Liver Cancer: One or Many Different Cancers?
December 20, 2021Information
December 19, 2021
Yale Cancer Center
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- 00:00Funding for Yale Cancer Answers
- 00:02is provided by Smilow Cancer
- 00:04Hospital and Astra Zeneca.
- 00:08Welcome to Yale Cancer Answers with
- 00:10your host doctor Anees Chagpar.
- 00:12Yale Cancer Answers features the
- 00:14latest information on cancer care by
- 00:16welcoming oncologists and specialists
- 00:17who are on the forefront of the
- 00:20battle to fight cancer. This week
- 00:22it's a conversation about liver cancer
- 00:24with doctors Amy Justice and Tamar Taddei.
- 00:26Dr Justice is the CNH
- 00:28Long professor of Medicine and Doctor
- 00:30Taddei is associate professor of
- 00:32medicine at the Yale School of Medicine,
- 00:34where Doctor Chagpar is a
- 00:36professor of surgical oncology.
- 00:39So maybe I'll start with you doctor Taddei,
- 00:42tell us a little bit more about
- 00:44yourself and what you do.
- 00:46So I'm a hepatologist and my research
- 00:49focuses on outcomes in liver disease
- 00:51and liver cancer as well as in
- 00:53clinical trials and prevention
- 00:55and detection of liver cancer.
- 00:58So that's sort of me in a nutshell.
- 01:00OK, what about you doctor Justice?
- 01:03So I'm a clinical epidemiologist and
- 01:05I have spent my career harnessing
- 01:08the national electronic health
- 01:10record system that the VA has to
- 01:12try to study important clinical
- 01:14phenomenon like liver cancer.
- 01:16Also, HIV, hepatitis C,
- 01:18and a number of other conditions
- 01:20using that national database.
- 01:22And so I mean, it seems like the two of
- 01:25you would have obvious research synergy,
- 01:28but one of the things that's always
- 01:31exciting and interesting to me is to see
- 01:33how people from arguably different fields.
- 01:36One an epidemiologist 1A hepatologist
- 01:39kind of collide to come up with
- 01:43interesting research ideas.
- 01:45So Doctor Daddy tell us a little
- 01:47bit more about how you met and about
- 01:50how this collaboration started.
- 01:53So I wouldn't call it a collision.
- 01:55I actively. I actively sought
- 01:57Amy's mentorship so Amy has
- 02:00more than 20 year history of
- 02:03developing cohorts in the VA in VA.
- 02:06Data to carefully develop
- 02:09clinical phenotypes of disease
- 02:11specifically around HIV and aging,
- 02:14and many other diseases.
- 02:16Because a lot of this work
- 02:19in HIV patients has also,
- 02:21you know HIV patients commonly
- 02:22have hepatitis C, for example.
- 02:24They commonly have metabolic disorders.
- 02:26And so she's really built a research
- 02:29environment that can study systems
- 02:32related diseases in a way that
- 02:35was incredibly intriguing to me.
- 02:37As a young person who wanted to
- 02:40develop a cohort of patients with
- 02:43cirrhosis at risk of liver cancer.
- 02:45And so I sought her advice,
- 02:47and this was in somewhere around 2011, 2012.
- 02:51I asked to meet with her and I said,
- 02:53look, you know, I've I've seen your work.
- 02:55I want to know how to do this.
- 02:57I think I'm going to need a
- 02:58lot of handholding,
- 02:59and there began a decade of a
- 03:02phenomenal mentorship for me,
- 03:03so that's that's how we met.
- 03:06And doctor Justice tell us a
- 03:08little bit more about kind of
- 03:10the ideas that were generated.
- 03:12The projects that you've designed,
- 03:14and what the Genesis was of that.
- 03:18Well, I'm a general internist,
- 03:20so I think broadly,
- 03:22which is sort of complementary to
- 03:24and being an epidemiologist because
- 03:26epidemiologists also think fairly broadly.
