Transcript:Richard S. Finn, MD: Thank you for joining this OncLive Peer Exchange®, “Moving the Needle in Hepatocellular Carcinoma (HCC): International Experts Weigh in.” Comorbidities and underlying cirrhosis complicate the management of HCC. Recent advances, however, are improving survival and shedding light on optimal patient selection in multidisciplinary approaches. In this OncLive® global Peer Exchange®, I’m joined by a group of international experts in liver cancer who will provide a global perspective on screening, staging, and therapeutic sequencing strategies in advanced disease. We will also review the latest clinical trial evidence likely to impact clinical practice.

I’m Dr. Richard Finn, and I’m an associate professor of medicine in the Division of Hematology/Oncology at the Geffen School of Medicine at the University of California, Los Angeles, in California. Joining me for this discussion are: Dr. Jordi Bruix, head of the BCLC Group Liver Unit at the Hospital Clinic University of Barcelona in Spain; Dr. Richard Marshall, assistant professor of clinical radiology and associate interventional radiology residency program director at the University Medical Center New Orleans, of Louisiana Health Sciences Center, in New Orleans, Louisiana; Dr. Amit Singal, associate professor of medicine and medical director of the Liver Tumor Program at UT Southwestern Medical Center in Dallas, Texas; and Dr. Arndt Vogel, a professor at Hanover Medical School in Hanover, Germany. Thank you for joining us. Let’s begin.

As represented by our panel, here, today, liver cancer is a very diverse group of malignancies with a global impact. Dr. Singal, can you talk to us about the differences, globally, in liver cancer?

Amit Singal, MD, MSCS: As you know, HCC is the fifth most common tumor worldwide, and the highest incidence rates are actually in East Asia and in Africa. In those areas, it’s really driven by high rates of endemic hepatitis B. In Europe, the United States, and, actually, most of the Americas, it has a much lower incidence and mortality rate than in East Asia and Africa. The risk factors are much different. Whereas, those areas are mostly driven by hepatitis B, in the United States and in Europe, it’s mainly driven by chronic hepatitis C, which is also changing over time.

With the new hepatitis C therapies, we’ve seen, hopefully, that the incidence for HCC will decrease in the future. We’re going to see a shift in epidemiology from this being a disease that’s being driven by nonalcoholic steatohepatitis, which is related to obesity and diabetes. This is really going to be the future of HCC, in my opinion, in the United States and in Europe.

Richard S. Finn, MD: Yes, it has been a very exciting time in the management of hepatitis C. Obviously, there has been an impact with these new drugs curing hepatitis C. And, as you commented, there’s going to be a rise in the incidence of liver cancer from metabolic causes.

Jordi Bruix, MD: Can I comment on one thing? To what extent do you think there is an overlap between nonalcoholic steatohepatitis (NASH) and alcoholic liver damage? Normally, we look at overweight countries with too much food, but too much food comes with too much drinking. Do you think this has been properly teased out?

Amit Singal, MD, MSCS: I think it’s tough. There is an ascertainment bias in terms of alcohol use. There are people that we know that drink, but you ask them and they say, “Oh, I just have a couple beers.” And so, sometimes it is very difficult to tease those 2 apart. The other thing is, I’m not sure if it really matters. I think these are 2 common pathways in which you come in through different means—whether it’s being fat that’s derived from food or fat that’s being derived from alcohol. I think it’s really just 2 pathways to 1 single common pathway, at the end. We are seeing that there’s probably some people who are affected by alcohol and who have metabolic syndrome, but there’s probably some that also do not. What do you think? In Europe, I imagine it’s also difficult to tease out?

Jordi Bruix, MD: I think that there is a big overlap, obviously, in both NASH and alcoholic liver disease, coming through mitochondrial damage. But, really, there is an overlap that has not been properly defined in epidemiological studies. And when you look to molecular signatures of the liver, there is no difference between NASH and alcoholic liver disease in some studies. What probably happens is that the interview to test their amount of alcohol is not accurate. I think that is something that we need to clarify.

Amit Singal, MD, MSCS: I think one final point on this is that, for heavy alcohol use, we’re pretty good at quantifying that. But, I think the other question is, what is moderate alcohol use? What is light alcohol use? What does that add in terms of HCC risk? Some of these things will be important for us to figure out over the next few years.

Jordi Bruix, MD: There is something that also affects when you look to the etiology in liver cancer patients that comes with an advanced stage. The intensity of the interview to clarify if they were drinking too much or not doesn’t matter. They have advanced cancer. If we begin to ask, “Did you smoke 10 years ago?”, it will not be well taken by the patients. So, epidemiologic studies have to be done as defined by the epidemiology guidelines.

Transcript Edited for Clarity