Abstract
BackgroundTransarterial chemoembolization (TACE) is one of the most frequently applied treatments for hepatocellular carcinoma (HCC) worldwide. In this study, we aimed at evaluating whether and how TACE application and repetition, as well as the related outcome, have changed over the last three decades in Italy.MethodsData of 7,184 patients with HCC were retrieved from the Italian Liver Cancer (ITA.LI.CA) database. Patients were divided according to the period of diagnosis in six cohorts: P1 (1988–1993), P2 (1994–1998), P3 (1999–2004), P4 (2005–2009), P5 (2010–2014), and P6 (2015–2019). All the analyses were repeated in the overall patient population and in Barcelona Clinic Liver Cancer (BCLC) B patients, who are the subgroup of HCC patients originally supposed to receive TACE according to guidelines. TACE was defined as either the first or the main (more effective) treatment.ResultsThe proportion of patients receiving TACE as first or main therapy declined over time, and less than 50% of BCLC B patients were treated with chemoembolization from P3 onward. Conversely, TACE was widely used even outside the intermediate stage. Survival of TACE-treated patients progressively increased from P1 to P6. Although TACE was performed only once in the majority of patients, there was an increasing proportion of those receiving 2 or ≥3 treatments sessions over time. The overall survival (OS) of patients undergoing repeated treatments was significantly higher compared to those managed with a single TACE (median OS 40.0 vs. 65.0 vs. 71.8 months in 1, 2, and ≥3 TACE groups, respectively; p < 0.0001). However, after a first-line TACE, the adoption of curative therapies provided longer survival than repeating TACE (83.0 vs. 42.0 months; p < 0.0001), which in turn was associated with better outcomes compared to systemic therapies or best supportive care (BSC).ConclusionsDespite a decline in the percentage of treated patients over time, TACE has still an important role in the management of HCC patients. The survival of TACE-treated patients gradually improved over time, probably due to a better patient selection. Iterative TACE is effective, but an upward shift to curative therapies provides better outcomes while transition to systemic therapies and BSC leads to a worse prognosis.
Highlights
Liver cancer ranked as the sixth most common cancer and the third leading cause of cancer-related death worldwide in 2020, with approximately 906,000 incident cases and about 830,000 deaths [1]
Considering the availability in the Italian Liver Cancer (ITA.LI.CA) database of a large series of patients managed along a period of 30 years, our study aimed to evaluate whether in real-life clinical practice the use of transarterial chemoembolization (TACE) and its outcome have changed over time, as well as the oncologic and clinical characteristics that guide the choice of this treatment
We evaluated the first therapeutic choice and the main treatment according to the following hierarchy: liver transplantation (LT), liver resection (LR), ABL, TACE, trans-arterial embolization (TAE) and selective internal radiation therapy (SIRT), sorafenib or other tyrosine kinase inhibitors (SOR), and best supportive care (BSC) [29]
Summary
Liver cancer ranked as the sixth most common cancer and the third leading cause of cancer-related death worldwide in 2020, with approximately 906,000 incident cases and about 830,000 deaths [1]. The adoption of an aggressive schedule might lead to the development of liver failure in a high proportion of patients, most of whom are affected by cirrhosis [15] This approach has been substantially abandoned, following the recommendation of the guidelines to retreat with TACE only when residual viable tumor is detected at imaging, and to stop performing TACE when 2 subsequent attempts fail to obtain a significant oncologic response [9]. The benefit of retreating with TACE is uncertain, because survival prediction in these patients is a difficult issue that only complicated recalibration [16] or time-varying models (i.e., mHAP-III) [17] seem to accurately solve This uncertainty has been increased by the growing availability of several lines of effective systemic therapy based on tyrosine kinase inhibitors, ramucirumab and immunotherapy [18,19,20,21,22,23]. We aimed at evaluating whether and how TACE application and repetition, as well as the related outcome, have changed over the last three decades in Italy.
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