- 03:28But I realized early on that I
- 03:30could not be an expert in every
- 03:32one of the conditions that were
- 03:34worthy of study using the VA data,
- 03:36so I've always had my eyes out for a
- 03:38young promising people who want to be
- 03:40the experts in those particular domains
- 03:43and tomorrow absolutely fit that Bill.
- 03:45And part of what I think is really
- 03:48exciting about doing this work is
- 03:49that there are a number of cores
- 03:51and work groups affiliated with the
- 03:53cohort studies that I've created,
- 03:54and each one of those cores in
- 03:56workgroups has greater depth and
- 03:57understanding of the clinical questions
- 03:59that they are looking at than I do.
- 04:01But what Ioffer is sort of the
- 04:02connectivity among those groups so that
- 04:04we can learn how to do a phenotype
- 04:06once somebody develops diabetes
- 04:07in the endocrine group and we can
- 04:09use it in the liver group without
- 04:11having to recreate another wheel so
- 04:13that we are definitely more as a.
- 04:16We are more than the sum of our parts
- 04:18and I find that exciting and a lot
- 04:20of fun coming into work every day.
- 04:23So just for people who are not
- 04:25familiar with your work when you're
- 04:27talking about these different cores
- 04:29and and kind of spanning research
- 04:32phenomena across different groups,
- 04:34tell us more about how that exactly works.
- 04:38Can you contextualize that for us and
- 04:40maybe give us a specific example? Sure,
- 04:44so I'll talk about tomorrow's work
- 04:45because that's most relevant to this.
- 04:47Call so when Tamar came to me initially
- 04:50she wanted to create her own cohort study,
- 04:52which she did with aplomb.
- 04:54But then, over time,
- 04:55she realized that she could also benefit
- 04:57from doing some analysis with some of
- 04:59the databases that we had created.
- 05:00The cohorts we created that were a
- 05:02little bit more generic than only
- 05:04people who had cirrhosis per say.
- 05:06Not to mention that we had other
- 05:07data that we had merged into our
- 05:10cohort studies that wasn't yet
- 05:11available to her in the other study.
- 05:13So she wrote up a proposal,
- 05:15which was a brief, suggest,
- 05:16brief outline of what she wanted to do.
- 05:19I reviewed it,
- 05:19thought it had the critical
- 05:21information that we needed it,
- 05:22and then it went to the liver core,
- 05:24which is a standing group of
- 05:26people who are very interested in
- 05:28liver research in the VA data bin.
- 05:30Lorry is the head of that core,
- 05:32along with Jan Tate,
- 05:33who is the Methodologist Ben
- 05:35Larae being the clinician.
- 05:36They reviewed it.
- 05:37They made suggestions to her.
- 05:39Several people in the course said
- 05:40they were interested in participating
- 05:42and signed on to be on the writing
- 05:44committee and we went from there.
- 05:47And and so doctor Taty tell us a little
- 05:49bit more about the questions that you
- 05:52were trying to answer with these studies.
- 05:55So the first question was really
- 05:58how to understand via data.
- 06:01So where do you go to develop a cohort?
- 06:04How is it housed within the you
- 06:08know V8 computing infrastructure?
- 06:12How do you actually look at that
- 06:13data in a way that makes sense
- 06:16and ask the right question?
- 06:17So just having the data doesn't really
- 06:20lead you to the right endpoint.
- 06:22You have to actually start with
- 06:24a good question and sometimes.
- 06:26Good questions actually require a
- 06:28lot of effort to actually be able
- 06:31to define your population properly,
- 06:33and so in the beginning when
- 06:34we set up the cirrhosis cohort,
- 06:36which is called the vocal cohort,
- 06:38I did this with my colleague
- 06:40Dave Kaplan at Upenn.
- 06:41There's a lot of parallels
- 06:43between Upenn and Yale,
- 06:44a lot of collaboration going on there,
- 06:47and so we actually had to really define
- 06:49severity of liver disease in that cohort,
- 06:52which is hard to do,
- 06:53and we took a lot of advice from from.
