Health-related quality of life in patients with hepatocellular carcinoma after hepatic resection, transcatheter arterial chemoembolization, radiofrequency ablation or no treatment

The first validation of the Functional Assessment of Cancer Therapy Hepatobiliary (FACT-Hep) for evaluating health-related quality of life (HRQOL) in patients with advanced-stage intrahepatic cholangiocarcinoma (biliary tract cancer)

BACKGROUND

The FACT-Hep questionnaire has been used to evaluate the health-related quality of life (HRQOL) in various types of hepatobiliary cancer. Nevertheless, the application in intrahepatic cholangiocarcinoma (iCCA) has been limited. The study aimed to validate the applicability of FACT-Hep as a reliable tool for evaluating HRQOL in patients with advanced-stage iCCA.

METHODS

Atractylodes lancea capsules were tested for efficacy and safety in a randomized, controlled phase IIA. Internal consistency, intraclass correlation, test-retest reliability, discriminant and convergent validity, and FACT-Hep score-clinical response connection were assessed.

RESULTS

Thirty-nine patients qualified for the research. Cronbach's alpha coefficients > 0.7 showed internal consistency for all subscale items from baseline (day 1) to 90 days. For ICC, convergent, and discriminant validity, all items except the HepCS subscale were reliable. Patients with ECOG scores of 0-1 or 2 had significantly different HepCS subscale values-calculated effect size for subscale score change over time. FACT-G and FWB differed significantly in low-dose group 1. At 3-month, 1-month, and 2-month follow-ups, Group 2 (high dose) patients had significant differences in FACT-Hep, TOI, and HepCS. The effect size was the same in Group 3 (untreated). Group 1 and 2 non-progressive patients exhibited lower FWB and EWB scores than progressive patients. The treated survivors had lower FACT-Hep, TOI, HepCS, FWB, and EWB scores than the non-treated survivors, which was linked to AL treatment side effects.

CONCLUSION

The FACT-Hep detects changes and is a reliable and valid tool for assessing HRQOL in patients with advanced-stage iCCA.

Hepatocellular Carcinoma Incidence Threshold for Surveillance in Virologically Cured Hepatitis C Individuals

BACKGROUND & AIMS

Guidelines recommend biannual surveillance for hepatocellular carcinoma (HCC) in hepatitis C individuals with cirrhosis if the HCC incidence rate is above 1.5 per 100 person-years (PY). However, the incidence threshold for surveillance in individuals who achieve a virologic cure is unknown. We estimated the HCC incidence rate above which routine HCC surveillance is cost-effective in this growing population of virologically cured hepatitis C individuals with cirrhosis or advanced fibrosis.

METHODS

We developed a Markov-based microsimulation model of the natural history of HCC in individuals with hepatitis C who achieved virologic cure with oral direct-acting antivirals. We used published data on the natural history of hepatitis C, competing risk post virologic cure, HCC tumor progression, real-world HCC surveillance adherence, contemporary HCC treatment options and associated costs, and utilities of different health states. We estimated the HCC incidence above which biannual HCC surveillance using ultrasound and alpha-fetoprotein would be cost-effective.

RESULTS

In virologically cured hepatitis C individuals with cirrhosis or advanced fibrosis, HCC surveillance is cost-effective if HCC incidence exceeds 0.7 per 100 PY using $100,000 per quality-adjusted life year willingness-to-pay. At this HCC incidence, routine HCC surveillance would result in 2650 and 5700 additional life years per 100,000 cirrhosis and advanced fibrosis persons, respectively, compared with no surveillance. At $150,000 willingness-to-pay, surveillance is cost-effective if HCC incidence exceeds 0.4 per 100 PY. Sensitivity analysis showed that the threshold mostly remained below 1.5 per 100 PY.

CONCLUSIONS

The contemporary HCC incidence threshold is much lower than the previous 1.5% incidence value used to guide HCC surveillance decisions. Updating clinical guidelines could improve the early diagnosis of HCC.

An Update on Patient-Reported Outcomes in Interventional Radiology: The Future Measure of Our Success

The field of interventional radiology continues to expand rapidly, offering an increasing range of alternatives to open surgical procedures. This minimally invasive imaging-guided approach promises faster recovery times and a theoretically improved patient experience; however, there is limited evidence documenting that these promises are actually delivered. Patient-reported outcomes are a way of collecting data on the patient experience increasingly used in clinical trials and the provision of surgical services and informing clinical practice across a range of elective procedures. Currently underutilised in interventional radiology, patient-reported outcomes have the potential to significantly impact how we deliver care by allowing evaluation of the perceived benefit derived by a patient after undergoing a procedure and to permit comparison with more invasive open procedures from the patient perspective.

Ablative and non-surgical therapies for early and very early hepatocellular carcinoma: a systematic review and network meta-analysis

Background

A wide range of ablative and non-surgical therapies are available for treating small hepatocellular carcinoma in patients with very early or early-stage disease and preserved liver function.

Objective

To review and compare the effectiveness of all current ablative and non-surgical therapies for patients with small hepatocellular carcinoma (≤ 3 cm).

Design

Systematic review and network meta-analysis.

Data sources

Nine databases (March 2021), two trial registries (April 2021) and reference lists of relevant systematic reviews.

Review methods

Eligible studies were randomised controlled trials of ablative and non-surgical therapies, versus any comparator, for small hepatocellular carcinoma. Randomised controlled trials were quality assessed using the Cochrane Risk of Bias 2 tool and mapped. The comparative effectiveness of therapies was assessed using network meta-analysis. A threshold analysis was used to identify which comparisons were sensitive to potential changes in the evidence. Where comparisons based on randomised controlled trial evidence were not robust or no randomised controlled trials were identified, a targeted systematic review of non-randomised, prospective comparative studies provided additional data for repeat network meta-analysis and threshold analysis. The feasibility of undertaking economic modelling was explored. A workshop with patients and clinicians was held to discuss the findings and identify key priorities for future research.

Results

Thirty-seven randomised controlled trials (with over 3700 relevant patients) were included in the review. The majority were conducted in China or Japan and most had a high risk of bias or some risk of bias concerns. The results of the network meta-analysis were uncertain for most comparisons. There was evidence that percutaneous ethanol injection is inferior to radiofrequency ablation for overall survival (hazard ratio 1.45, 95% credible interval 1.16 to 1.82), progression-free survival (hazard ratio 1.36, 95% credible interval 1.11 to 1.67), overall recurrence (relative risk 1.19, 95% credible interval 1.02 to 1.39) and local recurrence (relative risk 1.80, 95% credible interval 1.19 to 2.71). Percutaneous acid injection was also inferior to radiofrequency ablation for progression-free survival (hazard ratio 1.63, 95% credible interval 1.05 to 2.51). Threshold analysis showed that further evidence could plausibly change the result for some comparisons. Fourteen eligible non-randomised studies were identified (n ≥ 2316); twelve had a high risk of bias so were not included in updated network meta-analyses. Additional non-randomised data, made available by a clinical advisor, were also included (n = 303). There remained a high level of uncertainty in treatment rankings after the network meta-analyses were updated. However, the updated analyses suggested that microwave ablation and resection are superior to percutaneous ethanol injection and percutaneous acid injection for some outcomes. Further research on stereotactic ablative radiotherapy was recommended at the workshop, although it is only appropriate for certain patient subgroups, limiting opportunities for adequately powered trials.

Limitations

Many studies were small and of poor quality. No comparative studies were found for some therapies.

Conclusions

The existing evidence base has limitations; the uptake of specific ablative therapies in the United Kingdom appears to be based more on technological advancements and ease of use than strong evidence of clinical effectiveness. However, there is evidence that percutaneous ethanol injection and percutaneous acid injection are inferior to radiofrequency ablation, microwave ablation and resection.

Study registration

PROSPERO CRD42020221357.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment (HTA) programme (NIHR award ref: NIHR131224) and is published in full in Health Technology Assessment; Vol. 27, No. 29. See the NIHR Funding and Awards website for further award information.

Rescue therapy for local tumor progression after radiofrequency ablation of small hepatocellular carcinoma: a comparison between repeated ablation and transcatheter arterial chemoembolization

OBJECTIVE

To compare the therapeutic outcomes of repeated radiofrequency ablation (RFA) and transcatheter arterial chemoembolization (TACE) as rescue therapy for the treatment of local tumor progression (LTP) after initial RFA for hepatocellular carcinoma (HCC).

METHODS

This retrospective study evaluated 44 patients who had LTP as initial tumor recurrence after RFA and underwent repeated RFA (n = 23) or TACE (n = 21) for local disease control. Local disease control and overall survival rates were evaluated using the Kaplan-Meier method. A Cox proportional-hazards regression model was used to identify the independent prognostic factors. The local disease control rate after the first rescue therapy and the number of rescue therapies applied until the last follow-up were also evaluated.

