Liver Transplant Associated With Improved OS vs Systemic Therapy Alone for Non-Metastatic Hepatocellular Carcinoma

Firas Baidoun, MD, Cleveland Clinic, OH, discusses results from a study which compared survival outcomes between upfront liver transplant, liver transplant with bridge systemic therapy, and systemic therapy only, for non-metastatic hepatocellular carcinoma (HCC). A statistically significant advantage in overall survival (OS) was noting for those treated with upfront liver transplant or liver transplant with bridge therapy than with systemic therapy alone.

These findings were presented at the 2022 ESMO World Congress on Gastrointestinal Cancer in Barcelona, Spain.

Transcript:

Hello, I'm Firas Baidoun, I'm a clinical associate staff at the Department of Hospital Medicine at Cleveland Clinic. I'm very excited to present our study at ESMO GI this year titled "Impact of Sequencing of Different Treatment Modalities on Survival Outcomes Among Patients with Non-Metastatic Hepatocellular Carcinoma." As we know, liver cancer or hepatocellular carcinoma is the must common type of liver malignancy and the third leading cause of cancer related death in the world. While surgical resection is the most common treatment approach in non-metastatic disease, there is a high recurrence rate, especially, after 5 years of surgical resection.

Liver transplant is the cornerstone in treating non-metastatic disease with a curative potential. The big challenge is there's a big waiting time and a lot of patients miss the opportunity for upfront liver transplant, and that's mainly because of the organ shortage. In our study, we used the National Cancer Database to include adult patients who were diagnosed with hepatocellular carcinoma between 2004 and 2017. All were non-metastatic disease. We included only patients with a clinical N0 stage and patients who received either systemic therapy alone or liver transplant alone or liver transplant after they received systemic therapy.

We excluded patients with unknown timing of systemic therapy relative to a liver transplant and patients who lost follow-up. We split the cohort into 3 groups. In group 1, patients received systemic therapy only. In group 2, patients had upfront liver transplant without bridge therapy. In group 3, patients received systemic therapy followed by liver transplant. Then we compare the overall survival between the 3 groups. We use Kaplan–Meier curves and Cox regression analysis to estimate survival and to evaluate factors associated with overall survival. We also did propensity score matching accounting for age, gender, clinical T-stage for more robust results.

We had a total of 29,691 patients with non-metastatic disease, of which 84.6% were treated with systemic therapy only. 8.5% had systemic therapy followed by liver transplant, and 6.9% had upfront liver transplant without systemic therapy. In baseline characteristic comparison, we found that patients who received systemic therapy only were older compared to the other 2 groups. Also African American patients, and patients who had lower income and education levels, and those who did not have medical insurance were more likely to miss the opportunity to receive liver transplants. This reflects the socioeconomic disparities in receiving optimal treatment. When we compared the overall survival, we found that patients who were treated with liver transplants, either as an upfront treatment or after bridge therapy, had a significant improvement in overall survival compared to patients who were treated with systemic therapy alone.

In multivariate analysis and after adjusting for baseline characteristics and available disease related factors, we found that liver transplant, either as an upfront treatment or after systemic therapy, was associated with better overall survival compared to systemic therapy alone. Also after propensity score matching, we saw the same trend in overall survival. Patients who were treated with liver transplant, either as an upfront treatment or after systemic therapy, had significant improvement in overall survival compared to patients who had systemic therapy alone.

Our study is one of the largest studies that evaluated the critical role of liver transplant after bridge therapy in patients with non-metastatic hepatocellular carcinoma. We have some limitations in our study that we would like to acknowledge, including the retrospective nature of data collection. We did not have many details about the liver function or the type of chemotherapy the patient received, and there was a lack of detail about other oncologic endpoints. In conclusion, patients with non-metastatic hepatocellular carcinoma who were treated with liver transplant, either as an upfront treatment or after bridge therapy, had significant improvement in overall survival compared to patients who were treated with systemic therapy only.

Our study highlights the socioeconomic disparities in liver transplant access among hepatocellular carcinoma patients in the US. Also, our study raises the importance of proceeding with liver transplant after bridge therapy for patients who either were not eligible for initially or missed the opportunity for upfront liver transplant. Thank you so much.

Source:

Baidoun F, Abdel-Rahman O. Impact of sequencing of different treatment modalities on survival outcomes among patients with non-metastatic hepatocellular carcinoma. Presented at: ESMO World Congress on Gastrointestinal Cancer; June 29-July 2, 2022. Barcelona, Spain. Abstract SO-15.