- 06:56Amy and from then and how to do that and
- 06:59and so since the inception of that cohort,
- 07:03we set that cohort cohort up in 2012.
- 07:06We've published some probably 25 papers
- 07:08now on cirrhosis and outcomes in
- 07:11cirrhosis from everything to important
- 07:14clinical questions around the use of
- 07:16anticoagulants in these patients to
- 07:18the burden of cost of liver cancer.
- 07:21Care to you know,
- 07:23all kinds of different questions
- 07:25that are that are.
- 07:27Well answered in a large cohort,
- 07:29but I think one of the issues
- 07:31that's very important is that when
- 07:33you develop a population cohort,
- 07:35you make a lot of assumptions, right?
- 07:37You say, well,
- 07:37I'm going to be looking at people
- 07:39with cirrhosis, right?
- 07:40And yet, cirrhosis happens over decades.
- 07:43There are many risk factors
- 07:45that lead to cirrhosis,
- 07:46and while cirrhosis is the
- 07:47single most important risk
- 07:49factor leading to liver cancer,
- 07:50I wanted to have a better
- 07:52idea of what happens to people
- 07:54before they develop cirrhosis.
- 07:56And are we missing upstream risk factors?
- 07:59Perhaps by selecting pre selecting
- 08:02this population and because
- 08:04I'm not an epidemiologist,
- 08:06I really rely heavily on Amy's
- 08:10Broadview because you know,
- 08:11the more specialized you become
- 08:13in in medicine.
- 08:14The more blinders you have and and
- 08:16sometimes you need somebody to sort of
- 08:17shock you into saying wait a second,
- 08:19you know,
- 08:20don't look at that population.
- 08:22Look at the whole population and
- 08:24let's think about this rationally.
- 08:26And so in in more recent work
- 08:28we've been looking at the whole
- 08:30VA population to look at upstream
- 08:32risk factors for liver cancer
- 08:34and what was important about that was
- 08:37the realization that if you only if
- 08:39you looked at cirrhosis and put that
- 08:42in as the risk factor, it washed out.
- 08:44All the factors that occurred
- 08:46before cirrhosis occurred,
- 08:47yet cirrhosis is hard to reverse
- 08:50whereas fatty liver diabetes can
- 08:52be addressed more effectively.
- 08:54So it was very important to look
- 08:55at the whole population and begin
- 08:57to look at upstream phenomenon
- 08:58like tomorrow was talking about.
- 09:01Yeah, I mean, it seems that there's
- 09:04a very heterogeneous population
- 09:05that kind of all leads to the
- 09:08same endpoint of of cirrhosis.
- 09:10So tomorrow maybe you can tell
- 09:12us a little bit more about.
- 09:14The epidemiology of of cirrhosis
- 09:17and of liver cancer. How?
- 09:19How common is this anyways?
- 09:22So cirrhosis is actually quite common.
- 09:26And liver disease in the general
- 09:28population is also quite common,
- 09:30so there's at least thirty million
- 09:33Americans living living with liver
- 09:35disease with known liver disease.
- 09:37And there's probably many more
- 09:38millions that are at risk for
- 09:40liver disease and don't know it.
- 09:42OK, so the major risk factors
- 09:45for liver disease are viral,
- 09:48hepatitis, hepatitis, B&C, alcohol,
- 09:52excessive or unhealthy alcohol use and then.
- 09:55What we call fatty liver disease,
- 09:59which can be alcohol associated and
- 10:01non alcohol associated and and that's
- 10:04part of a bigger metabolic syndrome
- 10:06that we actually see being sort of
- 10:08a canonical risk factor for cancers.
- 10:10All kinds of cancers in fact,
- 10:13and our epidemiology in in liver
- 10:15disease and liver cancer is
- 10:17shifting fairly quickly because we
- 10:19now have a cure for hepatitis C.