RESULTS

Local disease control after rescue therapy for LTP was significantly higher with repeated RFA than with TACE (p < 0.001). Treatment type was a significant factor for local disease control (p < 0.001). The overall survival rates after rescue therapy were not significantly different between the two treatments (p = 0.900). The local disease control rate after the first rescue therapy was significantly higher with RFA than with TACE (78.3% vs 23.8%, p < 0.001). The total number of rescue therapies applied was significantly higher in the TACE group than that in the repeated RFA group (median 3 vs 1, p < 0.001).

CONCLUSION

Repeated RFA as rescue therapy for LTP after initial RFA for HCC was more efficient and had significantly better local disease control than TACE.

ADVANCES IN KNOWLEDGE

Even if LTP occurs after initial RFA, it should not be considered a failure of RFA, and repeated RFA should be performed over TACE if possible for more effective local disease control.

Impact of Oocyte Extract Supplement on Quality of Life after Hepatectomy for Liver Tumours: A Prospective, Multicentre, Double-Blind Randomized Clinical Trial

BACKGROUND

Previous studies on oocyte extract supplementation showed benefits in patients with liver tumours. In this trial, we hypothesized that the oocyte extract supplement impacted the QoL after hepatectomy for hepatocellular carcinoma and intrahepatic cholangiocarcinoma.

METHODS

This was a multicentre, double-blind, randomized clinical trial designed to assess the QoL of patients receiving a supplement of oocyte extract or placebo postoperatively. QoL was assessed using the Short Form-36 questionnaire in participants randomly assigned to treatment (Synchrolevels) or placebo. All study personnel and participants were masked to treatment assignment. The endpoint was the change in the QoL score.

RESULTS

Between June 2018 and September 2022, 66 of 128 expected patients were considered as per interim analysis, of which 33 were assigned to the treatment and 33 to the placebo group. Baseline and clinicopathological characteristics were similar between the two groups. In the treatment group, the health, mental and psychological status improved for many of the items considered, reaching statistical significance, while in the placebo group, those items either did not change or were impaired in comparison with the corresponding baseline.

CONCLUSIONS

Supplementation with oocyte extract modifies QoL after liver surgery by enhancing functional recovery. Further in-depth studies are required to confirm this evidence.

Inverse Probability of Treatment Weighting in 5-Year Quality-of-Life Comparison among Three Surgical Procedures for Hepatocellular Carcinoma

This prospective longitudinal cohort study analyzed long-term changes in individual subscales of quality-of-life (QOL) measures and explored whether these changes were related to effective QOL predictors after hepatocellular carcinoma (HCC) surgery. All 520 HCC patients in this study had completed QOL surveys before surgery and at 6 months, 2 years, and 5 years after surgery. Generalized estimating equation models were used to compare the 5-year QOL among the three HCC surgical procedures. The QOL was significantly (p < 0.05) improved at 6 months after HCC surgery but plateaued at 2−5 years after surgery. In postoperative surveys, the effect size was largest in the nausea and vomiting subscales in patients who had received robotic surgery, and the effect size was smallest in the dyspnea subscale in patients who had received open surgery. It revealed the following explanatory variables for postoperative QOL: surgical procedure type, gender, age, hepatitis C, smoking, tumor stage, postoperative recurrence, and preoperative QOL. The comparisons revealed that, when evaluating QOL after HCC surgery, several factors other than the surgery itself should be considered. The analysis results also implied that postoperative quality of life might depend not only on the success of the surgical procedure, but also on preoperative quality of life.

Early Implementation of Palliative and Supportive Care in Hepatocellular Carcinoma

Early palliative and supportive care referral is the standard of care for many malignancies. This paradigm results in improvements in patients' symptoms and quality of life and decreases the costs of medical care and unnecessary procedures. Leading oncology guidelines have recommended the integration of early referral to palliative and supportive services to care pathways for advanced malignancies. Currently, early referral to palliative care within the hepatocellular carcinoma (HCC) population is not utilized, with gastroenterology guidelines recommending referral of patients with Barcelona Clinic Liver Cancer stage D to these services. This review addresses this topic through analysis of the existing data within the oncology field as well as literature surrounding palliative care intervention in HCC. Early palliative and supportive care in HCC and its impact on patients, caregivers, and health services allow clinicians and researchers to identify management options that improve outcomes within existing service provisions.

Duration and cost-effectiveness of hepatocellular carcinoma surveillance in hepatitis C patients after viral eradication

BACKGROUND & AIMS

Successful treatment of chronic hepatitis C with oral direct-acting antivirals (DAAs) leads to virological cure, however, the subsequent risk of hepatocellular carcinoma (HCC) persists. Our objective was to evaluate the cost-effectiveness of biannual surveillance for HCC in patients cured of hepatitis C and the optimal age to stop surveillance.

METHODS

We developed a microsimulation model of the natural history of HCC in individuals with hepatitis C and advanced fibrosis or cirrhosis who achieved virological cure with oral DAAs. We used published data on HCC incidence, tumor progression, real-world HCC surveillance adherence, and costs and utilities of different health states. We compared biannual HCC surveillance using ultrasound and alpha-fetoprotein for varying durations of surveillance (from 5 years to lifetime) vs. no surveillance.

RESULTS

In virologically cured patients with cirrhosis, the incremental cost-effectiveness ratio (ICER) of biannual surveillance remained below $150,000 per additional quality-adjusted life year (QALY) (range: $79,500-$94,800) when surveillance was stopped at age 70, irrespective of the starting age (40-65). Compared with no surveillance, surveillance detected 130 additional HCCs in 'very early'/early stage and yielded 51 additional QALYs per 1,000 patients with cirrhosis. In virologically cured patients with advanced fibrosis, the ICER of biannual surveillance remained below $150,000/QALY (range: $124,600-$129,800) when surveillance was stopped at age 60, irrespective of the starting age (40-50). Compared with no surveillance, surveillance detected 24 additional HCCs in 'very early'/early stage and yielded 12 additional QALYs per 1,000 patients with advanced fibrosis.

CONCLUSION

Biannual surveillance for HCC in patients cured of hepatitis C is cost-effective until the age of 70 for patients with cirrhosis, and until the age of 60 for patients with stable advanced fibrosis.

LAY SUMMARY

Individuals who are cured of hepatitis C using oral antiviral drugs remain at risk of developing liver cancer. The value of lifelong screening for liver cancer in these individuals is not known. By simulating the life course of hepatitis C cured individuals, we found that ultrasound-based biannual screening for liver cancer is cost-effective up to age 70 in those with cirrhosis and up to age 60 in those with stable advanced fibrosis.

Patient-reported outcomes in HCC: A scoping review by the Practice Metrics Committee of the American Association for the Study of Liver Diseases

BACKGROUND AND AIMS

HCC is a leading cause of mortality in patients with advanced liver disease and is associated with significant morbidity. Despite multiple available curative and palliative treatments, there is a lack of systematic evaluation of patient-reported outcomes (PROs) in HCC.

APPROACH AND RESULTS

The American Association for the Study of Liver Diseases Practice Metrics Committee conducted a scoping review of PROs in HCC from 1990 to 2021 to (1) synthesize the evidence on PROs in HCC and (2) provide recommendations on incorporating PROs into clinical practice and quality improvement efforts. A total of 63 studies met inclusion criteria investigating factors associated with PROs, the relationship between PROs and survival, and associations between HCC therapy and PROs. Studies recruited heterogeneous populations, and most were cross-sectional. Poor PROs were associated with worse prognosis after adjusting for clinical factors and with more advanced disease stage, although some studies showed better PROs in patients with HCC compared to those with cirrhosis. Locoregional and systemic therapies were generally associated with a high symptom burden; however, some studies showed lower symptom burden for transarterial radiotherapy and radiation therapy. Qualitative studies identified additional symptoms not routinely assessed with structured questionnaires. Gaps in the literature include lack of integration of PROs into clinical care to guide HCC treatment decisions, unknown impact of HCC on caregivers, and the effect of palliative or supportive care quality of life and health outcomes.

CONCLUSION

Evidence supports assessment of PROs in HCC; however, clinical implementation and the impact of PRO measurement on quality of care and longitudinal outcomes need future investigation.

Is laparoscopic liver resection safe for super-elderly patients (aged ≥80)? A propensity score-matched analysis

BACKGROUND/PURPOSE

The safety of laparoscopic liver resection in super-elderly patients with comorbidities is unknown. We used propensity score matching to evaluate the utility and safety of laparoscopic liver resection in super-elderly patients.

