National Comprehensive Cancer Network

Clinical Recommendations

JNCCN – The Journal of the National Comprehensive Cancer Network

Table of Contents - Volume 7 Number 4: April 2009

• NCCN Clinical Practice Guidelines in Oncology™
• Hepatobiliary Cancers
• Palliative Care
• Featured Articles
• Selection of Patients With Hepatocellular Carcinoma for Sorafenib
• Transplantation for Hepatocellular Carcinoma and Cholangiocarcinoma
• The Increasing Incidence of Intrahepatic Cholangiocarcinoma and its Relationship to Chronic Viral Hepatitis
• A Communication Approach for Oncologists: Understanding Patient Coping and Communicating About Bad News, Palliative Care, and Hospice
• Palliative Care Across the Continuum of Cancer Care

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NCCN Clinical Practice Guidelines in Oncology™

Hepatobiliary Cancers

Hepatobiliary cancers are highly lethal cancers. It was estimated that approximately 21,370 persons were diagnosed with liver or intrahepatic bile duct cancer and 9520 with gallbladder cancer or other biliary tract cancer in the United States in 2008, with approximately 18,410 deaths from liver or intrahepatic bile duct cancer and 3340 deaths from gallbladder cancer or other biliary tract cancer. Risk factors for the development of hepatocellular carcinoma (HCC), the most common of the hepatobiliary malignancies, include hepatitis B and/or C viral infection, particular comorbidities or conditions, and certain external sources. The types of hepatobiliary cancers covered in this guideline include HCC, gallbladder cancer, intrahepatic cholangiocarcinoma, and extrahepatic cholangiocarcinoma.

Palliative Care

Palliative care is both a philosophy of care and an organized, highly structured system for delivering care to persons with life-threatening or debilitating illness. Palliative care is patient- and family-centered care that focuses on effective management of pain and other distressing symptoms, while incorporating psychosocial and spiritual care according to patient/family needs, values, beliefs, and cultures. The goal of palliative care is to prevent and relieve suffering and to support the best possible quality of life for patients and their families, regardless of disease stage or the need for other therapies. Palliative care can be delivered concurrently with life-prolonging care or as the main focus of care. The goal of the NCCN Palliative Care Guidelines is to help assure that each cancer patient experiences the best quality of life that is possible throughout the illness trajectory.

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Featured Articles

Selection of Patients With Hepatocellular Carcinoma for Sorafenib
Ghassan K. Abou-Alfa, MD

Sorafenib, a multitargeted anti–vascular endothelial growth factor receptor and raf kinase inhibitor, was recently approved by the FDA for treating unresectable hepatocellular carcinoma (HCC). Sorafenib has now been widely studied in patients with HCC, including a phase II study evaluating sorafenib in patients with HCC and Child-Pugh A and B, and a phase I study evaluating sorafenib in patients with organ dysfunction. These studies provide some limited insights about the safety and efficacy of sorafenib in patients with HCC and more advanced cirrhosis. The lack of objective responses observed in the sorafenib arm in the SHARP study also raises practical issues about how to assess response or efficacy of the therapy and thus how long a patient should receive sorafenib. This article addresses these questions on the use of sorafenib in HCC, in addition to the potential future applications and uses.

Transplantation for Hepatocellular Carcinoma and Cholangiocarcinoma
B. Daniel Campos, MD, and Jean F. Botha, MD

Hepatocellular carcinoma (HCC) and cholangiocarcinoma represent more than 95% of the primary hepatic malignancies in adults, with the incidences of both rising. Any form of cirrhosis and primary sclerosing cholangitis represent independent risk factors for the development of HCC and cholangiocarcinoma, respectively. Surgical treatment of both has evolved significantly in the past decade, with liver transplantation (LT) revolutionizing the prognoses. Provided both malignancies are diagnosed early in their natural history, LT offers a greater than 75% chance of survival at 4 years. This compares favorably with any other form of treatment, including partial liver resection. The application of specific pre-transplantation staging criteria, along with the addition of neoadjuvant chemoradiation therapy for cholangiocarcinoma, has made these results possible. The development of living donor liver transplantation further expands the treatment horizon for both diseases The future challenge is to better characterize biologic staging/prognostic indicators that could expand understanding and success in treating both malignancies.

The Increasing Incidence of Intrahepatic Cholangiocarcinoma and its Relationship to Chronic Viral Hepatitis
Kwang-Yu Chang, MD; Jang-Yang Chang, MD; and Yun Yen, MD

Primary liver cancer is for the sixth most common cancer and third most common cause of cancer death worldwide. Cholangiocarcinoma is the second most common primary liver tumor after hepatocellular carcinoma. Because the incidence of intrahepatic, but not extrahepatic, cholangiocarcinoma is rising in most areas worldwide, it is urgent to identify the main causes of this disease. Despite well-known risk factors in the development of intrahepatic cholangiocarcinoma, recent reports focus on chronic hepatitis B and C viral infections as an increasing number of studies have observed the association between viral hepatitis and cholangiocarcinoma. The relationship, however, is still not conclusive because of the diversity in clinical reports and lack of in vitro evidences; this issue should be emphasized and more investigation is required for clarification.

A Communication Approach for Oncologists: Understanding Patient Coping and Communicating About Bad News, Palliative Care, and Hospice
Juliet Jacobsen, MD, DPH, and Vicki A. Jackson, MD, MPH

Oncologists frequently approach patients to discuss difficult topics, such as bad news about cancer progression, and referrals to palliative care and hospice. To communicate effectively in these difficult situations, it is helpful to assess what the patient knows and wants to know about their disease in general and, specifically, their prognosis. Although some patients fully accept the diagnosis of cancer and cope well, most patients struggle with how best to cope. This struggle often manifests itself with the patient vacillating between unrealistic hopes for longevity while also indicating prognostic awareness by talking about funeral plans. Although this coping is normal, it is difficult for most clinicians to interpret. This article presents a framework for understanding normal patient coping and gives specific examples of how to talk with patients during difficult transitions, such as times of disease progression, and about referral to hospice and palliative care.

Palliative Care Across the Continuum of Cancer Care
Tara B. Sanft, MD, and Jamie H. Von Roenn, MD

Optimal oncology care requires the integration of palliative medicine into oncology care across the disease trajectory. All patients require screening for palliative care services at the initial oncologic visit and reassessment throughout the continuum of care. The domains of palliative cancer care have been elucidated and fostered the development of guidelines for quality palliative care. This is a result of the increasing attention focused on palliative care nationally and internationally. The palliative approach is subsumed in cancer care; it provides assistance with decision making; symptom management; and access to financial, emotional, and spiritual services. A fully integrated program of oncology and palliative care provides the greatest opportunity for care and cure.