- 10:22And so while hepatitis C dominated as a
- 10:24risk factor in the US for many decades.
- 10:27We're able to cure it now,
- 10:28and we're actually seeing more obesity
- 10:32and alcohol associated liver disease
- 10:34and liver cancer coming to the fore.
- 10:37So these are major public health
- 10:41issues that that really need to
- 10:43be addressed at at a national
- 10:45at a federal and state level.
- 10:48And so Amy, when you think about you,
- 10:51know fatty liver and obesity and alcoholism.
- 10:56What proportion would you say of the VA
- 10:59cohorts or of the cohorts in general
- 11:02that you've looked at are at risk of one
- 11:05of these such that you really wanted
- 11:07to look at the global population? At
- 11:10least 1/4 I'm depending on and
- 11:12depending on how you define it more
- 11:15than 1/4, possibly even up to half
- 11:17and and for all of those
- 11:20people is the mechanism and the
- 11:22endpoint of cirrhosis the same?
- 11:24In other words, both from a molecular
- 11:28standpoint that you know there
- 11:31is some sort of liver injury that
- 11:33essentially then results in cirrhosis.
- 11:36As well as the degree and
- 11:37the type of cirrhosis,
- 11:39are those of the same whether you
- 11:42happen to have gotten to that
- 11:44endpoint through obesity versus
- 11:46a hepatite E versus alcoholism.
- 11:50I'm going to let tomorrow address that
- 11:52'cause she spent a lot of time on that
- 11:53and it's a beautiful question.
- 11:56So I think the question is,
- 11:57do you want to make things sound
- 11:59simple or do you want to just
- 12:01embrace the complexity that's there?
- 12:03You know Amy's always telling me.
- 12:05Just embrace complexity, right?
- 12:07And it's true.
- 12:08I think cirrhosis is a final
- 12:11common pathway of all of the
- 12:13Cascades that lead to liver injury
- 12:16and repair and aberrant repair.
- 12:19You know, Yep, you can call
- 12:21cirrhosis the final common pathway,
- 12:23but that tells you very little about all
- 12:25of the Cascades that happen to get there,
- 12:28and I think actually we need to look
- 12:30at liver disease and liver cancer
- 12:32from an ideological standpoint.
- 12:34Meaning what is it?
- 12:35What's the etiology or the
- 12:36'cause that brought you here?
- 12:38Because there are different molecular
- 12:41sort of biologies of those pathways
- 12:44and then the cancers themselves.
- 12:47You know,
- 12:47even though we think about
- 12:49two sort of dominant.
- 12:50Primary liver cancers.
- 12:52The 90% of these liver cancers
- 12:55are are termed hepatocellular
- 12:57cancer and they arise from the
- 12:59liver cell from the hepatocyte.
- 13:01But they look totally different
- 13:02under the microscope.
- 13:03So that begs the question,
- 13:05are we dealing with so much
- 13:07heterogeneity here that we're just
- 13:08lumping these things into one name?
- 13:10Liver cancer?
- 13:12Yeah, so you know I I really want
- 13:15to dive more into liver cancer.
- 13:18The different types of liver cancer.
- 13:20Whether the etiologies of these
- 13:21cancers actually play a role in
- 13:23terms of prognosis and treatment and
- 13:25where things are going in the future.
- 13:28But right now we have to take a
- 13:29short break for a medical minute.
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- 14:41to Connecticut Public Radio.
- 14:45Welcome back to Yale Cancer answers.
- 14:47This is doctor a nice check part
- 14:49and I'm joined tonight by my guests,
- 14:51doctor, Amy Justice and Tamar Taddei.
- 14:54We're learning about liver
- 14:55cancer treatments and research,
- 14:57and before the break we were talking a
- 14:59little bit about cirrhosis and the different
- 15:02pathways that people can get cirrhosis.
- 15:04But I thought maybe we'd start
- 15:07first with thinking about,
- 15:08you know, doctor Justice.