METHODS

Two-hundred and five patients who underwent laparoscopic liver resection were retrospectively reviewed. They were classified into two groups based on age: ≥80 years (elderly group, n = 49) and <80 years (control group, n = 156). Propensity score matching (PSM) was performed based on preoperative clinical parameters. The intraoperative and postoperative outcomes were compared.

RESULTS

After matching, 45 patients were included in each group. The intraoperative blood loss was identical between the control and elderly groups (60 vs 60 mL, respectively, P = .588); the frequency of serious postoperative complications (Clavien-Dindo class ≥3, 1/45 vs 1/45, P = 1.00) was also similar. There was no significant difference in terms of the exacerbation of malignancy (22.2% vs 11.1%, P = .258) or other diseases (8.9% vs 22.2%, P = .144). There was no difference in overall survival before and after PSM. However, 5-year overall survival excluding primary cancer-related death showed a difference after PSM (90.7% vs 70.4%; P = .048).

CONCLUSIONS

Laparoscopic liver resection is feasible and safe in super-elderly patients. The long-term prognosis was poor in patients affected by other illnesses compared to the younger population with similar risk profiles, but there was no difference in overall survival.

Quality of Life and Cost Considerations: Y-90 Radioembolization

Objective  Transarterial radioembolization (TARE) offers a minimally invasive and safe treatment option for primary and metastatic hepatic malignancies. The benefits of TARE are manifold including prolonged overall survival, low associated morbidities, and improved time to progression allowing prolonged treatment-free intervals. The rapid development of new systemic therapies including immunotherapy has radically changed the treatment landscape for primary and metastatic liver cancer. Given the current climate, it is critical for interventional oncologists to understand the benefits of TARE relative to these other therapies. Therefore, this report aims to review quality-of-life outcomes and the cost comparisons of TARE as compared with systemic therapies.

Anatomic Resection for Hepatocellular Carcinoma: Prognostic Impact Assessed from Recurrence Treatment

BACKGROUND

The oncologic advantage of anatomic resection (AR) for primary hepatocellular carcinoma (HCC) remains controversial. This study aimed to evaluate the clinical advantages of AR for primary HCC by using propensity score-matching and by assessing treatment strategies for recurrence after surgery.

METHODS

The study reviewed data of patients who underwent AR or non-anatomic resection (NAR) for solitary HCC (≤ 5 cm) in two institutions between 2004 and 2017. Surgical outcomes were compared between the two groups in a propensity score-adjusted cohort. The time-to-interventional failure (TIF), defined as the elapsed time from resection to unresectable/unablatable recurrence, also was evaluated.

RESULTS

The inclusion criteria were met by 250 patients: 77 patients (31%) with AR and 173 patients (69%) with NAR. In the propensity score-matched populations (AR, 67; NAR, 67), the 5-year recurrence-free survival (RFS) for AR was better than for NAR (62% vs 35%; P = 0.005). No differences, however, were found in the 5-year overall survival between the two groups (72% vs 78%; P = 0.666). The 5-year TIF rates for the NAR group (60%) also were similar to those for the AR group (66%) (P = 0.413). In the cohort of 67 patients, curative repeat resection or ablation therapy was performed more frequently for the NAR patients (42%) than for the AR patients (10%) (P < 0.001).

CONCLUSION

For solitary HCC, AR decreases recurrence after the initial hepatectomy. However, aggressive curative-intent interventions for recurrence compensate for the impaired RFS, even for patients undergoing NAR.

Health-related quality of life in primary hepatic cancer: a systematic review assessing the methodological properties of instruments and a meta-analysis comparing treatment strategies

PURPOSE

Patient-reported outcomes including health-related quality of life (HRQoL) are important oncological outcome measures. The validation of HRQoL instruments for patients with hepatocellular and cholangiocellular carcinoma is lacking. Furthermore, studies comparing different treatment options in respect to HRQoL are sparse. The objective of the systematic review and meta-analysis was, therefore, to identify all available HRQoL tools regarding primary liver cancer, to assess the methodological quality of these HRQoL instruments and to compare surgical, interventional and medical treatments with regard to HRQoL.

METHODS

A systematic literature search was conducted in MEDLINE, the Cochrane library, PsycINFO, CINAHL and EMBASE. The methodological quality of all identified HRQoL instruments was performed according to the COnsensus-based Standards for the selection of health status Measurements INstruments (COSMIN) standard. Consequently, the quality of reporting of HRQoL data was assessed. Finally, wherever possible HRQoL data were extracted and quantitative analyses were performed.

RESULTS

A total of 124 studies using 29 different HRQoL instruments were identified. After the methodological assessment, only 10 instruments fulfilled the psychometric criteria and could be included in subsequent analyses. However, quality of reporting of HRQoL data was insufficient, precluding meta-analyses for 9 instruments.

CONCLUSION

Using a standardized methodological assessment, specific HRQoL instruments are recommended for use in patients with hepatocellular and cholangiocellular carcinoma. HRQoL data of patients undergoing treatment of primary liver cancers are sparse and reporting falls short of published standards. Meaningful comparison of established treatment options with regard to HRQoL was impossible indicating the need for future research.

Transarterial chemoembolisation in patients with hepatocellular carcinoma: low-dose doxorubicin reduces post-embolisation syndrome without affecting survival-prospective interventional study

Background

No chemotherapeutic agents have been standardised for transarterial chemoembolisation (TACE). In particular, doxorubicin has no defined optimal dosage in TACE procedures. We compared low versus currently used dose of doxorubicin for TACE in patients with hepatocellular carcinoma (HCC) in terms of severity of post-embolisation syndrome (PES) and overall survival (OS).

Methods

From October 2014 to March 2018, we enrolled patients with primary HCC scheduled for TACE. Patients were randomised to receive 50 mg (group A) or 100 mg (group B) of doxorubicin. Outcomes were the rate of patients with PES; free-time-to-PES; changes in laboratory results; tumour response at 1, 3, and 6 months after TACE; and overall survival.

Results

Twenty-eight patients (24 males, 4 females) were enrolled, aged 58.9 ± 6.8 years (mean ± standard deviation). Fifteen of them palliated with 50 mg (group A) and 13 with 100 mg (group B) of doxorubicin for a total of 68 TACE procedures (of 28 patients who had repeated TACE procedures). Visual analogue scale (VAS) and duration of pain were significantly differently lower in group A than in group B (p < 0.001). The median duration of fever was shorter in group A than in group B (p = 0.003). No significant differences between both groups were observed for tumour response to TACE and OS. The doxorubicin dose was significantly correlated with duration of pain, fever, and VAS score.

Conclusion

A lower dose of doxorubicin (50 mg) was associated with fewer PES symptoms compared with 100 mg, without effects on tumour response nor OS.

Systematic Review of Studies Assessing the Health-Related Quality of Life of Hepatocellular Carcinoma Patients from 2009 to 2018

We reviewed all studies assessing the health-related quality of life (HRQoL) in patients with hepatocellular carcinoma (HCC) between 2009 and 2018 (n = 45). Most studies assessed HRQoL as an outcome, and evaluated or compared the HRQoL of HCC patients depending on the type of treatment or stage of disease. HCC patients had a worse HRQoL than the general population, including in those with early-stage HCC. Patients commonly experienced pain, fatigue, sleep disturbance, distress, and lack of appetite, and these symptoms remained problematic even a few years after treatment. TNM classification of malignant tumors stage, tumor stage, presence of cirrhosis, being Asian, being female, living alone, or being unemployed were associated with a poor HRQoL. While recent studies have included a more diverse patient population, various topics, and different study designs, there were limited studies on supportive interventions. Given the increase in HCC cases and HCC survivors, addressing the HRQoL of HCC patients requires more attention.

Quality of life analysis after stereotactic radiofrequency ablation of liver tumors

The purpose of this study was to evaluate the health-related quality of life (HRQoL) after stereotactic radiofrequency ablation (SRFA) of liver tumors and identify variables associated with decreased HRQoL and to compare it to other treatments in case of concurrency. From 2011 to 2017 577 patients underwent SRFA for liver tumors in 892 ablation sessions. 303 (52.5%) patients completed a HRQoL questionnaire once after the ablation. HRQoL was assessed by the Short Form (SF)-12 health survey with mental and physical component scales and by a general questionnaire to assess disease and treatment-specific items as well as to compare tolerability of SRFA to transarterial chemoembolization (TACE), hepatic resection (HR) and chemotherapy (CTX). The median SF-12 PCS was 46.6 and MCS was 53.2. Patients experiencing pain or complications and patients refusing repeat SRFA showed significantly lower PCS (43.2 vs 48.6, p = 0.0003; 32.8 vs 46.9, p = 0.005 and 40.6 vs 46.9, p = 0.009). 355 (97.8%) patients indicated willingness to undergo repeat SRFA with little to no fear in 292 (80.7%) patients. Among patients with multiple therapies, SRFA was rated by 40 (90.9%) as preferred re-treatment, HR by 1 (2.3%) and CTX by 3 (6.8%). In conclusion, we have shown that SRFA has good HRQoL-outcomes and reported low morbidity rates. Consequently the vast majority of study patients would accept a repeated SRFA if necessary (97.8%), without fear (80.7%). SRFA was preferred among patients who experienced concurrent treatments, such as HR or CTX.

