Peter Galle, MD: The history goes in a way that until 2002, when we had the definition of TACE [trans-arterial chemoembolization] as a successful treatment, we basically had surgery. That was transplantation, resection, and not much else. Then interventional radiologists entered the field, and medical oncologists and hepatologists did not play a major role. This changed in 2007 when we, for the first time, defined a center of care in systemic therapy. Ever since, systemic therapies have been evolving. Particularly in the last 6 months, we have seen a dramatic improvement in systemic therapeutic options, meaning that medical oncologists and hepatologists—those in charge for systemic therapy—are playing a much more important role compared with 20 years ago. That is something that is currently changing.

Of course, if you want to offer the patient the best of all worlds, then you need to integrate all the different specialties and subspecialties in the multidisciplinary team assessment. Surgeons, interventional radiologists, oncologists, and hepatologists should be on those teams, adding to the choice and the optimal treatment decision.

It is handled differently in Germany. For example, MDTs [multidisciplinary teams] are mandatory. You are required to get reimbursement and, for example, the specific certificates as a liver cancer center—to have MDT regular meetings, and that needs to be documented. It’s actually required that more than 95% of your patients are seen in these MDTs. This is not the case in all European countries, so it’s quite variable. The other issue, what needs to be addressed in terms of the quality and the relevance of MDTs, is that it always depends on who is sitting there and how is the balance. If there is a dominating subspecialty—for example, radiologists—then it might not result in the best choice in all means, because dominance in these settings is not really what is best for the patient. You need to have a balanced view with respect to all the involved subspecialties.

Minsig Choi, MD: The role of medical oncologists in the treatment of liver cancer has been evolving rapidly over the last 5 years. This is because of the increasing options in the treatment of systemic therapy in liver cancer. Just 3 or 4 years ago, we didn’t have a lot of treatment options except for sorafenib, which has been around for the last 10 years, but because nowadays we have so many tyrosine kinase inhibitors, immunotherapy treatment options, and monoclonal antibodies like ramucirumab, medical oncologists are becoming a more integral part of the multidisciplinary team that cares for liver cancer patients.

Most multidisciplinary cancer teams comprise a diverse group of physicians, including gastroenterologists, hepatologists, liver surgeons, liver transplant surgeons, interventional radiologists, radiation oncologists, and medical oncologists. Our interventional radiologists are involved in the locoregional therapy, while surgical oncologists are involved in local resection and liver transplant.

Because of available systemic options, including immunotherapeutic agents and different tyrosine kinase inhibitors, medical oncologists are getting involved both early on in the adjuvant clinical trials treatment as well as in the more advanced liver cancer patients. Many of the studies have shown that when you have multiple groups of subspecialists taking care of liver cancer, those patients’ clinical outcome improves with the multidisciplinary treatment approach.

Masatoshi Kudo, MD, PhD: Regarding HCC [hepatocellular carcinoma], mainly the hepatologists treat HCC. Most medical oncologists also do, and some oncologists treat HCC because, in general, the oncologist is familiar with the systemic therapy and adverse-event management. However, in HCC, there are many liver-specific adverse events, such as hepatic encephalopathy or bleeding or some very strict evaluation of liver function using the ALBI [albumin-bilirubin] score. It’s slightly difficult for medical oncologists. In Japan, hepatologists typically treat HCC.

How important is the multidisciplinary team, and how different is it in Asia and Japan? In Asia, most HCC cases have big or multiple tumors at time of detection. But in Japan many lesions are small and in fewer regions, since nationwide surveillance is established. The multidisciplinary team in Japan consists of a surgeon, a hepatologist, and an interventional radiologist, because 65% of the initially detected cases are early stage disease, and 30% are intermediate. Only 5% have advanced-stage disease, so medical oncologists rarely attend the multidisciplinary team. In Asian countries, more patients with advanced-stage disease are interventional, so of course the surgeons and interventional radiologists and oncologists will attend that multidisciplinary team to discuss how to pay for the treatment.

Transcript Edited for Clarity