should begin within four weeks of the MDM.

Training and experience required of the surgeon

Surgeon (Fellow of the Royal Australasian College of Surgeons (FRACS) or equivalent) with adequate training and experience in HPB surgery and institutional cross-credentialing and agreed scope of practice within this area.

Documented evidence of training and experience of the surgeon, including their specific experience with HCC and procedures to be undertaken, should be available.

Health service characteristics

To provide safe and quality care for patients having surgery, health services should have these features:

  • critical care support
  • 24-hour medical staff availability
  • 24-hour operating room access and intensive care unit
  • a clearly defined path to emergency care and advice after hours
  • full support from other surgical specialties including vascular surgery, colorectal surgery, urological surgery and upper gastrointestinal surgery
  • diagnostic imaging
  • expert and timely interventional radiology
  • pathology.

Evidence suggests that high-volume hospitals have better clinical outcomes for complex cancer surgery (Lu et al. 2014). Centres that do not have sufficient caseloads should establish processes to routinely refer surgical cases to a high-volume centre.

Local ablative therapies and regional therapies

Local ablative therapies used to treat HCC are:

  • radiofrequency ablation
  • microwave ablation
  • percutaneous ethanol
  • percutaneous acetic acid injections
  • stereotactic radiation therapy
  • image-guided cryoablation.

Local ablative therapies may have the following benefits:

  • curative treatment in cases of advanced liver disease
  • the downsizing of tumours before definitive treatment
  • treatment of recurrent tumours
  • improved length of survival and quality of life.

Regional therapies used to treat HCC are:

  • transarterial chemoembolisation (TACE) – a type of chemotherapy that is injected directly into the liver along with a gel or small beads that are injected into the blood vessels surrounding the tumours
  • transarterial embolisation (TAE) (as for TACE but without chemotherapy) – a rarely used alternative
  • selective internal radiation therapy (SIRT) – a type of radiation and embolisation therapy where radioactive material is injected directly into the blood vessels supplying the tumours.

Regional therapies may have the following benefits:

  • as a palliative treatment to slow down tumour growth (for early or advanced disease)
  • for patients waiting for a transplant (shrinking of tumours)
  • for patients with major vascular invasion (SIRT)
  • for selected tumours using chemo-ablation therapy.

Timeframe for starting treatment

Local ablative therapies or regional therapies should begin within four weeks of the MDM.

Training and experience required of the appropriate specialists

  • Interventional radiologist (FRANZCR or equivalent) with adequate training and experience with institutional credentialing and agreed scope of practice in liver cancer
  • SIRT should only be performed by credentialled specialists
  • European Board of Interventional Radiology (EBIR) certification, or equivalent standard, is recommended.

Documented evidence of training and experience of the radiologist, including their specific experience with liver ablation and procedures to be undertaken, should be available.

Health service unit characteristics

To provide safe and quality care for patients having regional or radiation therapy, health services should have these features:

  • dedicated CT planning
  • access to MRI and PET imaging
  • automatic record-verify of all radiation therapies delivered
  • a treatment planning system
  • trained medical physicists, experienced nuclear medicine technologists, radiation therapists and nurses with radiation therapy experience
  • coordination for combined therapy with systemic therapy, especially where facilities are not collocated
  • participation in Australian Clinical Dosimetry Service audits
  • an incident management system linked with a quality management system

Localised therapies

Localised therapies are the most common treatment for early-stage HCC and are used with cure in mind. Localised therapies may be used in conjunction with surgery and may be thermal or chemical, depending on local expertise.

Localised therapies may benefit patients:

  • with unresectable disease (due to the size, number or location of the tumour and severity of liver disease)
  • with small tumour(s) (lesions 5 cm or smaller)
  • awaiting liver transplant
  • with small recurrent tumours (particularly after prior resection).

Localised therapies should be monitored by imaging four weeks after the procedure to assess the response and then at three-monthly intervals for two years, and six-monthly after that.

Timeframe for starting treatment

Localised therapies should begin within four weeks of the MDM.

Training and experience required of the appropriate specialists

  • Interventional radiologist (FRANZCR or equivalent) with adequate training and experience in ablative therapies, with institutional credentialing and agreed scope of practice within this area
  • EBIR or equivalent standard is recommended.

Documented evidence of training and experience of the radiologist, including their specific experience with localised therapies and procedures to be undertaken, should be available.

The standard treatment for patients with advanced HCC is systemic therapies. In patients who show low intolerance or disease progression, consider enrolment in clinical trials where available. First-line approved systemic therapy in Australia for advanced HCC is either sorafenib or lenvatinib. Approved second-line therapies for patients who progress on a first-line therapy includes regorafenib, nivolumab and cabozantinib; however, these are currently not reimbursed by the Pharmaceutical Benefits Advisory Committee.

The combination of atezolizumab and bevacizumab is currently submitted to the Pharmaceutical Benefits Advisory Committee for approval (Finn et al. 2020).

Palliation of symptoms may include TACE, surgery, radiation and other therapies.

Patients should be offered clinical trials where appropriate.

Several new drugs and combination therapies will become available based on the results of clinical trials.

The key principle for precision medicine is prompt and clinically oriented communication and coordination with an accredited laboratory and pathologist. Tissue analysis is integral for access to emerging therapies and, as such, tissue specimens should be treated carefully to enable additional histopathological or molecular diagnostic tests in certain scenarios.