- 15:10Do all cirrhotics get liver cancer,
- 15:14and does all liver cancer
- 15:15come from cirrhosis?
- 15:17So the answer is that not all
- 15:20cirrhotics develop liver cancer,
- 15:22but cirrhosis by itself has a pretty
- 15:25poor prognosis associated with it.
- 15:27So you want to avoid
- 15:29cirrhosis if at all possible.
- 15:31And it is possible to develop
- 15:33liver cancer without cirrhosis.
- 15:35Most classically,
- 15:36if you have hepatitis B viral infection,
- 15:39you can go directly to liver cancer
- 15:42without passing through cirrhosis.
- 15:43But more typically the vast majority
- 15:46of people who develop liver cancer
- 15:48or at least have had a cellular liver
- 15:50cancer have had cirrhosis previously
- 15:54and and doctor Taty.
- 15:56If you have cirrhosis.
- 15:59How is cirrhosis diagnosed
- 16:01so cirrhosis has to be suspected
- 16:04and that's the problem.
- 16:06So your liver is your largest
- 16:07solid organ and it regenerates,
- 16:10which is marvelous.
- 16:11But it doesn't tell you
- 16:13it's sick until it's very,
- 16:15very sick, and that's a problem.
- 16:17So we would love to detect cirrhosis in
- 16:20that early stage where patients don't feel
- 16:24any different and their counts are still OK,
- 16:27and there's still more or less healthy.
- 16:29But more often than not,
- 16:31we detect cirrhosis when people present with.
- 16:34Signs of early liver failure,
- 16:36like jaundice or bleeding or
- 16:38very low platelet counts.
- 16:39This is already very,
- 16:40very advanced and it very much limits what we
- 16:42can offer that patient in terms of treatment.
- 16:44If they do have a liver cancer.
- 16:47All patients with cirrhosis should
- 16:49have screening for liver cancer in the
- 16:52form of an ultrasound every six months.
- 16:54And it's really important to talk to
- 16:57patients about the fact that your body may
- 16:59have problems even if you don't feel it.
- 17:02And I think this is something that
- 17:04people have a hard time wrapping their
- 17:06head around that you could actually be
- 17:09harboring a chronic illness and really
- 17:11not notice any change in how you feel.
- 17:13Which is why people really do need
- 17:15to go to the doctor regularly.
- 17:16It's it's an important thing to have
- 17:18a physical and to have an established
- 17:21rapport with a primary care doc who
- 17:23knows you and has looked at you over
- 17:25time and can see subtle changes when
- 17:27they come up before you even feel them
- 17:30doctor justice talk a
- 17:31little bit more about that.
- 17:32I mean, we talked about some of the
- 17:34things that can lead to cirrhosis,
- 17:36and I think some of us might be thinking.
- 17:39You know, maybe I am a little bit overweight.
- 17:41Maybe I do enjoy a couple of
- 17:44drinks every now and then.
- 17:46If these are factors that
- 17:48potentially can lead to cirrhosis,
- 17:50and cirrhosis is silent except
- 17:52for when it's pretty late and
- 17:55can affect my blood work,
- 17:57how is that diagnosed?
- 17:58I mean, should should I be going to the
- 18:02doctor and getting an ultrasound of my
- 18:04liver to see if if I have cirrhosis?
- 18:07And would cirrhosis even show up
- 18:09on an ultrasound or a CT scan?
- 18:12Well again it depends on at
- 18:14what stage you're talking about.
- 18:15So very early signs of liver injury that
- 18:18could lead to cirrhosis and may maybe
- 18:21an early harbinger of cirrhosis is the
- 18:25ratio of AST aspartate transaminase to
- 18:28alanine transaminase and platelets,
- 18:30which is also called FIB 4,
- 18:32and that's a very routine test of patients.
- 18:36Get it very frequently when
- 18:37they see their doctors.
- 18:38It's part of the the routine panel of
- 18:40tests that are sent for blood work.