A systematic review and meta-analysis on the quality of life after hepatic resection

BACKGROUND

Quality of life (QoL) after hepatic resection is a pertinent issue that has been poorly studied. The aim of this study was to compare changes in QoL before and after hepatic resection.

METHODS

A systematic review was performed using Medline, EMBASE, and the Cochrane library. Whenever possible, pooled mean differences of survey scores pre- and post-operatively were calculated.

RESULTS

22 studies were included comprising a total of 1785 participants. Using the EORTC-QLQ 30C survey, patients with benign disease tend to have better QoL post-surgery than those with malignant disease. There were post-operative improvements in the following FACT-HEP domains: physical at 9 months (MD 3.14, 95%CI 2.70 to 3.58, P < 0.001), social and family at 3 (MD 1.45, 95%CI 0.12 to 2.77, p = 0.030), 6 (MD 1.12, 95%CI 0.21 to 2.04, p = 0.020), 9 (MD 0.66, 95%CI 0.03 to 1.28, p = 0.040), and 12 (MD 0.58, 95%CI 0.12 to 1.03, p = 0.010) months, emotional at 9 (P < 0.001) and 24 months (P < 0.001), hepatobiliary at 24 months (p < 0.001), and global health status at 9 months (p = 0.002).

CONCLUSION

QoL scores tend to deteriorate post-surgery, but recover to baseline in the long-term at 9-months. Patients with malignant disease, and those who underwent major hepatectomy, have poorer QoL scores.

Impact of interventions and tumor stage on health-related quality of life in patients with hepatocellular carcinoma

PURPOSE

This study aims to examine the health-related quality of life in patients with hepatocellular carcinoma.

METHODS

181 patients attending a tertiary center outpatient clinic were interviewed and completed the short form 36 (SF36) questionnaire. The SF36 was used to assess health-related QoL. Cross-sectional analyses by group (age, gender, clinical scores, systemic, and local interventions) as well sequel questionnaires were conducted.

RESULTS

Participants included were 79% (143/181) men [mean age at first SF36: 63.8 (± 12.3; 18.4-85.8) years]. Barcelona Clinic Liver Cancer (BCLC) stadium C was associated with significantly lower SF36 total scores, and elevated initial alpha-fetoprotein (AFP) concentrations were associated with lower SF36 functional and mental health sum scores throughout the course of the third questionnaire. Patients treated with sorafenib had within the sub-dimension scores a significantly lower result for role limitations due to physical health compared to patients without sorafenib treatment. Patients who underwent a transarterial chemoembolization (TACE) had within the sub-dimension scores a significantly higher result for control of pain compared to patients without TACE. Kaplan-Meier analysis revealed significant survival benefits for patients who underwent any intervention at the first SF36 (mean survival in years 4.3 vs. 1.6; P < 0.01) as well as for patients who underwent hepatic resection (mean survival in years 6.3 vs. 2.7; P < 0.0001).

CONCLUSION

Advanced tumor stages marked by BCLC stadium C and elevated initial AFP concentrations were associated with lower SF36 total scores and functional sum scores, respectively. During the course of sorafenib treatment, the sub-dimensional score for role limitations due to physical health decreased significantly, whereas TACE performance was associated with a significant improvement of the control of body pain.

Health-Related Quality of Life as a Prognostic Factor in Patients After Resection of Hepatic Malignancies

BACKGROUND

Numerous studies have argued health-related quality of life (HRQoL) measures to be prognostic of survival in patients with chronic disease processes including cancer; however, only a few small studies have evaluated HRQoL changes in the setting of oncologic resections. The objectives of the present study were to investigate factors predicting HRQoL, the change in HRQoL over time, and HRQoL prognostic value in patients undergoing surgical resection of hepatic malignancies.

METHODS

We administered the Functional Assessment of Cancer Therapy-Hepatobiliary, Center for Epidemiologic Studies-Depression, Functional Assessment of Cancer Therapy-Fatigue, and Brief Pain Inventory to 128 patients with primary and metastatic hepatic malignancies enrolled between January 2008 to November 2011 and November 2013 to June 2015. Quality of life was obtained at the baseline, 4, 8, and 12 mo, using HRQoL questionnaires.

RESULTS

The mean age of all patients included was 61 y, 42.6% had hepatocellular carcinoma, and 50.7% had metastatic colorectal carcinoma. HRQoL decreased from baseline at the 4-mo follow-up but stabilized to preoperative values at 8 and 12 mo. Depressive symptoms (P < 0.001), pain (P = 0.032), and fatigue (P < 0.001) were associated with HRQoL before surgery. Variables associated with HRQoL at 8 mo included extrahepatic recurrence (P = 0.002), depressive symptoms (P < 0.001), pain (P < 0.001), fatigue (P < 0.001), tumor macrovascular (P = 0.011), and microvascular invasion (P = 0.003). Using Cox regression and adjusting for demographics and disease-specific factors, preoperative HRQoL was significantly associated with overall survival.

CONCLUSIONS

HRQoL is independently associated with survival in patients with liver malignancies undergoing surgical resection. Major curative liver surgery can be performed with short-term worsening of HRQoL but long-term improvement and stabilization in overall quality of life for patients with cancer.

Current Treatment Landscape for Advanced Hepatocellular Carcinoma: Patient Outcomes and the Impact on Quality of Life

Hepatocellular carcinoma (HCC) is the fifth most common cancer and the second leading cause of cancer mortality worldwide. Heterogeneity of clinical conditions contributes to the complex management of care for patients with advanced HCC. Recently, the treatment landscape for advanced HCC has expanded rapidly, with the additional FDA approvals of several oral tyrosine kinase inhibitors (lenvatinib, regorafenib, and cabozantinib), as well as immunotherapies such as immune check point inhibitors (nivolumab and pembrolizumab) and the monoclonal IgG1 antibody, ramucirumab. This expansion has generated a need for novel treatment sequencing strategies in this patient population. In light of these developments, an evaluation of the impact of FDA-approved therapeutics on patient-centered outcomes such as health-related quality of life (HRQoL) is warranted. An increased understanding of HRQoL in patients included in advanced HCC clinical trials could potentially help physician decision-making for treatment sequencing in patients with advanced HCC.

Comparison of health-related quality of life after transarterial chemoembolization and transarterial radioembolization in patients with unresectable hepatocellular carcinoma

PURPOSE

The purpose of this study was to compare quality of life (QoL) after two different transarterial therapies [transarterial chemoembolization (TACE) and transarterial radioembolization (TARE)] for patients with unresectable hepatocellular carcinoma (HCC) to assess tumor therapy in palliative situation additional to traditional aims like survival or image response.

MATERIAL AND METHODS

QoL was evaluated with two validated questionnaires (EORTC QLQ-30 and EORTC HCC18) before and 14d after treatment in 94 initial therapies (TACE n = 67; TARE n = 27). QoL changes after treatment were analyzed. Tumor response was evaluated using RECIST/WHO/mRECIST/EASL criteria. A multivariate linear regression was undertaken to identify potential influence factors on change of QoL.

RESULTS

Mean return rate of questionnaires was 71.3% allowing analysis of 67 therapies (TACE n = 46; TARE n = 21). Initial global health status/QoL was significantly higher in TACE (62.5%) compared to TARE with 50.8%. Absolute global health decrease was higher in TACE (- 10.5%) compared to TARE (- 4.8%, p = 0.396). Also relative global health decrease was higher in TACE (- 16.82%) compared to TARE (- 9.37%). Findings for other items were corresponding, as less impairment was found for TARE compared to TACE for physical/social functioning, fatigue and pain. Objective mRECIST response rate was 22.8% in TACE and 21.1% in TARE.

CONCLUSION

Neither TACE nor TARE showed a major decrease in QoL after first treatment. TACE showed a slightly but not significantly higher decrease, so this study is not clearly in favor for one treatment. But with the addition that TARE showed less decrease even in patients with higher tumor burden and lower baseline.