Early referral to palliative care can improve the quality of life for people with cancer and in some cases may be associated with survival benefits (Haines 2011; Temel et al. 2010; Zimmermann et al. 2014). This is particularly true for cancers with poor prognosis.

The lead clinician should ensure patients receive timely and appropriate referral to palliative care services. Referral should be based on need rather than prognosis. Emphasise the value of palliative care in improving symptom management and quality of life to patients and their carers.

The ‘Dying to Talk’ resource may help health professionals when initiating discussions with patients about future care needs (see ‘More information’). Ensure that carers and families receive information, support and guidance about their role in palliative care (Palliative Care Australia 2018).

Patients, with support from their family or carer and treating team, should be encouraged to consider appointing a substitute decision-maker and to complete an advance care directive.

Refer to Step 6 for a more detailed description of managing patients with recurrent, residual or metastatic disease.

More information

These online resources are useful:

The team should support the patient to participate in research or clinical trials where available and appropriate. Many emerging treatments are only available on clinical trials that may require referral to certain trial centres.

For more information visit the Cancer Australia website.

See validated screening tools mentioned in Principle 4 ‘Supportive care’.

A number of specific challenges and needs may arise for patients at this time:

  • assistance for dealing with emotional and psychological issues, including body image concerns, coping with stomas, fatigue, quitting smoking, traumatic experiences, existential anxiety, treatment phobias, anxiety/depression, interpersonal problems and sexuality concerns
  • potential isolation from normal support networks, particularly for rural patients who are staying away from home for treatment
  • management of underlying liver disease to prevent worsening or complications
  • management of physical symptoms such as pain and weight loss
  • nutrition screening and support
  • support for alcohol or other substance misuse (related to hepatitis or underlying liver disease)
  • assistance with managing complex medication regimens, multiple medications, assessment of side effects and assistance with difficulties swallowing medications – referral to a pharmacist may be required
  • decline in mobility or functional status as a result of treatment
  • assistance with beginning or resuming regular exercise with referral to an exercise physiologist or physiotherapist (COSA 2018; Hayes et al. 2019).

Early involvement of general practitioners may lead to improved cancer survivorship care following acute treatment. General practitioners can address many supportive care needs through good communication and clear guidance from the specialist team (Emery 2014).

Patients, carers and families may have these additional issues and needs:

  • financial issues related to loss of income (through reduced capacity to work or loss of work) and additional expenses as a result of illness or treatment
  • advance care planning, which may involve appointing a substitute decision-maker and completing an advance care directive
  • legal issues (completing a will, care of dependent children) or making an insurance, superannuation or social security claim on the basis of terminal illness or permanent disability.

Cancer Council’s 13 11 20 information and support line can assist with information and referral to local support services.

For more information on supportive care and needs that may arise for different population groups, see Appendices A and B, and special population groups.

Rehabilitation may be required at any point of the care pathway. If it is required before treatment, it is referred to as prehabilitation (see section 3.6.1).

All members of the multidisciplinary team have an important role in promoting rehabilitation. Team members may include occupational therapists, speech pathologists, dietitians, social workers, psychologists, physiotherapists, exercise physiologists and rehabilitation specialists.

To maximise the safety and therapeutic effect of exercise for people with cancer, all team members should recommend that people with cancer work towards achieving, and then maintaining, recommended levels of exercise and physical activity as per relevant guidelines. Exercise should be prescribed and delivered under the direction of an accredited exercise physiologist or physiotherapist with experience in cancer care (Vardy et al. 2019). The focus of intervention from these health professionals is tailoring evidence-based exercise recommendations to the individual patient’s needs and abilities, with a focus on the patient transitioning to ongoing self-managed exercise.

Other issues that may need to be dealt with include managing cancer-related fatigue, improving physical endurance, achieving independence in daily tasks, optimising nutritional intake, returning to work and ongoing adjustment to cancer and its sequels. Referrals to dietitians, psychosocial support, return-to-work programs and community support organisations can help in managing these issues.

The lead or nominated clinician should take responsibility for these tasks:

  • discussing treatment options with patients and carers, including the treatment intent and expected outcomes, and providing a written version of the plan and any referrals
  • providing patients and carers with information about the possible side effects of treatment, managing symptoms between active treatments, how to access care, self-management strategies and emergency contacts
  • encouraging patients to use question prompt lists and audio recordings, and to have a support person present to aid informed decision making
  • initiating a discussion about advance care planning and involving carers or family if the patient wishes.

The general practitioner plays an important role in coordinating care for patients, including helping to manage side effects and other comorbidities, and offering support when patients have questions or worries. For most patients, simultaneous care provided by their general practitioner is very important.

The lead clinician, in discussion with the patient’s general practitioner, should consider these points:

  • the general practitioner’s role in symptom management, supportive care and referral to local services
  • using a chronic disease management plan and mental health care management plan
  • how to ensure regular and timely two-way communication about:
    • the treatment plan, including intent and potential side effects
    • supportive and palliative care requirements
    • the patient’s prognosis and their understanding of this
    • enrolment in research or clinical trials
    • changes in treatment or medications
    • the presence of an advance care directive or appointment of a substitute decision-maker
    • recommendations from the multidisciplinary team.
More information

Refer to Principle 6 ‘Communication’ for communication skills training programs and resources.