Definitive Stereotactic Body Radiation Therapy in Early-Stage Solitary Hepatocellular Carcinoma: An Australian Multi-Institutional Review of Outcomes

AIMS

Standard curative options for early-stage, solitary hepatocellular carcinoma (HCC) are often unsuitable due to liver dysfunction, comorbidities and/or tumour location. Stereotactic body radiation therapy (SBRT) has shown high rates of local control in HCC; however, limited data exist in the treatment-naïve, curative-intent setting. We report the outcomes of patients with solitary early-stage HCC treated with SBRT as first-line curative-intent therapy.

MATERIALS AND METHODS

A multi-institutional retrospective study of treatment-naïve patients with Barcelona Clinic Liver Cancer stage 0/A, solitary ≤5 cm HCC, Child-Pugh score (CPS) A liver function who underwent SBRT between 2010 and 2019 as definitive therapy. The primary end point was freedom from local progression. Secondary end points were progression-free survival, overall survival, rate of treatment-related clinical toxicities and change in CPS >1.

RESULTS

In total, 68 patients were evaluated, with a median follow-up of 20 months (range 3-58). The median age was 68 years (range 50-86); 54 (79%) were men, 62 (91%) had cirrhosis and 50 (74%) were Eastern Cooperative Oncology Group 0. The median HCC diameter was 2.5 cm (range 1.3-5) and the median prescription biologically effective dose with a tumour a/b ratio of 10 Gy (BED10) was 93 Gy (interquartile range 72-100 Gy). Two-year freedom from local progression, progression-free survival and overall survival were 94.3% (95% confidence interval 86.6-100%), 59.5% (95% confidence interval 46.3-76.4%) and 88% (95% confidence interval 79.2-97.6%), respectively. Nine patients (13.2%) experienced grade ≥2 treatment-related clinical toxicities. A rise >1 in CPS was observed in six cirrhotic patients (9.6%).

CONCLUSION

SBRT is an effective and well-tolerated option to consider in patients with solitary, early-stage HCC. Prospective, randomised comparative studies are warranted to further refine its role as a first-line curative-intent therapy.

An Evidence-Based National Cancer Control Program (NCCP) Quality Assessment Checklist

Background: The 2017 World Health Assembly resolution on cancer (WHA70.12) defined a key action for governments to be the implementation of a national cancer control plan (NCCP) with a focus on equity and access. A survey of member states performed in 2015 by WHO found that 87% of countries have NCCPs but only 68% are operational. There are limited data analyzing the quality of NCCPs and an evidence-based 'best practice' appraisal tool is lacking. Aim: We formulated an evidence-based comprehensive checklist for the critical appraisal of an NCCP, for potential application for countries across all continents and income classifications. Methods: An extensive literature review was performed to identify previous publications used to advise on or assess NCCPs. Each article was reviewed by three investigators and potential quality items were created to form the preliminary checklist. Items were ranked according to the frequency of appearance in the identified publications, then further refined by an expert panel of global cancer partners including NCCP researchers, civil society, NGOs and technical content experts. Checklist items were categorized to ensure comprehensiveness across both the cancer continuum and health systems building blocks. Multiple choice answers for checklist items were created to allow ease of use and reproducibility. Concordance between multiple reviewers was assessed to confirm precision of the appraisal. Results: Twelve publications/documents which advise on NCCP design were identified in the literature. From these, 65 checklist items were identified and included in the tool; each item was present in a median of 2 publications (range 1-8). An additional 13 items which were absent from the twelve documents were added, as the authors and the expert panel viewed these to be important in appraising an NCCP. This gave a total of 78 check list items for quality assessment, grouped in the following categories: (1) General overview; (2) Prevention; (3) Diagnosis, staging and screening; (4) Treatment (5) Service delivery (6) Governance; (7) Health workforce; (8) Health information systems; (9) Research; (10) Finance and (11) Overall summary. The checklist was refined for clarification of language and content after trialing the draft tool for current NCCPs from ten countries. A final validation was performed on six additional countries that demonstrated strong concordance between reviewers, no further changes were made. The final checklist also allows for non-communicable disease (NCD) plans to be appraised as part of cancer policy review in each country. Conclusion: We have developed a comprehensive tool for the quality assessment of NCCPs. An appraisal of all available NCCPs globally is currently underway using this recently-formed check-list. This tool can also potentially be used by governments, policy makers and stakeholders as a 'best practice' guide when formulating and/or updating their country's NCCP.