Effect of Daily and Every Other Day Stereotactic Body Radiation Therapy Schedules on Treatment-Related Fatigue in Patients With Hepatocellular Carcinoma

PURPOSE

We compared the rate and severity of fatigue in patients who completed stereotactic body radiation therapy (SBRT) to the liver daily (QD) compared with every other day (QOD).

METHODS AND MATERIALS

From 2010 to 2017, 91 patients with Child Pugh (CP) A (n = 57) or CP-B (n = 34) cirrhosis who completed 100 SBRT sessions to 110 hepatocellular carcinoma (HCC) lesions were analyzed in this study. Confounding variables with fatigue such as CP-C cirrhosis, Eastern Cooperative Oncology Group score >2, or a history of ascites or encephalopathy were excluded. Fatigue was assessed against several treatment- and patient-related variables with univariate and propensity score-matched multivariate analysis. The median follow-up time was 18 months.

RESULTS

Patients with HCC and Barcelona-Clinic Liver Cancer stages 0 (n = 10), A (n = 32), and B (n = 58), and a median age of 62 years were analyzed. The median tumor diameter was 3 cm (1.1-11 cm). The Eastern Cooperative Oncology Group performance status score was 0 (n = 44), 1 (n = 43), or 2 (n = 13). The median dose was 45 Gy in 5 fractions, and 65 treatments were QD and 45 QOD. Grades 1 and 2 fatigue developed in 49% and 14% of treatments, respectively. Among the patients who were treated daily, 78% developed Grade 1 or 2 fatigue compared with 44% who were treated QOD (odds ratio: 4.52; P = .001). Grade 2 fatigue occurred in 22% of patients compared with 7.3% for QD and QOD treatment, respectively (odds ratio: 3.83; P = .048). There was no difference in fatigue rate for time of treatment (morning or afternoon), dose, treated volume, CP score, Barcelona-Clinic Liver Cancer stage, or performance status, which were not associated with any level of fatigue. There was no difference in local control between QD and QOD treatments.

CONCLUSIONS

Compared with traditional daily treatment fractions, SBRT that is delivered QOD to cirrhotic patients with HCC may reduce the risk of fatigue.

Liver resection for hepatocellular carcinoma in oldest old patients

Background

For hepatocellular carcinoma (HCC), liver resection is a classical curative modality, despite its technical complexity. The incidence of HCC in the oldest old people (aged ≥ 85 years) is rising along with the global increase in life expectancy. Currently, no report has addressed liver resection for HCC in this aged population.

Patients and methods

We conducted a retrospective review of 1889 patients receiving curative liver resection for newly diagnosed HCC from 1992 to 2016. At the time of operation, 1858 of them were aged < 85 years (group A), and 31 were aged ≥ 85 years (group B). Another 18 oldest old patients, whose HCC was considered resectable but were not operated on due to the patient’s refusal, served as the control group (group C). The clinicopathological characteristics and early and long-term outcomes were compared between groups A and B. All associated co-morbidities of the patients were well-treated before liver resection. The overall survival (OS) rates were also compared between groups B and C.

Result

Group B had a significantly higher incidence of associated co-morbidities and hepatitis C infection. Postoperative complication rates and 90-day mortality rates after liver resection did not differ between groups A and B (p = 0.834 and p = 1.000, respectively), though group B had a longer postoperative stay (p = 0.001). In groups A and B, the 5-year disease-free survival rates were 29.7% and 22.6% (p = 0.163), respectively, and their overall survival rates were 43.5% and 35.5% (p = 0.086). The overall survival rate of group B was significantly different from group C (35.5% vs. 0%, p = 0.001).

Conclusion

Despite a longer postoperative recovery period, liver resection for HCC in the oldest old patients may be justified if co-morbidities are well controlled.

Quality of life in patients undergoing repetitive TACE for the treatment of intermediate stage HCC

PURPOSE

With a limited overall survival (OS) of 20 months in patients diagnosed with intermediate stage hepatocellular carcinoma (HCC), the preservation of quality of life (QoL) during transarterial chemoembolization (TACE) procedures remains a primary goal. The aim of our study was to evaluate the change in QoL amongst patients undergoing repetitive TACE and to identify specific risk factors that may predict change in QoL.

METHODS

QoL was assessed in 82 patients undergoing at least two TACE, before and 14 days after TACE, using validated EORTC QLQ-C30 and EORTC HCC18 questionnaires. Tumour response was assessed using established response criteria. Laboratory and clinical parameters were analysed.

RESULTS

Functional scores decreased due to first TACE treatment (p < 0.01), conversely symptom scores increased significantly (p < 0.01). During repetitive TACE no statistically significant changes were observed. Higher Global Health- and Physical Functioning scores at baseline were identified as independent prognostic factors for greater decrease in QoL. Tumour response did not alter QoL at all. Furthermore higher symptom scales including pain (p = 0.00), nausea and vomiting (p = 0.00) and fever (p < 0.01 for repetitive TACE) at baseline were predictive of a significantly lesser increase of symptom severity, and a greater reduction in pain during a course of TACE. Higher C-reactive protein (CRP) at baseline and female gender were associated with a greater decrease of functional scales and increase of symptom scales.

CONCLUSION

QoL amongst patients receiving repetitive TACE showed neither significant nor clinically relevant changes over time. Pre-treatment assessment of QoL-scores, clinical and laboratory parameters can improve patient selection for TACE whilst optimizing QoL.

Health-Related Quality of Life Comparisons After Radical Therapy for Early-Stage Hepatocellular Carcinoma

BACKGROUND

For cancer patients, health-related quality of life (HRQoL) is as important as other key outcomes, such as overall survival and tumor-free survival. Liver transplantation (LT), resection, and radiofrequency ablation (RFA) are 3 radical therapies for hepatocellular carcinoma (HCC) that result in similar survival. The main objective of this study was to assess and compare long-term HRQoL scores for patients with early-stage (tumor diameter ≤3 cm) HCC after LT, resection, or RFA.

METHODS

A total of 128 HCC patients with a single tumor ≤3 cm and who agreed to undergo LT, resection, or RFA were included in the present analysis. Postoperative HRQoL was evaluated by using the Medical Outcomes Study 36-Item Short Form Health Survey questionnaire. The 3 groups were compared at the 6-month and 3-year time points.

RESULTS

The 3 groups showed comparable 3-year HCC recurrence rates (P > .05). Compared with the LT and resection groups, the RFA group had significantly higher scores for bodily pain, general health, and vitality 6 months after surgery (all P values < .05). Moreover, at 3 years after surgery, the RFA group had higher scores for bodily pain and vitality than the other 2 groups (P < .05) and a higher general health score than the resection group. Other aspects of HRQoL were comparable among the 3 groups at both time points.

CONCLUSIONS

Due to its comparable HCC recurrence rate and superior long-term HRQoL scores relative to other radical therapies, RFA may be the first-choice treatment for solitary early-stage HCC.

Prospective longitudinal quality of life and survival outcomes in patients with advanced infiltrative hepatocellular carcinoma and portal vein thrombosis treated with Yttrium-90 radioembolization

Background

To determine the effect of Yttrium-90 (Y90) radioembolization on health-related quality of life (HRQOL) and its effect on overall survival advanced, unresectable infiltrative hepatocellular carcinoma (HCC) patients with concurrent portal vein thrombosis (PVT).

Methods

Consecutive patients with unresectable infiltrative HCC and PVT were recruited. The Short-Form 36 (SF-36) questionnaire was used to assess HRQOL for consecutive patients treated with glass-based Y90 based on a prospective phase II trial. MR imaging was used to determine tumor progression every 3 months post-treatment. Overall survival (OS) from treatment and time to progression (TTP) was analyzed using Kaplan-Meier estimation and log-rank test.

Results

Thirty patients were treated and followed for 17.4 months; physical and mental component summary scores (PCS & MCS) remained unchanged at one, three, and six months. While no difference was observed in baseline SF-36 scores for patients with prolonged TTP (≥4 months) and OS (≥ 6 months), corresponding 1-month PCS were significantly higher than those with TTP < 4 months and OS < 6 months. At 1 month, patients with normalized Physical Function (PF), Role Physical (RP) and PCS within 2 standard deviations (SD) of US normalized baseline scores had a significantly prolonged median OS (15.7 vs. 3.7 months; p < 0.001) and TTP (12.4 vs. 1.8 mo; p < 0.001) compared those with physical component scores greater than 2SD below normalized US population values.

Conclusion

Y90 radioembolization for HCC demonstrated long-term preservation of HRQOL. Lower baseline HRQOL scores were predictive of poorer OS. Early (1 month post-treatment) significant decreases in PCS were independent predictors of poorer OS and TTP.

Trial registration

ClinicalTrials.gov identifier NCT01556282, registered March 16, 2012.

