Liver cancer has always been a difficult diagnosis. And today, the number of people who develop liver cancer is increasing, making primary liver (and bile duct) cancer the fastest-rising cause of cancer-related death in the United States.
Experts attribute this to the high prevalence of fatty liver disease, a condition associated with insulin resistance, obesity, high blood pressure and high cholesterol levels.
The good news is we have newer treatments that are making a significant impact in helping patients with liver and bile duct cancers live longer and with a better quality of life. These new approaches include the latest immunotherapy drugs, a focus on making complicated liver surgery safer for more patients, and using embolization procedures in new ways and new combinations.
Immunotherapy for Liver Cancer
Immunotherapies stimulate the body’s immune system to recognize the cancer as an invader and attack it. Two of these latest drugs—nivolumab (Opdivo®) and pembrolizumab (Keytruda®)—have had success with other difficult cancers such as melanoma and non-small cell lung cancer. We are rapidly learning that these can be effective for primary liver cancer as well.
Nivolumab recently received accelerated FDA approval for patients with advanced liver cancer. (Nivolumab was the drug that former President Jimmy Carter took after his melanoma was found to have metastasized to both his brain and liver. Months later he announced he was cancer-free and needed no further treatment.) Pembrolizumab, initially approved for melanoma, recently received approval for any inoperable or metastatic solid tumor with certain genetic characteristics, regardless of disease site—a first for the FDA.
These represent a new class of drugs to use against liver cancer. Currently the only standard drug is sorafenib, a chemotherapy drug that inhibits certain enzymes in the cancer cells, causing them to break down and die off, at least for a little while. Unfortunately, it only extends survival by about three months and produces some harsh side effects. Clearly, we need better therapies.
Currently, we are using these new immunotherapy drugs in patients with metastatic liver cancer and in those who have a large burden of disease and cannot undergo surgery or a liver transplant. We hope to study these drugs in more trials, and in combination with other treatments such as radiation.
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Surgery for Patients with Cirrhosis
Most primary liver cancer occurs in patients with cirrhosis of the liver, a progressive liver disease in which scar tissue replaces healthy liver cells. Patients with cirrhosis typically are not able to undergo surgical treatment, because after tumors are removed, the remaining liver is still diseased, and the risk for liver failure is much higher. Safely operating on patients with cirrhosis is one of the procedures I brought to Roswell Park. We are able to take certain measures before and after surgery to help reduce the risk for liver failure. These involve a combination of approaches, including food management, medications and strict patient selection criteria. As a result, we’re able to extend the benefit of surgery to these patients, and do it safely.
Radioembolization is a procedure that uses tiny glass or resin microspheres (beads) that contain radioactive material to combat liver cancer. When the spheres are injected into the artery leading to the tumor, they deliver radiation directly to the tumor itself. While this procedure does not usually cure the cancer, it does have good success in prolonging survival with very good quality of life. Roswell Park is a high-volume center for this procedure, and among the top 10 in the nation. We do about 80 transarterial radioembolization procedures a year. Survival with this procedure for patients with early- to mid-stage cancer is approaching three years. The procedure is also very well-tolerated and most patients go home the same day. Combining radioembolization with immunotherapy makes one of the safest treatment approaches for cancer.
These advances, even in just the past few years, have markedly prolonged survival and improved the quality of life for patients with primary liver and bile duct cancers.