Delivering Guideline-Based Hepatocellular Carcinoma Care with an Interactive Tool

Dr.  Takemoto:
This is Project Oncology on ReachMD, and I’m Dr. Jody Takemoto. Here with me today to discuss an interactive tool that can help clinicians implement the latest guidelines when diagnosing and treating patients with hepatocellular carcinoma is returning guest Dr. Robert Wong. Not only is he a Clinical Associate Professor of Medicine in the Division of Gastroenterology and Hepatology at Stanford University School of Medicine, but he’s also a physician at the Veteran Affairs Palo Alto Healthcare System. Dr. Wong, welcome back to the program.

Dr. Wong:
Great.  Thank you for having me.

Dr.  Takemoto:
So if we start with some background, Dr. Wong, what guidelines are currently out there regarding the treatment of hepatocellular carcinoma?

Dr. Wong:
In the US, from a GI/hepatology perspective, the main guideline that we rely on are the AASLD, so the American Association for the Study of Liver Disease.  The oncology societies also have their guidelines, and different world regions have their specific guidelines. But again, in the US, we use AASLD, and it’s a very comprehensive, well-written guidance document that really covers everything from epidemiology, who to screen, how to screen, how to interpret, and the complexities of staging and management, so there’s a lot of information there, which is good and also not so good. I mean the positive is it’s a one-stop shop, and really, you can find everything you need in terms of how to approach and manage HCC, but for many of the listeners here who are active, practicing, busy clinicians, you don’t have time to read through a 50, 70-page document, especially when you’re trying to answer quick clinical questions during a clinic visit with a patient in front of you.

Dr.  Takemoto:

And you mentioned some of these challenges associated with the guidelines, especially when it comes to implementing them in practice. Can you talk a little bit more about that?

Dr. Wong:
So just starting from screening, because I think identifying who needs to be screened and implementing screening is one aspect of HCC care that is very generalizable and broad.  Management of HCC—the intricacies and complexities of treatment, deciding what treatment—that probably is a relatively niche topic where GI, hepatology, surgeons, and oncologists are really gathered together to make multidisciplinary discussions, but I think more important to the broader audience, including primary care providers and general practitioners, is the first important step: identifying who’s at risk for HCC and then implementing screening and how to interpret it.  I think if we can get that aspect of HCC care done efficiently and uniformly across populations, I think that would be a huge improvement. 

Dr.  Takemoto:
Now as I understand it, you’ve actually done some work to help address these challenges. Can you tell us about the project and its overall goal?

Dr. Wong:
We as a group, part of the Chronic Liver Disease Foundation, we have a committee focused on HCC, and this committee focuses on all aspects of HCC, and the goal is trying to improve patient outcomes. How can we make it easier for providers to implement and provide guideline-concordant care? And how can we make these resources and these tools easily accessible for providers? 

So one of the projects we developed a year or two ago now is developing a web-based, easy-to-use algorithm. It basically incorporates the important aspects of different guidelines into a tool where it’s an easy, click-based web decision support tool.  If you search CLDF HCC, that probably will take you to the algorithm. And there’s a lot of tools available, as you see when you sign up.  It allows you to go through the process, identify what are risk factors for HCC, how to choose the right tests, how to interpret the tests; and then, more importantly, once you get the result, what are the next steps because oftentimes that’s one of the gaps, is you do a test, you get a result, and then you’re not sure what’s the next steps.  What do I do with the result? So we really try to create a decision support tool that spans all the way from early identification of who needs to be screened, how to choose a screening test, how to interpret the quality of the test, the results, and then leads you down the cascade on staging and linking these patients to appropriate treatments. So it’s a very easy tool that you can apply to individual patients.

Dr.  Takemoto:
For those just tuning in, you’re listening to Project Oncology on ReachMD. I’m Dr. Jody Takemoto, and I’m speaking with returning guest, Dr. Robert Wong, about a web-based algorithm that can help clinicians diagnose and treat patients with HCC. So if we continue examining the tool you helped create, Dr. Wong, how does it work?