Radiofrequency ablation versus surgical resection in elderly patients with early-stage hepatocellular carcinoma in the era of organ shortage

BACKGROUND/AIMS

To compare the survival benefits of surgical resection (SR) with those of radiofrequency ablation (RFA) in elderly patients (≥65 years) with single hepatocellular carcinoma (HCC) ≤5 cm.

PATIENTS AND METHODS

Using the Surveillance, Epidemiology, and End Results database, a total of 461 patients who underwent SR and 575 patients who underwent RFA were enrolled from 2004 to 2012. Overall survival (OS) and liver-cancer-specific survival (LCSS) comparisons were conducted between the two groups before and after propensity score matching (PSM).

RESULTS

Elderly patients with early-stage HCC had a lower rate of utilization of liver transplantation, and they were more likely to receive SR or RFA as their first-line treatment compared with younger patients (P < 0.05). In the whole cohort, the SR group had significantly better OS [RFA, hazard ratio (HR) = 1.680 (1.390, 2.031), P < 0.001] and LCSS (RFA, HR = 1.658 (1.327, 2.070), P < 0.001) than the RFA group. After PSM, the improved survival in the SR group was further confirmed (all P < 0.001). In the subgroup analyses, according to patients' age (65-75, >75 years) and tumor size (≤3.0, 3.1-5.0 cm), the SR group still presented better OS and LCSS than the RFA group (all P < 0.05), except for those older than 75 years with tumors ≤3.0 cm (all P > 0.05), both before and after PSM.

CONCLUSION

Treatment strategies for elderly patients (≥65 years) with single HCC ≤5 cm should emphasize SR as the primary therapy, while RFA can be an alternative to SR for those> 75 years with single HCC ≤3 cm.

Incorporating Quality of Life Metrics in Interventional Oncology Practice

Interventional radiologists care for a large number of cancer patients with the breadth of palliative intent minimally invasive procedures that we provide. Understanding our meaningful impact on patients' quality of life is essential toward validating our role in the palliation of cancer patients. As such, it is critically important for interventional radiologists to understand common instruments used for the reporting of patient's quality of life measures. Common instruments used to measure pain and quality of life for cancer patients include the numerical rating scale, visual analog scale, brief pain inventory, the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, and the Functional Assessment of Cancer Therapy. An ideal quality of life instrument should be a patient reported outcome measure across multiple domains (e.g., physical health, psychological, social), and be both validated and reliable.

Clinical assessment of computed tomography guided radiofrequency ablation in the treatment of inoperable patients with pulmonary tumors

Background

To enhance our understanding of the feasibility, effectiveness, safety and quality of life (QoL) of radiofrequency ablation (RFA) for inoperable patients with pulmonary tumors.

Methods

The data of 88 patients with pulmonary tumors undergoing RFA were collected. Proof of malignancy was obtained by biopsy in all patients. Diagnoses included non-small cell lung cancer (NSCLC) in 74 patients and pulmonary metastases in 14 patients. Patients underwent computed tomography (CT)-guided RFA according to standard protocol and had a 2-year follow-up. Results assessment included feasibility (correct placement of the ablation probe into all targeted tumors), effectiveness (overall survival rate and local control rate), safety (treatment-related complication and changes in pulmonary function) and QoL.

Results

One hundred and thirty-four RFAs were successfully conducted in 88 patients with 96 nodules. Correct placement of ablation probe into targeted tumors with completion of the planned treatment protocol was feasible in all 88 (100%) patients and no procedure-related deaths occurred. Major complication rate was 4.5% (4/88), which consisted of symptomatic pneumothorax (2/88) and high fever (2/88). No significant worsening of pulmonary function was observed. Tumors shrank obviously at 6 months after RFA with a statistically significance (P<0.001).The overall survival rate in 6 months, 1 year and 2 years were 100%, 95.5% and 70.5%, respectively while the local control rate in 6 months, 1 year and 2 years were 92.1%, 87.5% and 51.1% respectively. There was no significant difference of overall survival rate and local control rate between NSCLC and metastatic carcinoma. No significant worsening of QoL was observed.

Conclusions

CT-guided RFA is a feasible, effective and safe therapy for inoperable patients with pulmonary tumors. However, RFA could not obviously improve the QoL in the patients with pulmonary tumors. More prospective studies comparing RFA with standard non-surgical treatment options were needed.

Systematic review of patient reported quality of life following stereotactic ablative radiotherapy for primary and metastatic liver cancer

Background

Stereotactic ablative radiotherapy (SABR) is a safe and effective modality in patients with liver cancer who are ineligible for other local therapies. However SABR is not current standard of practice and requires further validation. Patient reported quality of life (QOL) is key to this validation, yet no systematic reviews to date have been performed to analyse QOL following liver SABR. QOL is a critical part of therapy evaluation, particularly in disease states with short life expectancy. The purpose of this study was to conduct a systematic review of QOL outcomes for liver SABR.

Materials and methods

MEDLINE and EMBASE databases from 1996 to October 2015 were queried to obtain English language studies analysing QOL following liver SABR. Included studies described patient-reported QOL as either a primary or secondary endpoint, and analysed QOL change over time. Studies were screened, and relevant data were abstracted and analysed.

Results

Of 2181 initially screened studies, 5 met all inclusion criteria. Extracted studies included a total of 392 eligible patients with hepatocellular carcinoma, liver metastases and intrahepatic cholangiocarcinoma. Four studies were prospective in design, and only one study was a conference abstract. Extracted studies were heterogeneous in dose prescription used (11–70 Gy in 3–30 fractions), in addition to reported QOL metrics (EORTC QLQ C-15 PAL,/C-30/LM-21, EuroQol 5D, FACT-Hep, FLIC) and final endpoints (range 6 weeks to 12 months). Despite this there were few statistically significant declines in QOL scores following SABR. Four studies demonstrated transient fatigue in the first 1–4 weeks, while 2 studies showed transient worsening of appetite at 1 month. In all but one instance (loss of appetite at 6 weeks), levels returned to insignificant difference baseline by the final endpoints. All studies showed no significant QOL decline in any domain at their respective endpoints. In studies with overlapping QOL tools, estimates of 3-month post SABR global QOL were similar.

Conclusion

Results of this systematic review demonstrate well-preserved post liver SABR QOL. These findings strengthen the argument for liver SABR, and should aim to support future comparative effectiveness trials with other local modalities including surgery, chemoembolization and radiofrequency ablation, with a focus on QOL outcomes as an important endpoint.

Electronic supplementary material

The online version of this article (doi:10.1186/s13014-017-0818-8) contains supplementary material, which is available to authorized users.

Health-Related Quality of Life in Patients with Hepatocellular Carcinoma Treated with Initial Transarterial Chemoembolization

PURPOSE

To investigate the impact of the first transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) on health-related quality of life (HRQoL) and identify predictors for low HRQoL following TACE.

MATERIALS AND METHODS

HRQoL was prospectively evaluated in 79 patients with standardized questionnaires (QlQ-C30 and HCC18) pre- and 2 weeks post-TACE. Treatment response was evaluated using common tumour response criteria. Clinical parameters [e.g. Eastern Cooperative Oncology Group (ECOG) performance status, Model of End Stage Liver Disease (MELD) score], tumour load and pre-TACE HRQoL scores were tested for predicting HRQoL after TACE.

RESULTS

Patients showed a 12.1% decrease in global health score (GHS). Major decreases were observed for physical (-21.4%), role (-23.4%), and social (-21.5%) functioning and increases in symptom severity for fatigue (+30.1%), loss of appetite (+25.3%), pain (+19.4%) after TACE. ECOG performance status >1 was associated with increased nausea/vomiting (p = 0.002) and decreased GHS (p = 0.01). MELD score >10 was associated with increased fatigue (p = 0.021) and abdominal swelling (p < 0.001). Our study showed an increase in symptom severity in patients with no symptoms before TACE for pain (p = 0.005) and abdominal swelling (p < 0.001).

CONCLUSION

The first TACE for treatment of HCC does not result in a major loss of HRQoL in general. For TACE as a palliative therapy maintaining HRQoL is of critical importance and standardized HRQoL assessment can help to detect HRQoL problems.

Cost-effectiveness of EOB-MRI for Hepatocellular Carcinoma in Japan

PURPOSE

The objective of the study was to evaluate the cost-effectiveness of gadoxetic acid-enhanced magnetic resonance imaging (EOB-MRI) in the diagnosis and treatment of hepatocellular carcinoma (HCC) in Japan compared with extracellular contrast media-enhanced MRI (ECCM-MRI) and contrast media-enhanced computed tomography (CE-CT) scanning.

