Intro: Welcome to UAB MedCast, a continuing education podcast for medical professionals, providing knowledge that is moving medicine forward. Here's Melanie Cole.

Melanie Cole, MS (Host): Welcome to UAB MedCast. I'm Melanie Cole. And joining me today is Dr. Robert Cannon. He's the Surgical Director of the Liver Transplant Program at UAB Medicine, and he's here to highlight the Multidisciplinary Hepatocellular Carcinoma Clinic. Dr. Cannon, thank you so much for joining us again today. I'd like you to start by telling us a little bit about the prevalence and a little info on the trends in hepatocellular carcinoma and other hepatic malignancies. Let us know what you're seeing in the trends.

Dr Robert Cannon: Thank you for having me. So, hepatocellular carcinoma is the most common primary liver cancer we see. By primary, I mean starting in the liver. Most people who have a cancer in the liver actually spreads from somewhere else, like the colon. But hepatocellular carcinoma, or HCC, actually starts in the liver.

Worldwide, HCC is the fifth most common cancer and the third most common cause of cancer death. So, it's actually quite common worldwide, and the prevalence has been increasing in the United States as well, particularly with the rise of metabolic-associated liver disease, which is formerly known as fatty liver disease.

Melanie Cole, MS: Well, tell us a little bit about the clinic. How did it come about? Give us some of the overview of the goals and the objectives of a multidisciplinary hepatocellular carcinoma clinic.

Dr Robert Cannon: Certainly. So, we've always had a long-standing liver tumor clinic here at UAB where we would evaluate all patients who had liver tumors. For a patient who was diagnosed with liver malignancy, then this would sort of become a very linear process. We would see the patient in liver tumor clinic. We would then review them in our tumor board every Friday. So, that's a multidisciplinary conference that would be attended by surgeons, diagnostic radiologists, and interventional radiologists, medical oncologists, and radiation oncologists. Each of these specialties has a role to play in the treatment of HCC. It's a very multidisciplinary disease.

So then once the patient was reviewed in the tumor board, we would then have to make separate appointments for the patient to see any of the other specialties who were going to be involved in their care. So. This would become sort of a very long, drawn out process for the patient and would often require multiple visits back and forth to UAB. This may not be such a big deal for a patient who's in town, but many of our patients come from far away. And also frequently, many of our patients are working and this requires multiple days off of work. And this could just be very inconvenient for patients. it can make access to care difficult and it also delayed care.

And so, recently, one of our medical oncologists actually had an idea of why don't we just go ahead and all see the patients together. So, we created this multidisciplinary HCC clinic. So now within the framework of liver tumor clinic, every Wednesday afternoon, this clinic is now attended, in addition to the surgeons and nurse practitioners who have always been there in the liver tumor clinic. Now, a representative from each specialty that treats HCC will also come. So, that will include, again, a medical oncologist, and this will include systemic or chemotherapy, immunotherapy, and potentially access to clinical trials. We'll have interventional radiologists who can perform interventional arterial procedures such as TACE or Y90, as well as radiation oncologists who perform stereotactic body radiation. So, this is very convenient for the patients. They show up. They typically will already have a diagnosis. But if they don't, they can leave with a diagnosis and a plan and they've already got all their initial consultations completed.

Melanie Cole, MS: Such a comprehensive approach and I really feel it's the wave of the future. For so many of these conditions, Dr. Cannon, tell us the parameters that would indicate a patient would be a candidate for the program.

Dr Robert Cannon: So, we've called this the multidisciplinary HCC clinic, although really we're open to all hepatic malignancies. So essentially, any patient with a diagnosis of a hepatic malignancy or one that is strongly suspected would be a patient that we would place into one of our multidisciplinary slots.

Melanie Cole, MS: Tell us about any exciting innovations that you've implemented in the clinic to improve patient outcomes. You mentioned obviously the multidisciplinary approach and the tumor board and meeting with the patient all as a group so that they get it all done in one place and hopefully in one day as some have traveled quite a distance. But what about some of the exciting advancements in hepatocellular carcinoma?

Dr Robert Cannon: So in hepatocellular carcinoma, the biggest probably breakthrough in the last several years is the introduction of effective systemic therapy. So previously, we really did not have any good options for advanced disease or any what we call adjuvant options or neoadjuvant options, meaning kind of systemic therapy that's given in addition to a more invasive therapy.

And so now, there are several regimens that have been FDA approved and have been shown at randomized control trials to significantly improve patient survival. We are now also the site for several trials involving novel uses of these immunotherapy and other systemic therapy agents. So really, we hope for this multidisciplinary clinic to be a gateway for clinical trials for patients so they can get cutting-edge care.

Melanie Cole, MS: Are you actively enrolling patients in clinical trials as of now?

Dr Robert Cannon: We are. We're actively enrolling in several clinical trials at this point, including patients who are potentially surgical candidates as well as patients with more advanced disease who aren't candidates for surgery.

Melanie Cole, MS: Doctor, if you were to look to the future of these hepatocellular carcinomas and malignancies, what is your vision for the program, the clinic? What would you like to see happen? What are you hoping to see happen in the future for these malignancies?

Dr Robert Cannon: So, what I'd hope to see happen is continue to make just real advances in patient survival and ultimately have a curative option available for all patients. For those who present with non-curative disease, we'd like to be able to significantly extend life and most importantly, quality of life. Get them more time to spend time with their loved ones and do the things they enjoy.

Melanie Cole, MS: In what ways, as we're speaking about the clinic and as we wrap up, do you involve the patients in that shared decision-making and their families? Because obviously, this can be quite scary. So, speak a little bit as we wrap up, kind of reinforce that multidisciplinary approach and how the families are involved in this.

Dr Robert Cannon: So oftentimes, there will be sort of several different treatment options that are available to the patient and there's really not strong evidence one way or the other that one is superior. For example, there may be a clinical trial open to the patient, but also there may be a standard of care option that we would have done before this clinical trial. And those are often things that when we're having our multidisciplinary discussion before we meet the patient, we say, "Okay, here's option A and here's option B. We think these are both good." We'll discuss both with the patient and their families who are in the room with them, and they will ultimately make the decision, having been able to hear all sides from all providers. So, it's not just getting a biased approach from one group versus the other.

Melanie Cole, MS: Do you have any final thoughts you'd like to leave other providers with about the multidisciplinary clinic for hepatocellular carcinoma at UAB Medicine?

Dr Robert Cannon: Essentially we're happy to see all patients. We want to be a patient friendly environment and really just want to increase access to patients. Our goal is to make it easy for patients to get here to us and to get into our system and provide them the best treatment possible in a personalized manner.

Melanie Cole, MS: Thank you so much, Dr. Cannon. You're always a great guest. And for more information, please visit our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. I'm Melanie Cole.