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LECTURE 4 - Intro To HCC

Hepatocellular carcinoma (HCC) is a major global health issue, being the sixth most common cancer and the third leading cause of cancer-related deaths. Risk factors include chronic hepatitis infections, cirrhosis, and lifestyle choices, with early detection being crucial for effective treatment. The document emphasizes the need for improved access to care and preventive strategies, especially in low-resource settings, to combat the rising incidence and mortality of HCC.

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20 views30 pages

LECTURE 4 - Intro To HCC

Hepatocellular carcinoma (HCC) is a major global health issue, being the sixth most common cancer and the third leading cause of cancer-related deaths. Risk factors include chronic hepatitis infections, cirrhosis, and lifestyle choices, with early detection being crucial for effective treatment. The document emphasizes the need for improved access to care and preventive strategies, especially in low-resource settings, to combat the rising incidence and mortality of HCC.

Uploaded by

Ebere Achi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Introduction to

hepatocellular cancer
(African Access Initiative (AAI)
lecture series - Introduction to common cancers in the
community)

Prof. Ntokozo Ndlovu


Clinical Oncologist/Clinical Epidemiologist
Dept of Oncology Medical Physics and Imaging Sciences
University of Zimbabwe Faculty of Medicine and Health Sciences
Objectives

Introduction to Hepatocellular carcinoma:


 What is hepatocellular carcinoma?
 Hepatocellular carcinoma causes, risk factors, and prevention
 Early detection for hepatocellular carcinoma
 Signs and symptoms of hepatocellular carcinoma
 Role of nurses in patient management
The Global Burden of hepatocellular
Carcinoma
 Hepatocellular carcinoma (HCC) is a significant global health issue.
 The burden of HCC varies widely by region, driven by disparities in: risk
factors,
 healthcare infrastructure,
 and access to prevention and treatment.
Incidence

 Worldwide: HCC is the sixth most common cancer globally.


 In 2020, there were approximately 905,700 new cases of liver cancer, with
HCC making up about 75%-85% of these.
 Regional Variations: Highest incidence rates are in East Asia, Southeast Asia,
and sub-Saharan Africa, linked to endemic hepatitis B virus (HBV) infection
and aflatoxin exposure.
 Lower incidence in North America and Europe, though rates are rising due to
obesity, diabetes, and hepatitis C virus (HCV) infections.
Mortality

 Liver cancer is the third leading cause of cancer-related deaths globally,


accounting for about 830,200 deaths in 2020.
 HCC has a high mortality-to-incidence ratio (~0.92), reflecting the aggressive
nature of the disease and late-stage diagnosis in many cases.
Hepatocellular
Carcinoma
 What is HCC?

 HCC is a type of cancer that originates in


the liver's main type of cell, called
hepatocytes.
 It occurs when there is a mutation in the
DNA of these cells, leading to
uncontrolled growth and tumor
formation (carcinogenesis).
 HCC is the most common type of primary
liver cancer, accounting for about 75% of
all liver cancer cases.
 One of over 100 different types of
cancer.
What causes HCC

 Causes of cancer in general are largely unknown


 Hepatocellular carcinoma (HCC) is primarily caused by chronic liver damage and
inflammation.
 This leads to liver cell mutations and tumor formation.
 Genetic mutations: Inherited conditions or acquired mutations can predispose to HCC.
 Immune suppression: Organ transplant recipients or HIV-infected individuals have a
higher risk.
Hepatocellular carcinoma risk factors

Risk factors are many and include cirrhosis, chronic HBV/HCV infection, alcohol
abuse, and aflatoxin exposure.
Chronic Hepatitis Infections

 Hepatitis B Virus (HBV):


 Is a major cause of HCC globally, especially in regions like Asia and sub-
Saharan Africa.
 HBV can integrate into the liver cell genome, causing mutations even without
cirrhosis.
 Hepatitis C Virus (HCV):
 Common in North America, Europe, and Japan.
 HCV causes chronic liver inflammation, fibrosis, and often cirrhosis,
increasing HCC risk.
Cirrhosis

 Cirrhosis is the final stage of chronic liver damage where


scar tissue replaces healthy liver tissue.
 Common causes of cirrhosis leading to HCC include:
 Chronic alcohol use.
 Non-alcoholic fatty liver disease (NAFLD): Associated
with obesity, diabetes, and metabolic syndrome.
 Autoimmune liver diseases (e.g., primary biliary
cholangitis, autoimmune hepatitis).
Toxins and Environmental Exposures