Dr. Wong:
Yeah. So it starts off very simple. And the other key aspect to remember is the way we’ve designed it is you can pick and choose, so you don’t have to go through it from step one to step 10.  For example, if you have a specific question like “I have a patient with HCC, I want to know what treatment,” you can skip and go to the treatment step.  But if you go along from beginning to end, the first step starts at identifying who needs to be screened.  You plug in your patient information, and the tool will guide you through: “Does this person need HCC screening based on the guidelines? Yes or no?” If yes, the next stage is “This is what the guidelines recommend: ultrasound and alpha fetoprotein.” “How often?” “Every six months.” 

The next step is, once you get those results, how do you interpret it?  So it’s very user-friendly and guides you on the interpretation of the results.  And based on those results, what else do you need to do?  Do you need to do a multiphase CT scan or an MRI scan?  And how do you interpret that?  And ultimately, if you go down step by step, it guides the provider from screening all the way to treatments and then generates a summary of all this information that you can use to discuss with your patient and discuss with the providers that you’re referring to link them to the appropriate treatment for their specific stage of tumor.

Our most recent update of this tool is we added two cool new features that further helps link treatment.  So one, once you have an HCC, there’s a lot of therapies available. Sometimes patients with advanced-stage disease may not be eligible because of the disease severity, and those are patients we have to look to clinical trials.  There’s not a good easy source to find clinical trials for HCC, so one thing we tried to improve with this tool is there is now a resource where it links to all the HCC clinical trials and helps providers identify what are the trials that are available for patients and provides that information, so that’s one recent update.

The second update is once you go down this pathway and you stage your patient and we identify what treatment they need, then the next question is, well, how do I get access to those treatments because you may be at a center or a setting where you don’t have some of these therapies.  So now that we identified what treatment you have, how do you find those? So the second innovation is we created a link and a list of regional providers so you can link it based on your ZIP code or your geography, and it will help identify the nearest referral centers in your region, what treatments they have, transplants, and insurance. So it helps simplify and creates a one-stop shop for providers to really provide comprehensive HCC care for their patients.

Dr.  Takemoto:
As a quick follow-up to that, who was this tool designed for?

Dr. Wong:
Great question.  So the tool was designed initially with the primary care and first-line providers in mind because we saw in our studies that there’s a big gap there.  People are not getting screened.  Some studies show that less than 30 percent of cirrhosis patients are getting appropriate HCC screening and surveillance.  So the initial goal was to design a tool that helps first-line, primary care, and general practitioners and guide them to accurately identify who needs screening, what screening to order, and then how to do it regularly because one time is not enough.  You have to continue doing it every six months.  So that was the initial goal, but as we expanded and evolved it, we really incorporated tools from beginning to end, as I mentioned.  So this is not just applicable to primary care providers, but it’s applicable to people seeing these patients with HCC—GI providers, hepatologists, oncologists—because it helps guide them to the specific guideline-recommended therapy based on their stage of disease.

Dr.  Takemoto:
Before we close, Dr. Wong, are there any other thoughts or insights you’d like to share about this tool or HCC?

Dr. Wong:
Yeah. So this is just the first step. And as I mentioned, this is a constantly evolving process, and we’re constantly trying to update and develop better ways to disseminate this because it’s a cool tool, it’s useful, and I think it will improve care; and for those that are listening, share this with your colleagues, your trainees, your residents, your fellows, and your students because the more people use it and the more they talk about it, the better we can in terms of implementing guideline care for patients with cirrhosis and HCC.

Dr.  Takemoto:
Certainly. Well, with those final thoughts in mind, I’d like to thank my guest, Dr. Robert Wong, not only for joining me today, but also for his great work to help make the diagnosis and treatment of hepatocellular carcinoma a bit easier in clinical practice. Dr. Wong, it was great having you on the program again.

Dr. Wong:
Absolute pleasure. Thank you so much.

Dr.  Takemoto:
For ReachMD, I’m Dr. Jody Takemoto. To access this and other episodes in our series, visit Project Oncology on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening.