Uptake of Palliative Care in Liver Cancer Needs Improvement, Report Says

September 5, 2020

Hepatocellular carcinoma is rising, and so is the need for increased awareness and use of palliative care, say the authors of a recent review.

A recent review looked at palliative care in hepatocellular carcinoma (HCC), a cancer with a poor prognosis, increasing incidence, and one that carries with it a certain amount of stigma.

HCC has been rising and is predicted to keep trending upward, according to the review; it is more deadly than pancreatic, lung, and colorectal cancer. The mortality-to-incidence ratio is 0.89 for HCC versus pancreas (0.83), lung (0.72), and colorectal (0.27).

In 2018, there were 841,080 incident cases of HCC and 781,631 deaths worldwide. After diagnosis, the 5‐year survival is under 20%, ranging from 9% in Asia to 19% in the West.

Early in the disease, HCC is often silent, contributing to its late diagnosis. More than half of patients have incurable disease at the time it is discovered. Furthermore, almost all patients with HCC have underlying liver disease, and up to 90% have cirrhosis.

HCC also expensive—US per-person costs are estimated at $29,000 to $44,000 annually, with the greatest burden happening in the end stages of the disease.

Despite advancements in intermediate and advanced HCC, most treatments remain noncurative.

Given these factors, the authors sought to review palliative care’s benefits and use, as well as implementation barriers.

Palliative care is known to improve quality of life, reduce depression, reduce health care costs, and prolong survival, according to other studies that examined cancers other than liver.

In liver cancer, palliative care is underused in this cancer and typically has late referrals. For example, looking at one group of patients with advanced or terminal stage HCC, the authors said only 40% were referred and seen by palliative care.

The main indications for referral were pain (44%), end of life care (37%), nausea (11%), and dyspnea (3%). For inpatients, the median time to death after consulting with palliative care was just 3 days (interquartile range [IQR] 0–28.5); for outpatients, it was 21.5 days (IQR 4–146) for outpatients.

Barriers to accessing palliative care in HCC and accompanying cirrhosis include stigma related to hepatitis and alcohol use, the most common cause of the disease. In addition, as with other cancers, some patients and families may think of palliative care as “giving up.”

The authors also said they were concerned by the findings of a survey of gastroenterologists, where 81% believed the misconception that palliative care starts only when active therapy ends.

Gastroenterologists refer to palliative care less frequently than oncologists, the authors said, although they manage HCC more often. In addition, providers caring for patients with advanced or terminal liver cancer cited a lack of time (91%) as well as a lack of cultural awareness to start the referral (81%).

The authors also said that although the American Society of Clinical Oncology recommends palliative care in all cancers, hepatology societies have yet to adopt the same conclusion.

Future action is needed, the authors said, including education, awareness campaigns, increased funding and improved models of care.

Reference

Laube R, Sabih A-H, Strasser SI, Lim L, Cigolini M, Liu K. Palliative care in hepatocellular carcinoma. JGH Open. Published online July 6, 2020. Doi: 10.1111/jgh.15169