057 Improvement of patients' survival with hepatocellular carcinoma as a result of a multidisciplinary management

Context Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide. Eighty to 90% of HCC develops in patients with chronic liver injury and/or cirrhosis, and HCC is the major cause of death of patients with cirrhosis. In France, the incidence is estimated at 6000 new cases/year. Commonly, diagnosis of HCC is made in advanced stage (50–60%). Potentially curative treatments for HCC include liver transplantation, resection and local ablative therapy. However, these options are only applicable to less than 30% of the patients due to late diagnosis (30% detected at early stage) and non integrated clinical pathways. Overall survival at 5 years is poor, less than 30% in advanced stage. Multidisciplinary committees assessing the adequate treatment play a major role in the management of patients with HCC. Aim To evaluate in a referral centre the clinical and prognosis impact of a multidisciplinary committee dedicated to primary liver tumours and management of therapeutic program for patients with HCC. Program A multidisciplinary committee exclusively dedicated to liver tumours was set up for the area of North Paris in Beaujon Hospital. This weekly conference, involves clinicians (hepatologist, liver surgeon, oncologist and interventional radiologist), one clinical trial technician, one coordinating nurse and one medical secretary. Patient9s data and treatment decisions were prospectively recorded on a database allowing a better traceability and follow-up of decisions applications. Results From January 2006 to December 2008, 380 patients with HCC never treated were managed by the committee. The diagnosis was made in early stage (small tumour, normal liver function) in 61% of cases. A curative treatment was performed in 40% of patients (transplantation: 20%, resection: 9%, local ablation with radiofrequency: 11%). Chemoembolization, considered as border between curative and palliative treatment was proposed to 28% of the patients. Chemo- and targeted therapies included in clinical trials were proposed to 10% of patients. A curative treatment was performed in 57% of patients with early stage disease. Overall survival of the population was 70% at 1 year and 50% at 3 years. Survival rate was improved in early stage patients (1 and 3 years survival: 89% and 67% respectively). Discussion Management of patients with HCC by a multidisciplinary committee, according validated guidelines and clinical trials programs, leads to a diagnosis of the disease at early stage in most cases (61% in our series vs 40% in the literature). A curative treatment was proposed to 40% of patients (vs less than 30% in literature), and 57% of those diagnosed at early stage. This approach resulted in a clear improvement of overall patients9 survival. This experience of a referral centre should be validated in a more extensive program at national level and extended to other centres able to offer the patients all the possibilities of the available therapeutic arsenal. Conclusion Improvement of patient-centred clinical pathway increased the survival of HCC due to the advantages of combining early diagnosis (and a screening plan of patients at high risk) and a multidisciplinary management, giving access and controlling all treatment options. Our study demonstrates the possible improvement of patients9 survival with multidisciplinary committees for HC. Contexte Le carcinome hepatocellulaire (CHC) est le 5eme cancer dans le monde. Il se developpe sur une maladie chronique du foie et/ou une cirrhose dans 80 a 90% des cas, et le CHC est la principale cause de mortalite chez les patients atteints de cirrhose. En France l9incidence est estimee a 6000 cas par an. Le diagnostic est generalement fait a un stade avance de la maladie (560 a 60% des cas). Les traitements curatifs du CHC sont la transplantation hepatique, la resection et les traitements par ablation locale. Pourtant ces traitements ne sont possibles que dans moins de 30% des cas du fait d9un diagnostic tardif (30% des cas sont detectes a un stade precoce,) et de l9absence de prise en charge integree. La survie globale est mauvaise, inferieure a 30% a 5 ans. Les reunions de concertation pluridisciplinaires (RCP) qui proposent pour chaque patient le traitement adapte jouent un role majeur dans la prise en charge des patients avec CHC. But du travail Le but a ete d9evaluer, dans un centre de reference, les impacts clinique et pronostic d9une RCP comportant un programme de prise en charge de ces patients. Programme Une reunion multidisciplinaire exclusivement dediee aux tumeurs du foie a ete mise en œuvre pour la region Nord de Paris a l9hopital Beaujon. Cette reunion hebdomadaire implique des cliniciens (hepatologues, chirurgien hepatique, cancerologue, radiologue interventionnel) une technicienne d9etude clinique, une infirmiere de coordination et une secretaire medicale. Les donnees concernant les patients et les decisions therapeutiques sont colligees prospectivement sur une base de donnees permettant une bonne tracabilite, le suivi et le resultat des decisions therapeutiques. Resultats De janvier 2006 a decembre 2008, le comite a analyse les dossiers de 380 patients a la phase initiale de la prise en charge du CHC. Ce diagnostic a ete porte a un stade precoce (petite tumeur, bonne fonction hepatique) dans 61% des cas. Un traitement curatif a ete realise dans 40% de cas (transplantation 20%, resection 9%, traitement local par radiofrequence 11%). Une chimioembolisation, consideree comme intermediaire entre les traitements curatifs et palliatifs a ete proposee a 28% des patients. Les chimiotherapies et les therapeutiques ciblees ont ete proposees a 10% des patients dans le cadre de protocoles therapeutiques. Un traitement curatif a ete realise pour 57% des patients pris en charge a un stade precoce. La survie de l9ensemble de la population a ete de 70% a un an et de 50% a 3 ans. Pour les patients vus a un stade precoce elle etait a 1 an et 3 ans de 89 et 67%). Discussion La prise en charge du CHC par un groupe multidisciplinaire, selon des recommandations validees et des programmes de recherche clinique permet le diagnostic de la maladie a un stade precoce (61% dans notre serie vs 40% dans la litterature.) Un traitement curatif a pu etre propose a 40% des patients (vs 30% dans la litterature), et dans 57% en cas de diagnostic precoce. Cette pratique a permis une amelioration de la survie globale des patients. Cette experience d9un centre de reference merite validation a plus grande echelle et d9etre etendue a d9autres centres disposant de la panoplie de l‘arsenal th’rapeutique actuel. Conclusion L9amelioration du parcours de soin centre sur le malade a permis une augmentation de la survie, grâce aux avantages combines d9un diagnostic precoce (et d9un programme de detection des patients a haut risque) et d9une prise en charge pluridisciplinaire, donnant acces et maitrisant toutes les options therapeutiques. Notre etude demontre le role potentiel des RCP dans l9amelioration de la survie de ces patients.