- 18:42And if that test is abnormal
- 18:45or not rock solid normal,
- 18:47then it would be very reasonable
- 18:48to have a conversation around.
- 18:50Well, how much do you drink?
- 18:51How long have you been drinking?
- 18:53OK, let's look at your BMI,
- 18:54which is an indication of what your
- 18:56risk for fatty liver disease might be.
- 18:58What's your family history?
- 19:00You know those sorts of questions
- 19:02can be explored,
- 19:02and if enough of them are positive,
- 19:04then yes,
- 19:05an ultrasound would make some sense.
- 19:07I'll let tomorrow talk a little bit
- 19:09more about what would happen when
- 19:10I refer the patient over after.
- 19:12Ordering the ultrasound to the hepatologist,
- 19:15but as the primary care doc.
- 19:17Yes,
- 19:17I would consider getting an ultrasound
- 19:18on someone who I considered to
- 19:19be at high risk.
- 19:20So tomorrow just to to kind of
- 19:22pick up the conversation there.
- 19:25One of the things that you both
- 19:27mentioned was that cirrhosis in and
- 19:29of itself is not is not something
- 19:32that you should aspire to have.
- 19:35I mean, not only does it increase your
- 19:38risk of of Pato cellular carcinoma,
- 19:41but in and of itself.
- 19:43It it can have problems.
- 19:45You mentioned that the liver was
- 19:47an organ that can regenerate.
- 19:49If you do have cirrhosis.
- 19:51If your blood work is abnormal,
- 19:54is there a way that you can reverse that?
- 19:57Can you lose weight?
- 19:59Stop drinking,
- 20:00you know you mentioned drugs
- 20:03that can cure hepatitis C.
- 20:05Now, can that reverse cirrhosis?
- 20:09Or is is it the case that once
- 20:11you have a cirrhotic liver?
- 20:13You have a cirrhotic liver.
- 20:15It depends on how how significant
- 20:17the scarring is of the liver.
- 20:19So very, very early cirrhosis.
- 20:22We're beginning to think more and more
- 20:24can be reversed if you take away the
- 20:27whatever is insulting the liver, right?
- 20:29So if it's viral hepatitis
- 20:30you treat the hepatitis.
- 20:31If it's alcohol, you stop drinking.
- 20:33There are people who can have
- 20:36their fibrosis reverse even very,
- 20:39very early cirrhosis.
- 20:40But once you have a lot of
- 20:42scar laid down and a lot of.
- 20:44Thick trabeculae we call them
- 20:46sort of thick bands of collagen
- 20:48deposition in the liver.
- 20:50The liver really can't repair itself anymore,
- 20:53and so there is.
- 20:54There is a point at which you
- 20:56cannot turn back the clock,
- 20:58and so Amy, from an epidemiologic standpoint,
- 21:01and we we kind of touched on this a
- 21:03little bit before the break, but I just
- 21:05want to unpack it a little bit more.
- 21:08Is the rate at which you develop cirrhosis.
- 21:11If you have had any of these different.
- 21:16Sources of injury, whether it's alcohol,
- 21:18whether it's a hepatite E, whether it's.
- 21:22You know being obese is the rate
- 21:26at which you develop cirrhosis,
- 21:28different in in those different etiologic
- 21:31factors and is the potential to develop
- 21:36hepatocellular carcinoma based on those.
- 21:40Our priority risk factors different
- 21:43in amongst each of those risk factors.
- 21:46So obviously drinking a little
- 21:48alcohol versus drinking a lot of
- 21:50alcohol is going to influence how
- 21:52quickly you might develop cirrhosis.
- 21:53You know if you,
- 21:55if you are drinking extremely heavily
- 21:57cirrhosis can occur much earlier
- 21:59than if you're drinking fairly
- 22:01heavily for a longer period of time.
- 22:03We actually have studied this in HIV,
- 22:06which is a risk factor also
- 22:08for cellular cancer.