METHODS

A 6-stage Markov model was developed to estimate lifetime direct costs and clinical outcomes associated with EOB-MRI. Diagnostic sensitivity and specificity, along with clinical data on HCC survival, recurrence, treatment patterns, costs, and health state utility values, were derived from predominantly Japanese publications. Parameters unavailable from publications were estimated in a Delphi panel of Japanese clinical experts who also confirmed the structure and overall approach of the model. Sensitivity analyses, including one-way, probabilistic, and scenario analyses, were conducted to account for uncertainty in the results.

FINDINGS

Over a lifetime horizon, EOB-MRI was associated with lower direct costs (¥2,174,869) and generated a greater number of quality-adjusted life years (QALYs) (9.502) than either ECCM-MRI (¥2,365,421, 9.303 QALYs) or CE-CT (¥2,482,608, 9.215 QALYs). EOB-MRI was superior to the other diagnostic strategies considered, and this finding was robust over sensitivity and scenario analyses. A majority of the direct costs associated with HCC in Japan were found to be costs of treatment. The model results revealed the superior cost-effectiveness of the EOB-MRI diagnostic strategy compared with ECCM-MRI and CE-CT.

IMPLICATIONS

EOB-MRI could be the first-choice imaging modality for medical care of HCC among patients with hepatitis or liver cirrhosis in Japan. Widespread implementation of EOB-MRI could reduce health care expenditures, particularly downstream treatment costs, associated with HCC.

Health-Related Quality of Life and Psychological Distress in Patients With Early-Stage Hepatocellular Carcinoma After Hepatic Resection or Transplantation

BACKGROUND

The aim of our study was to compare the post-operative health-related quality of life in patients with small hepatocellular carcinoma (HCC; within the Milan criteria) after liver resection or liver transplantation.

METHODS

From August 2000 to December 2010, 207 patients were diagnosed with early HCC within the Milan criteria. We divided these patients into 2 groups according to their curative schedule: the liver transplantation group (n = 95) and the liver resection group (n = 110). We compared the baseline characteristics of these 2 groups of patients, after which we focused on comparing the post-operative health-related quality of life (HRQOL) and psychological outcome in these 2 groups.

RESULTS

The demographics of the patients in the 2 groups were similar, and there were no significant differences except for higher family income in the transplantation group (P = .002).With long-term follow-up, there were no significant differences in the 8 domains of the HRQOL and the 9 domains of the psychological outcome measure between the 2 groups. Both the transplantation and resection groups exhibited good outcomes in both HRQOL and psychological outcome measures.

CONCLUSIONS

Several years after operation, early-stage HCC patients who underwent liver transplantation or resection had similar long-term HRQOL and psychological outcomes.

Progress in surgical and nonsurgical approaches for hepatocellular carcinoma treatment

BACKGROUND

Hepatocellular carcinoma (HCC) is a complex and heterogeneous malignancy, frequently occurs in the setting of a chronically diseased organ, with multiple confounding factors making its management challenging. HCC represents one of the leading causes of cancer-related mortality globally with a rising trend of incidence in some of the developed countries, which indicates the need for better surgical and nonsurgical management strategies.

DATA SOURCES

PubMed database was searched for relevant articles in English on the issue of HCC management.

RESULTS

Surgical resection represents a potentially curative option for appropriate candidates with tumors detected at earlier stages and with well-preserved liver function. The long-term outcome of surgery is impaired by a high rate of recurrence. Surgical approaches are being challenged by local ablative therapies such as radiofrequency ablation and microwave ablation in selected patients. Liver transplantation offers potential cure for HCC and also correction of underlying liver disease, and minimizes the risk of recurrence, but is reserved for patients within a set of criteria proposed for a prudent allocation in the shortage of donor organs. Transcatheter locoregional therapies have become the palliative standard allowing local control for intermediate stage patients with noninvasive multinodular or large HCC who are beyond the potentially curative options. The significant survival benefit with the multikinase inhibitor sorafenib for advanced HCC has shifted the direction of research regarding systemic treatment toward molecular therapies targeting the disregulated pathways of hepatocarcinogenesis. Potential benefit is suggested from simultaneous or sequential multimodal therapies, and optimal combinations are being investigated. Despite the striking progress in preclinical studies of HCC immunotherapy and gene therapy, extensive clinical trials are required to achieve successful clinical applications of these innovative approaches.

CONCLUSION

Treatment decisions have become increasingly complex for HCC with the availability of multiple surgical and nonsurgical therapeutic options and require a comprehensive, multidisciplinary approach.

Quality of Life in Hepatocellular Carcinoma Patients Treated with Transarterial Chemoembolization

Hepatocellular carcinoma (HCC) is one of the most commonly diagnosed cancers worldwide. Majority of patients with HCC are diagnosed in the advanced stages of disease and hence they are only suitable for palliative therapy. TACE (transarterial chemoembolization) is the most commonly used treatment for unresectable HCC. It is however unclear if TACE improves the quality of life (QoL) in patients with HCC. The aim of this review is to evaluate the impact of TACE on QoL of HCC patients.

Cancer survivorship: long-term side-effects of anticancer treatments of gastrointestinal cancer

PURPOSE OF REVIEW

Surveillance of patients with a history of cancer is a frequent practice in oncology. However, it is often aimed at the early diagnosis of relapse and tends to underestimate the evaluation and care of factors impairing quality of life (QoL). Among these, long-term toxicities of anticancer treatments are one of the major threats to a complete physical and psychosocial recovery. We aimed to review the relevant literature on long-term side-effects of treatment in gastrointestinal cancers.

RECENT FINDINGS

We focused on esophageal, gastric, pancreatic, liver and colorectal cancers. A significant fraction of patients treated for these cancers suffer with some form of late toxicity from surgery, radiotherapy or chemotherapy. Prompt evaluation and management is of the utmost importance in reducing the impact of these symptoms on QoL.

SUMMARY

The knowledge of the reviewed data should encourage a multidisciplinary approach to surveillance and convince clinicians of the comprehensive role of survivorship care.

Prospective Longitudinal Assessment of Quality of Life for Liver Cancer Patients Treated With Stereotactic Body Radiation Therapy

PURPOSE

To evaluate quality of life (QoL), an important outcome owing to poor long-term survival, after stereotactic body radiation therapy (SBRT) to the liver.

METHODS AND MATERIALS

Patients (n=222) with hepatocellular carcinoma (HCC), liver metastases, or intrahepatic cholangiocarcinoma and Child-Pugh A liver function received 24-60 Gy of 6-fraction image-guided SBRT. Prospective QoL assessment was completed with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30 (QLQ-C30) and/or Functional Assessment of Cancer Therapy-Hepatobiliary (FACT-Hep, version 4) questionnaires at baseline and 1, 3, 6, and 12 months after treatment. Ten HCC patients with Child-Pugh B liver function were also treated.

RESULTS

The QLQ-C30 was available for 205 patients, and 196 completed the FACT-Hep. No difference in baseline QoL (P = .17) or overall survival (P = .088) was seen between the HCC, liver metastases, and intrahepatic cholangiocarcinoma patients. Appetite loss and fatigue measured by the QLQ-C30 clinically and statistically worsened by 1 month after treatment but recovered by 3 months. At 3 and 12 months after treatment, respectively, the FACT-Hep score had improved relative to baseline in 13%/19%, worsened in 36%/27%, and remained stable in 51%/54%. Using the QLQ-C30 Global Health score, QoL improved in 16%/23%, worsened in 34%/39%, and remained stable in 50%/38% at 3 and 12 months, respectively. Median survival was 17.0 months (95% confidence interval [CI] 12.3-19.8 months). Higher baseline scores on both FACT-Hep and QLQ-C30 Global Health were associated with improved survival. Hazard ratios for death, per 10-unit decrease in QoL, were 0.90 (95% CI 0.83-0.98; P = .001) and 0.88 (95% CI 0.82-0.95; P = .001), respectively. Tumor size was inversely correlated with survival.

CONCLUSIONS

Liver SBRT temporarily worsens appetite and fatigue, but not overall QoL. Stereotactic body radiation therapy is well tolerated and warrants comparison against other liver-directed therapies.

Assessment of the reporting of quality and outcome measures in hepatic resections: a call for 90-day reporting in all hepatectomy series

BACKGROUND

The aim of this paper is to assess the current state of quality and outcomes measures being reported for hepatic resections in the recent literature.

METHODS

Medline and PubMed databases were searched for English language articles published between 1 January 2002 and 30 April 2013. Two examiners reviewed each article and relevant citations for appropriateness of inclusion, which excluded papers of liver donor hepatic resections, repeat hepatectomies or meta-analyses. Data were extracted and summarized by two examiners for analysis.

