Connections is a quarterly newsletter for primary care providers covering the latest developments and advances in medicine at OHSU. Learn about the many clinical, education and outreach resources available to you and your patients.
From the OHSU Knight Cancer Institute
Skye C. Mayo, M.D., M.P.H.
Dr. Mayo is board certified in complex general surgical oncology and general surgery. He treats patients with tumors of the liver, bile ducts, pancreas and other gastrointestinal malignancies. Dr. Mayo founded and directs the OHSU Knight Cancer Institute Hepatic Arterial Infusion Program for Advanced Liver Malignancies.
Growing incidence of primary and metastatic cancers
At OHSU, we treat both primary liver cancers (hepatocellular carcinoma and intrahepatic cholangiocarcinoma) and liver metastases of other cancers. Here, we describe the rising incidence of liver malignancies and the promise of hepatic artery infusion (HAI), which can extend survival and improve quality of life.
Primary liver cancers
Primary liver cancer, including hepatocellular carcinoma and intrahepatic cholangiocarcinoma, is the fourth leading cause of cancer death worldwide, according to an October 2015 report in JAMA Oncology. This study also found that incidence in the United States rose more than 100 percent from 1990-2015. Hepatitis C infection is responsible for many of these cases, alcohol misuse remains a factor, and obesity is likely to become the leading cause of primary liver cancer in the next 20 years. As with most gastrointestinal malignancies, symptoms are often non-specific and cancer is not diagnosed until an advanced stage.
Metastatic colorectal cancer
Colorectal cancer frequently metastasizes to the liver, and more patients in their 30s and 40s are newly diagnosed. These cancers may go undetected until they are advanced because of the atypical demographic. By the time these cancers are found, they are more likely to have spread to the liver than cancers found on routine screening in older patients.
Standard therapies for primary liver cancers include hepatectomy or, for hepatocellular carcinoma, transplant; systemic chemotherapy; radiofrequency ablation; and radiation therapy or percutaneous ethanol injection. For patients with intrahepatic cholangiocarcinoma (ICC), some centers are treating liver malignancies with chemotherapy infused via a pump in the hepatic artery. The delivery mechanism is elegant: primary liver cancers and some metastases derive their main blood supply from this artery. HAI may render previously inoperable tumors resectable or deliver maximal post-surgery chemotherapy with minimal systemic effects.
Hepatic artery infusion program at OHSU
The goal of making all liver cancer options available in the Northwest led the OHSU Knight Cancer Institute to launch a hepatic artery infusion program in early 2016. Today, we are one of just seven U.S. centers offering HAI and the only West Coast center offering comprehensive care from a full multidisciplinary team, including social work support to ensure patient quality of life.
Delivering chemotherapy directly to the liver takes advantage of the approximately 95 percent first-pass metabolism of the drug in this organ. Because the chemotherapeutic agent is delivered directly to – and metabolized almost completely within – the liver, systemic effects are greatly reduced, allowing us to give patients much higher doses of chemotherapy than they could tolerate by other methods.
Benefits of HAI for metastatic colorectal cancer
For patients with colorectal cancer metastatic to the liver, the median overall survival is 30 months. Timely surgical intervention and the addition of chemotherapy via HAI can extend this to 40 or 50 months.
At the OHSU Knight Cancer Institute, 18 patients are now receiving HAI for advanced liver metastases of colorectal cancer. All are receiving a maximal chemotherapy dose via HAI and monthly systemic chemotherapy.
Surgery – At specialized centers, an option for more patients
HAI represents an exciting development in extending survival for patients with intrahepatic cholangiocarcinoma. However, surgery remains a mainstay of treatment. Unfortunately, at diagnosis, nearly 70 percent of patients may have inoperable tumors – but providers differ in defining which tumors are operable.
Many tumors that cannot be safely removed in a community or regional setting are resectable at high-volume centers where such operations are more common. Of the patients undergoing surgery for liver cancer at OHSU Knight Cancer Institute, 30 percent were referred with "unresectable" tumors. Evaluation at a high-volume center with surgical oncologists trained in complex liver surgery can give your patient a key survival advantage and help them understand the full spectrum of options, including the role of resection.
If your patient has liver cancer
We recommend specialist evaluation at a high-volume cancer center for any patient with primary or metastatic liver cancer. Our team includes surgical and medical oncologists, gastrointestinal surgeons, radiologists, pathologists and many other specialists. Regrettably, we do see patients who do not fully understand their options and may have received treatments that we would not consider as standard of care. With initial comprehensive evaluation, these patients will have the opportunity for potentially more effective treatment options and improved quality of life.
From the latest technology to the newest drugs that are increasing survival, OHSU Knight Cancer Institute, Oregon’s only NCI‑designated Cancer Center, offers a full range of options for cancer patients. We are always available to answer questions.
Please call the OHSU Physician Advice and Referral Service at 503‑494‑4567. To refer a patient, please fax to 503‑346‑6854.