- 22:10And we were able to show using the VA
- 22:12data that people who were able to suppress
- 22:15their HIV get their virus undetectable.
- 22:18Had a much slower progression
- 22:20to hepatocellular cancer than
- 22:22the people who were not.
- 22:24So I think that's actually a pretty good
- 22:26template for a lot of these phenomenon.
- 22:28If you can manage these risk factors,
- 22:30try to get them as low as possible.
- 22:32You can modify how rapidly someone
- 22:34is going to develop cirrhosis,
- 22:36and that's a very important
- 22:37modification in terms of their
- 22:39risk for hepatocellular cancer.
- 22:41So do we know just to follow up on that?
- 22:43Amy, do we know, for example,
- 22:46that whether if you have a history
- 22:49of hepatitis C that that's
- 22:51worse in terms of developing?
- 22:54Cirrhosis and subsequent Pato
- 22:56cellular carcinoma. Then,
- 22:58if you were a heavy drinker or you know,
- 23:01being a heavy drinker is a little bit
- 23:04worse than having a BMI of 30 do.
- 23:06Do we have any kind of ideas about the
- 23:09relative risk of each of these risk factors?
- 23:12So hepatitis B is probably the
- 23:15strongest individual risk factor.
- 23:17Thankfully, the prevalence of hepatitis
- 23:18B in the United States is relatively low.
- 23:21When you talk about things like hepatitis C,
- 23:24alcohol, fatty liver HIV,
- 23:28it's not one size fits all.
- 23:30It really depends on how severely you
- 23:32have those problems or conditions,
- 23:34and so it's it's not true to say that
- 23:36one is much worse than the other.
- 23:38It really depends on how
- 23:40out of control they are.
- 23:43Yeah, and so Tim are picking up on
- 23:46what Amy had kind of lead us to.
- 23:49You know if if you're referred to patient
- 23:53who's got a suspicion for cirrhosis,
- 23:56they come to you and they they've
- 23:59had an ultrasound or a CT scan.
- 24:03What's the next step in terms of you know,
- 24:06checking to see whether they
- 24:08have hepatocellular carcinoma?
- 24:10So if they come to me with an ultrasound,
- 24:12usually that ultrasound is sufficient
- 24:15to look for large tumors in the liver
- 24:18tumors over 2 centimeters, for example.
- 24:20But we know that ultrasound in and of itself
- 24:22is a very insensitive screening modality,
- 24:25which is why there are studies underway to
- 24:27look at more sensitive screening modalities.
- 24:30When I'm refer to patient,
- 24:32I actually think very carefully about.
- 24:34What brought them to me?
- 24:36So I think about viral,
- 24:38metabolic and inherited disorders of
- 24:40the liver that can lead to cirrhosis
- 24:43as well as autoimmune disorders.
- 24:45So I think you know,
- 24:47cirrhosis is stigmatized because people
- 24:49associate it entirely with alcohol.
- 24:51And actually there are many different
- 24:54causes of cirrhosis and even alcohol.
- 24:56Some people can drink very heavily
- 24:57and never have liver disease.
- 24:59And some people can drink fairly
- 25:00modestly and get liver disease.
- 25:02So I think you know there
- 25:03really should be no stigma.
- 25:04Associated with cirrhosis.
- 25:05So I I look at all of the sort
- 25:08of pathways that could have
- 25:10gotten them to where they are,
- 25:12and then we usually in the liver
- 25:14in the liver clinic now have non
- 25:17invasive ways of testing the liver
- 25:19stiffness which is a marker of of
- 25:21how fibrotic the liver is and those
- 25:24those ways of measuring are called
- 25:26transient elastography where we
- 25:28measure the stiffness of the liver
- 25:31and can give the patient right there
- 25:33in the clinic an estimation of.