Aflatoxins:
 Produced by molds (Aspergillus flavus) found in contaminated food (e.g.,
grains, nuts).
 Common in developing countries with poor food storage practices.
 Exposure to chemicals:
 Industrial chemicals like vinyl chloride and thorium dioxide may increase risk.
Genetic and Metabolic Disorders

 Hemochromatosis: Iron overload in the liver leads to cirrhosis and increases


HCC risk.
 Alpha-1 antitrypsin deficiency: Causes liver inflammation and fibrosis.
 Wilson’s disease: Copper accumulation in the liver.
Lifestyle Factors

 Chronic alcohol consumption: Leads to alcoholic liver disease and cirrhosis.


 Obesity and diabetes:
 Contribute to NAFLD and non-alcoholic steatohepatitis (NASH), both major
risk factors.
 Smoking: Linked to an increased risk of HCC.
 Synergistic Factors:
 Risk increases significantly when these causes overlap, such as:
 HBV/HCV infection combined with alcohol use.
 NAFLD combined with obesity and diabetes.
Preventive Strategies

 Vaccination for hepatitis B


 Screening and treatment for hepatitis C.
 Regular surveillance (ultrasound + AFP
every 6 months) for high-risk patients
(e.g., those with cirrhosis or chronic
HBV/HCV).
 Lifestyle modifications (reduce alcohol,
maintain a healthy weight).
 Avoid exposure to toxins like
aflatoxins/proper grain storage.
Understanding these risk factors can help with
prevention, early detection, and tailored
treatment strategies.
Early detection for hepatocellular
carcinoma
 Early Detection of Hepatocellular HCC is crucial to improving patient outcomes, as
early-stage HCC is more amenable to curative treatments.
 Enables curative treatments, such as:
 Surgical resection.
 Liver transplantation (if criteria are met).
 Local ablative therapies like radiofrequency or microwave ablation.
 Prevents progression to advanced stages, where treatment options are limited and
prognosis is poor.
 Early detection involves identifying at-risk individuals and employing surveillance tools
to diagnose HCC at its earliest stages.
 Regular surveillance (ultrasound + AFP every 6 months) for high-risk patients
(e.g., those with cirrhosis or chronic HBV/HCV).
Innovations in Detection

 Emerging tools that may enhance early detection include:


 Liquid biopsy: Analyzing circulating tumor DNA (ctDNA) in the blood.
 Advanced biomarkers: Glypican-3, des-gamma carboxyprothrombin (DCP).
 Artificial intelligence: Improving imaging interpretation accuracy.
By integrating regular surveillance into care plans for at-risk populations, healthcare
providers can significantly improve early detection and outcomes for HCC.
Signs and symptoms of hepatocellular
carcinoma
Patients may initially be asymptomatic. As HCC progresses,
symptoms can include:
 Abdominal pain (especially in the upper right quadrant).
 Unintentional weight loss.
 Fatigue and weakness.
 Jaundice (yellowing of the skin and eyes).
 Ascites (fluid buildup in the abdomen).
 Hepatomegaly (enlarged liver).
 Nausea and vomiting.
Diagnostic Tests

Imaging:
 Ultrasound, CT scan, or MRI of the liver.
 Contrast-enhanced imaging to identify vascular changes in
tumors.
Laboratory Tests:
Alpha-fetoprotein (AFP): Elevated in many HCC cases.
Liver function tests (LFTs) to assess liver damage.
Biopsy: Necessary to confirm diagnosis or if imaging is
inconclusive but may be omitted in some circumstances and in a
very sick patient .
Screening Methods
Imaging
Ultrasound (US):
 Non-invasive, widely available, and cost-effective.
 Recommended every 6 months for high-risk individuals.
 Sensitivity: 60%-80%, improved with experience and quality of equipment.
Biomarkers
Alpha-Fetoprotein (AFP):
 A tumor marker elevated in about 50% of HCC cases.
 Can be combined with ultrasound to improve sensitivity.
 Drawbacks: May be normal in early HCC or elevated due to other liver conditions
(e.g., hepatitis).
Combined Approaches