RESULTS

Fifty-five studies were identified with suitable reporting to assess peri-operative mortality in hepatic resections. In only 35% (19/55) of the studies was the follow-up time explicitly stated, and in 47% (26/55) of studies peri-operative mortality was limited to in-hospital or 30 days. The time period in which complications were captured was not explicitly stated in 19 out of 28 studies. The remaining studies only captured complications within 30 days of the index operation (8/28). There was a paucity of quality literature addressing truly patient-centred outcomes.

CONCLUSION

Quality outcomes after a hepatic resection are inconsistently reported in the literature. Quality outcome studies for a hepatectomy should report mortality and morbidity at a minimum of 90 days after surgery.

Preservation of quality of life with doxorubicin drug-eluting bead transarterial chemoembolization for unresectable hepatocellular carcinoma: Longitudinal prospective study

BACKGROUND AND AIM

The study aims to determine the effects of doxorubicin drug-eluting bead transarterial chemoembolization (DEB-TACE) therapies on health-related quality of life (HRQOL) in patients with unresectable hepatocellular carcinoma (HCC).

METHODS

This is a single-center, prospective study assessing HRQOL of consecutive patients with unresectable HCC who underwent DEB-TACE. Longitudinal assessment of HRQOL scores via Short-Form-36 (SF-36) was performed. Baseline HRQOL scores were evaluated for significant change (P < 0.05) pre-therapy, post-therapy, and at 6- and 12-month follow-up. Analysis of overall survival (OS) from HCC diagnosis and OS from first DEB-TACE was performed. Paired t-tests were used to compare HRQOL domain scores.

RESULTS

One hundred eighteen patients (83 male; median age 60 years) were enrolled. Patients had lower baseline scores within all eight HRQOL domains of the SF-36 compared with US age-adjusted healthy norms. No significant changes in all eight domains were observed post-therapy and at 6- or 12-month follow-up compared with baseline (P > 0.05). No significant differences in all eight domains were observed between patients receiving ≥ 4 versus ≤ 3 DEB-TACE (P > 0.05). Both groups were similar for age at HCC diagnosis, gender, ethnicity, HCC etiology, Child-Pugh class and Eastern Cooperative Oncology Group Performance Status (P > 0.05). Patients receiving staged DEB-TACE demonstrated significantly greater median OS from HCC diagnosis (≥ 4 vs ≤ 3 DEB-TACE procedures, 31.9 vs 23.7 months, P = 0.04) and from first DEB-TACE (≥ 4 vs ≤ 3 DEB-TACE, 29.1 vs 20.2 months, P = 0.03).

CONCLUSION

DEB-TACE therapy for HCC demonstrated long-term preservation of HRQOL. In addition, staged DEB-TACE with four or more therapies does not significantly impact long-term HRQOL compared with patients who received three or fewer therapies.

Prognostic effect of preoperative sequential transcatheter arterial chemoembolization and portal vein embolization for right hepatectomy in patients with solitary hepatocellular carcinoma

Backgrounds/Aims

Both preoperative transcatheter arterial chemoembolization (TACE) alone and portal vein embolization (PVE) alone have a detrimental prognostic effect on the post-resection outcomes in patients with hepatocellular carcinoma (HCC). The main objective of this study was to assess the prognostic impact of preoperative TACE on the long-term survival outcomes in patients undergoing preoperative PVE and right liver resection for solitary HCC.

Methods

Patients who underwent macroscopic curative right liver resection of solitary HCC that lied between 3.0 and 7.0 cm (n=113) with or without preoperative TACE and PVE were selected for the study, making these subjects were divided into three groups; the TACE-PVE group (n=27), the PVE-alone group (n=13), and the control group (n=73). The subjects in the three groups were followed up for ≥36 months or until death.

Results

The 1-, 3-, 5-, and 10-year overall patient survival rates of all 113 patients were 96.5%, 88.2%, 81.3% and 65.0%, respectively. The 1-, 3-, 5-, and 10-year overall patient survival rates were 96.3%, 83.4%, 83.4% and 47.6% respectively in the TACE-PVE group; 84.6%, 76.9%, 57.7% and 19.2% respectively in the PVE-alone group; and 98.6%, 91.7%, 85.1% and 81.7% respectively in the control group (p=0.047). Patients were also sub-grouped according to tumor size, and those with a tumor of up to cutoff at 5 cm showed no prognostic difference (p=0.774), but tumor size >5 cm was associated with inferior patient survival only in the TACE-PVE group (p=0.018).

Conclusions

Preoperative sequential TACE and PVE appear to be compliant to the conventional oncological concept in addition to induction of the future remnant liver regeneration. Therefore, we suggest that preoperative TACE should be come first whenever preoperative PVE for major hepatectomy is planned, especially in patients with hypervascular HCC tumors.

Quality of life changes in patients undergoing treatment for hepatocellular carcinoma

PURPOSE

Hepatocellular carcinoma (HCC) is the second leading cause of cancer-related death worldwide. One of the primary treatment goals for incurable advanced cases is to prolong quality of life (QoL). Thus, to determine which HCC therapies may be linked to a more favorable QoL, we assessed the association between QoL changes and different treatments in HCC patients.

METHODS

We analyzed a non-randomized multicenter longitudinal study, which included 171 patients treated with surgery (n = 53), ablation (n = 53) or embolization (n = 65) from seven centers: four Asian and three European sites. All participants completed the EORTC QLQ-C30 and QLQ-HCC18 questionnaires before and after treatment. Propensity scores were calculated and used in addition to race for adjustment in the logistic regression model to account for the confounding effects of patient characteristics including age, gender, race, employment, living with family, at least one comorbid condition, years since diagnosis, prior treatment history, BCLC stage, Child-Pugh grade, cirrhosis, bilirubin levels and QoL score before treatment.

RESULTS

After adjustment for confounders, patients tended to have higher odds of QoL deterioration when treated with ablation versus embolization (dyspnea: p = 0.019; appetite loss: p = 0.018; body image: p = 0.035) or ablation versus surgery (dyspnea: p = 0.099; appetite loss: p = 0.100; body image: p = 0.038).

CONCLUSIONS

There were significant differences in QoL deterioration across different treatment groups. This information may assist patients and providers when selecting patient-centered treatment approaches for HCC.

Transarterial embolization therapies for the treatment of hepatocellular carcinoma: CEPO review and clinical recommendations

BACKGROUND

Hepatocellular carcinoma (HCC) is one of the most deadly cancers in the world and its incidence rate has consistently increased over the past 15 years in Canada. Although transarterial embolization therapies are palliative options commonly used for the treatment of HCC, their efficacy is still controversial. The objective of this guideline is to review the efficacy and safety of transarterial embolization therapies for the treatment of HCC and to develop evidence-based recommendations.

METHOD

A review of the scientific literature published up to October 2013 was performed. A total of 38 studies were included.

RECOMMENDATIONS

Considering the evidence available to date, the CEPO recommends the following: (i) transarterial chemoembolization therapy (TACE) be considered a standard of practice for the palliative treatment of HCC in eligible patients; (ii) drug-eluting beads (DEB)-TACE be considered an alternative and equivalent treatment to conventional TACE in terms of oncological efficacy (overall survival) and incidence of severe toxicities; (iii) the decision to treat with TACE or DEB-TACE be discussed in tumour boards; (iv) bland embolization (TAE) not be considered for the treatment of HCC; (v) radioembolization (TARE) not be considered outside of a clinical trial setting; and (vi) sorafenib combined with TACE not be considered outside of a clinical trial setting.

Patient-reported outcome and quality of life after total en bloc spondylectomy for a primary spinal tumour

Total en bloc spondylectomy (TES) is the total resection of a vertebra containing a tumour. Many authors have investigated patient-reported outcomes after routine spinal surgery and surgery for tumours in general. However, this is the first report of patient-reported outcomes, including health-related quality of life (HRQoL) and satisfaction, after en bloc vertebral resection for a spinal tumour.

Of the 54 patients who underwent TES for a primary tumour between 1993 and 2010, 19 died and four were lost to follow-up. In January 2012, a questionnaire was sent to the 31 surviving patients. This included the short form-36 to assess HRQoL and questions about the current condition of their disease, activities of daily living (ADL) and surgery. The response rate was high at 83.9% (26/31 patients). We found that most patients were satisfied and maintained good performance of their ADLs.

The mental health status and social roles of the HRQoL scores were nearly equivalent to those of healthy individuals, regardless of the time since surgery. There was significant impairment of physical health in the early post-operative years, but this usually returned to normal approximately three years after surgery.

Cite this article: Bone Joint J 2014;96-B:1693–8.