Arndt Vogel, MD: Patients with HCC usually have underlying liver diseases and most of them eventually develop liver cirrhosis. And currently, we can assume that around 70% to 80% of patients with HCC have an underlying liver fibrosis or liver cirrhosis. But this might change in the future because we have learned that in some chronic liver diseases, you really require cirrhosis to develop the HCC or it’s very closely correlated like in HCV, for example. But in other diseases like hepatitis B infection, nonalcoholic steatohepatitis, or fatty liver disease, the tumor can also develop in a nonfibrotic and noncirrhotic liver. So, at the moment, most of our patients do have liver fibrosis and cirrhosis, but with a shift in the underlying liver diseases, we might see more patients who do not have liver cirrhosis.

The underlying liver cirrhosis clearly impacts the treatment options we have for our patients with HCC. We have learned in the past that there are different staging systems to decide and to see how good the liver function is. They were used for a long time. The Child-Pugh scoring system, which was never developed for treatment decisions in hepatocellular carcinoma, was more of a tool to decide on the liver function in patients with advanced liver fibrosis but not with liver tumors. Because there was nothing else, we used this scoring system. But recently, we have noted that the Child-Pugh A scoring system is not sensitive enough to really define the underlying liver function or the remaining liver function. And there are new scores like, for example, the ALBI score, which just relies on 2 objective parameters: albumin and bilirubin. And the ALBI score is much more sensitive to really see how good the underlying liver function is. I think we really have seen in the last 2 to 3 years a publication of publications that have clearly shown that the prognosis of patients clearly depends on the liver function. So, with the same tumor burden, depending on the liver function, median survival can be half a year, a year, or 2 years. The liver function is critically important for the prognosis of our patients.

Oliver Waidmann, MD: The most important comorbidities are chronic infection with hepatitis C virus, chronic HBV infection, diabetes, nonalcoholic steatohepatitis, and, also, obesity. In my opinion, chronic HCV infection is not a big issue, because it doesn’t really affect the treatment for the patient. But if you have a patient with chronic HBV infection, you should treat. If the patient has HBV DNA in the blood, you should treat the patients with very potent antiviral drugs, namely tenofovir or entecavir. If you have a patient who is really obese, this really, of course, can affect the treatment of the hepatocellular carcinoma, especially if you have to do surgery or radiofrequency ablation.

Arndt Vogel, MD: The underlying liver disease can affect our treatment decisions. First of all, a patient might have developed liver fibrosis and cirrhosis, so this could clearly affect the ability of some treatments, such as a surgery, especially if the liver function is not good enough. And on the other hand, specifically if you talk about fatty liver disease, for example, it is usually associated with obesity, which could also make it difficult. The patient might not have liver cirrhosis but just because of him being overweight, to apply local therapies could be much more difficult than in somebody who is not overweight. On the other hand, in terms of viral hepatitis, for example, there was sometimes a concern for hepatitis B where we can have a good control of the viral replication with the treatments that are currently available. With hepatitis C, which we can treat now very well, there still was a question if you treat the patient, how does it really affect, for example, viral replication, and how does this affect the underlying hepatitis inflammation, which again might affect the outcome of systemic therapies? So, depending on the underlying liver disease, this might impact on which treatment we can really choose for our patients.

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