Liver Cancer: One or Many Different Cancers?

December 20, 2021

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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
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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.