 Ultrasound + AFP:
 Increases diagnostic accuracy compared to
either method alone.
 Advanced Imaging for Diagnosis
 When ultrasound or biomarkers raise
suspicion:
 CT Scan (with contrast):
 Detects characteristic vascular patterns of
HCC (arterial enhancement, venous
washout).
 MRI (with contrast):
 More sensitive than CT for detecting small
tumors or lesions in challenging cases
Treatment
Depends on the stage of the disease and the patient’s liver function (Child-
Pugh score):
 Surgical Resection: For patients with localized tumors and good liver
function.
 Liver Transplantation: For those meeting the criteria.
 Ablative Therapies:
 Radiofrequency ablation (RFA).
 Microwave ablation.

Locoregional Therapies:
 Transarterial chemoembolization (TACE).
 Transarterial radioembolization (TARE).
Treatment continued

 Systemic Therapies:
 Targeted therapies (e.g., Sorafenib, Lenvatinib).
 Immunotherapy (e.g., Atezolizumab-Bevacizumab).
 Molecular testing facilitates the use of many other
agents with cost implications (MSI-H, dMMR, NTRK
gene fusion).
 Palliative Care: Focus on symptom management
and quality of life for advanced HCC.
Role of nurses in patient management
 Throughout the Cancer Continuum of Care - Nurses are essential
in the multidisciplinary care of HCC patients, participating in and
ensuring:
 prevention,
 early detection,
 effective management,
 and compassionate support.
 Their role extends beyond clinical tasks to advocacy, education, and
emotional care, enhancing patients’ overall quality of life.
Nursing Role in Prevention and Early Detection

 Vaccination: Hepatitis B vaccination reduces HCC risk.


 Advocate for vaccination (e.g., hepatitis B) and treatment of risk
factors (e.g., hepatitis C).
 Lifestyle Changes:
 Reduce alcohol intake.
 Maintain a healthy weight to prevent
 Educate at-risk patients on the importance of regular screening.
 Ensure timely referrals for interventions when needed.
Education

Educate patients on:


 Importance of regular follow-ups and imaging.
 Adherence to medications and therapies.
 Lifestyle modifications:
 Avoiding alcohol.
 Following a balanced/required diet (low sodium if ascites is
present).
 Recognizing symptoms of disease progression.
Patient Assessment and Psychosocial/Emotional
care

 Monitor for signs of liver failure (e.g., jaundice, ascites,


encephalopathy).
 Assess for treatment side effects (e.g., nausea, fatigue, bleeding
tendencies).
 Pain management.
 Nutritional support.
 Psychological support for patients and families coping with a cancer
diagnosis.
 Address emotional distress, anxiety, and depression related to a
cancer diagnosis.
 Provide resources for counselling or support groups.
Coordination of Care

 Facilitate communication between oncologists, hepatologists,


and palliative care teams as MDT player.
 Help patients navigate healthcare systems for access to care
programs.
In Africa
 372 participants were from Africa. Most provided hepatitis B vaccination and treatment for hepatitis B and
C.
 More than half of the participants use serum alpha-fetoprotein and ultrasound for surveillance.
 Only 20% reported using image-guided diagnostic liver biopsy.
 Liver transplant is available for only 28% of NS and 3% EW. C
 Availability of local therapy ranged from 94% in NS to 62% in C.
 Sorafenib is the most commonly used systemic therapy (66%).
 Only 12.9% reported access to other medications including immune checkpoint inhibitors.
 Second-line treatments were rarely provided.
 Conclusion: This reconfirms the major gaps in access and availability of care. This is a call for concerted
multidisciplinary efforts to achieve and sustain a reduction in incidence and mortality from HCC in Africa.

Ghassan K. Abou-Alfa et al., Africa Guidelines for Hepatocellular Carcinoma Buildup Process. JCO Glob Oncol 9,
e2300159(2023).
DOI:10.1200/GO.23.00159
In Conclusion

HCC represents a significant global health challenge,


particularly in low-resource settings.
Efforts to reduce the global burden include widespread HBV
vaccination, antiviral treatments for HCV, and addressing
modifiable risk factors like obesity, alcohol consumption,
and metabolic syndrome.
Early detection and equitable access to care are critical for
improving survival rates and reducing the global impact of
HCC.
THANK YOU!

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