- 25:35How serious this may be,
- 25:37and then from there I try to figure out
- 25:40if there's anything I can help remove
- 25:42that could be stressing the liver,
- 25:45and so there are some treatments for
- 25:47some of these different causes obviously,
- 25:50and then you know they I make sure
- 25:51I go over what we call cirrhosis,
- 25:53health maintenance with the patient,
- 25:56you know what they can do to
- 25:57protect their liver,
- 25:57how often they need to be seen,
- 26:00how to protect themselves
- 26:01against other illnesses,
- 26:02because when the liver has cirrhosis,
- 26:04it sort of loses a lot of its.
- 26:06You know immune surveillance
- 26:08ability for certain pathogens.
- 26:10You know they need to be up to
- 26:11date with their adult vaccines,
- 26:13that sort of thing.
- 26:14And then you know if if the
- 26:15liver disease is very severe.
- 26:17We talk about things like
- 26:19liver transplantation.
- 26:20And certainly if the patient
- 26:21comes to me with liver cancer,
- 26:23as many of my patients come to me with,
- 26:24you know,
- 26:25newly diagnosed liver cancer,
- 26:26that's a whole other conversation around
- 26:29prognosis and treatment and all of that.
- 26:32So, so in our last minute,
- 26:34maybe we can just talk a little bit.
- 26:37About prognosis and treatment of
- 26:40liver cancer tell us more about
- 26:42how that's treated and and what
- 26:44the prognosis really is Amy.
- 26:47Well, this is really tomorrow specialty,
- 26:49but unfortunately because people present
- 26:51so late the prognosis is quite grim.
- 26:54With that I will hand it over tomorrow.
- 26:56So tomorrow are there.
- 26:58Are there new treatments that can
- 27:00make that prognosis less grim?
- 27:02Yes, so in the last five years we've
- 27:04seen a number of new agents come to
- 27:07the market for advanced liver cancer.
- 27:10We'd still really like to detect
- 27:11liver cancer at its earliest stages,
- 27:14where it either can be removed by
- 27:16surgery or treated ablative Lee.
- 27:18And so I think it's important to
- 27:20really raise awareness for people
- 27:22to get screened if they have
- 27:24been diagnosed with cirrhosis.
- 27:26Certainly we're always looking
- 27:27at screening and risk factors,
- 27:29and whether there are other things
- 27:30apart from cirrhosis that would
- 27:32bring a person to screening.
- 27:33Like chronic hepatitis B for example,
- 27:36but the treatments are dependent on
- 27:38stage and the overall survival in liver
- 27:41cancer is about 18% at five years,
- 27:44which is dismal.
- 27:45But it's getting better because
- 27:48we have new agents,
- 27:49things that can really change the
- 27:51course of a patient's life is,
- 27:53you know, surgery to remove the tumor,
- 27:55but also liver transplantation in
- 27:56patients who have liver disease and are
- 27:59perhaps too sick for those surgeries.
- 28:01And so you know,
- 28:02there are a number of different local
- 28:04treatments that can be done for sort
- 28:05of what we call intermediate disease.
- 28:07But the most important thing is for
- 28:09the patients case to be discussed
- 28:12in a multidisciplinary tumor board,
- 28:13because there are many people who
- 28:16manage liver cancer and we all need
- 28:18to come to the table to develop
- 28:20a a clear plan for the patient.
- 28:22And you know, to really think about that,
- 28:24patient their unique circumstances
- 28:26and what's best for them.
- 28:29Doctor Tamar Taddei is associate
- 28:31professor of medicine and digestive
- 28:33diseases and doctor Amy Justices CNH,
- 28:35Long professor of medicine at
- 28:37the Yale School of Medicine.
- 28:39If you have questions,
- 28:41the address is canceranswers@yale.edu
- 28:42and past editions of the program
- 28:45are available in audio and written
- 28:47form at yalecancercenter.org.
- 28:48We hope you'll join us next week to
- 28:51learn more about the fight against
- 28:53cancer here on Connecticut Public
- 28:54radio funding for Yale Cancer
- 28:56Answers is provided by Smilow
- 28:57Cancer Hospital and Astra Zeneca.