The Indian Council of Medical Research (ICMR) has issued a draft consensus document for management of hepatocellular carcinoma (HCC), the most common type of primary liver cancer. The document, prepared by top Indian scientists in the field, will be a guidance paper for oncologists and caregivers in the country.
The document is based on evidence obtained through randomised controlled trials and prospective comparative studies. Though the research paper doesn’t bind a medical professional to follow the guidelines verbatim or endorse any pharmaceutical drug for therapy, it gives a framework for clinicians during complex decision-making processes.
Information on epidemiology of HCC is highly fragmented in India as cancer is not a reportable disease here. Though the National Cancer Registry Programme launched by the ICMR has been trying to generate data on incidence and prevalence, the registries fail to reflect the real picture since the disease is managed by varied specialists such as oncologists, general surgeons and gastroenterologists. However, available data indicates that the age-adjusted incidence rate (AAIR) for men ranges from 0.7-7.5 and for women 0.2-2.2 per 1, 00,000 population. Male to female ratio is approximately 4:1 and HCC constitutes 4.8 per cent of all cancers. Median age of Indian patients with liver cancer is 40-70 years.
Since HCC is typically diagnosed late in its course, the mortality rate remains very high. A large-scale verbal autopsy study in 2010 showed liver cancer as the fourth leading cause of cancer-related deaths in men. It claimed 14,000 lives during the study period with an age-standardised mortality rate (AMSR) of 6.8 per 100,000 population. In women, it was the eighth highest cause of cancer related deaths with 12,000 fatalities, an AMSR of 5.1 per 100,000 population.
According to data obtained from tertiary cancer centres across the country, cirrhosis of liver has been noted in 70-90 per cent of HCC patients and hepatitis B virus (HBV) infection is documented as the probable causative agent in majority of patients. The data is a matter of concern considering that there are approximately 40-50 million HBV carriers and about 10 million hepatitis C virus carriers in India.
As HCC is a complex disease with various etiologies, the ICMR consensus document strongly recommends hepatitis B vaccination in newborns and health workers as a feasible strategy. Antiviral therapies are advised for secondary prevention.
“All patients at risk of developing HCC and who are eligible for HCC therapy are candidates for regular surveillance to ensure early detection of tumours that are amenable to treatment,” the document stated. The recommended surveillance test is a six-monthly abdominal ultrasound by an experienced radiologist.
The guidelines elaborate on diagnostic strategies including non-invasive lesion characterisation, tissue diagnosis and serological markers.
Though the role of liver transplantation is crucial, the main problem is the limited availability of organ and long waiting list with inherent risk of disease progression leading to drop outs. To circumvent this problem a number of strategies are available like living donor related transplant, the document observes.
The ICMR has asked stakeholders to send suggestions and comments on the draft document by July 17, 2018.