BOSTON—Elderly patients diagnosed with hepatocellular cancer should be treated aggressively because their response appears to depend upon their condition and not their age, researchers suggested here at the American Association for the Study of Liver Diseases Annual Meeting.
More important than chronological age was the severity of liver cirrhosis at the time of diagnosis and the tumor characteristics of the hepatocellular carcinoma, reported Elena Dionigi, MD, a resident in the Gastroenterology Unit at Azienda Ospedaliera in Melegnano, Italy.
In the retrospective study, she and her colleagues stratified patients into younger and older—defined here as younger than age 70, and age 70 and older. The median survival for both groups was about 35 months (34.89 vs. 34.35 months, respectively, a nonsignificant difference.
In analyzing the cumulative survival, the researchers observed that 60 percent of the younger patients survived one year following treatment compared with 42 percent of the older patients; at three years, 59 percent of the younger patients were alive, compared with 34 percent of the older group of patients.
“This study demonstrates that cumulative survival was mostly dependent on the underlining severity of cirrhosis and hepatocellular carcinoma profile at presentation, rather than on age,” Dionigi said. “Noteworthy, treatment per se emerged as the most important independent predictor of better outcome. These data should therefore discourage a nihilistic attitude of hepatologists towards the under-treatment of difficult-to-manage patients.”
Asked his opinion for this article, another liver cancer expert not involved with the study but who was looking at the poster at the same time as this reporter, Ashutosh Barve, MBBS, PhD, Head of the Liver Clinic at the Louisville VA Medical Center and Assistant Professor of Gastroenterology/Hepatology Medicine at the University of Louisville, said that in his practice he would definitely go ahead and treat these patients. “If a patient has good performance status and has small, isolated tumors, I would definitely treat them. I think this presentation indicates that these patients do quite well.”
Mean Age Progressively Increasing
The researchers reported in their poster presentation that the mean age in cirrhotic patients with hepatocellular carcinoma is progressively increasing, and with an aging population more liver cancer is being diagnosed. “Information on hepatocellular carcinoma management and outcome in the elderly are still limited and are heterogeneous,” the team said.
“International guideline recommendations on hepatocellular carcinoma derive from cohorts including younger patients, and thus are inadequate to depict the real magnitude of the problem.”
Hence, the investigators sought information on how age might impact hepatocellular carcinoma characteristics at presentation; the type of therapeutic approach taken; and the efficacy of that treatment, as well as overall outcomes, in a large series of newly diagnosed patients recruited in clinical practice.
Included in the multicenter study were cirrhotic patients with newly diagnosed hepatocellular carcinoma, who were consecutively enrolled in 31 Italian centers, starting in September 2008, as part of a national ongoing project of AIGO, the Italian Association of Hospital Gastroenterologists. The study did not include centers for transplantation or centers for specialized hepato-biliary surgery.
Also excluded were cases of HIV co-infection and patients who did not have evidence of liver cirrhosis. There were no fixed protocols for treatment, giving each institution free rein in determining therapy.
At the time of analysis in September 2013, the researchers identified 922 patients with data on therapy and survival, ranging in age from 26 to 92, and the group was divided by the 70-year milestone.
In general, the researchers said, “older patients displayed a well-compensated cirrhosis and a tumor profile that does not differ significantly from the younger cohort, and although the rate of treatment was similar in younger and older patients, the latter less frequently underwent surgical resection.”
The median age of the younger cohort of 422 patients was 61, versus 76 for the older patients. About 83 percent of the younger group were men vs. 64 percent of the older group.
The younger group was more likely to have Hepatitis B virus as the etiology of hepatocellular carcinoma (17.5%) compared with the older patients (7.4%), which was also significant. Among the elderly group, 61 percent had infection with Hepatitis C virus as the cause of the cancer, compared with 47.6 percent of the younger patients. Alcohol as a cause of cirrhosis and cancer was observed in 26 and 20 percent of the patients, respectively.
As would be expected, the older population had more moderate to severe co-morbidities (33%) compared with the younger patients (23%), and 62 percent of the younger patients fell into Child-Pugh Class I chronic liver disease compared with 69 percent of the older patients.
There was no difference in the rate of treatment according to age, with about 77 percent of patients treated in both groups. Surgical resection was performed in 12 percent of the younger patients and seven percent of the older patients, but other forms of treatment were not statistically different between the groups. The major other forms of treatment included ablation procedures, transcatheter arterial chemoembolization, and treatment with sorafenib. About 22 percent of patients in each group did not have any treatment.
In commenting on the study, Barve said, “All of the patients were receiving treatments that are available in most clinics in the United States. The tolerance for these treatments in this study seems pretty good, too. The point the authors are trying to make is that survival between the older and younger patients in this study was not different. I don't see any reason not to treat these older patients. I am glad to see that treating the older patients does make a difference in outcome.”
In the study, patients who accepted any form of treatment achieved a median survival of about 40 months; while patients who were not treated had a median survival of about 12 months. Among patients who were treated with curative intent, 52 percent were in the younger group. At 48 months, 62 percent of these younger patients were alive compared with 44 percent of the older patients.
Barve suggested that hepatologists, at least in the United States, might be more aggressive in treating older persons than oncologists. He said he agreed with the Italian researchers that “we should treat these patients on the basis of their condition, not their age.”