Clinical practice guidelines and real-life practice in hepatocellular carcinoma: A Taiwan perspective

Abstract

Hepatocellular carcinoma (HCC) is the fourth most common cancer and the second leading cause of cancer-related death in Taiwan. The Taiwan Liver Cancer Association and the Gastroenterological Society of Taiwan developed and updated the guidelines for HCC management in 2020. In clinical practice, we follow these guidelines and the reimbursement policy of the government. Abdominal ultrasonography, alpha-fetoprotein, and protein induced by vitamin K absence or antagonist-II (PIVKA-II) tests are performed for HCC surveillance every 6 months, which may be shortened to 3 months for highrisk patients. Dynamic computed tomography, magnetic resonance imaging, and contrast-enhanced ultrasound can be recommended for HCC surveillance in patients with extremely high-risk or poor ultrasonographic visualization results. HCC is usually diagnosed through dynamic imaging, and pathological diagnosis is recommended. The staging of HCC is based on a modified version of the Barcelona Clinic Liver Cancer (BCLC) system, and the HCC management guidelines in Taiwan actively promote curative treatments, including surgery and locoregional therapy for BCLC-B-C patients. Su et al. 4 Transarterial chemoembolization (TACE), drug-eluting bead TACE, radioembolization, and hepatic artery infusion chemotherapy may be administered for patients with BCLC-B-C HCC. Sorafenib and lenvatinib are reimbursed as systemic therapies, and regorafenib and ramucirumab can be reimbursed in cases of sorafenib failure. First-line atezolizumab with bevacizumab are not yet reimbursed but may be administered in clinical practice. Chemotherapy and external beam radiation therapy may be used in specific patients. Early switching to systemic therapy in TACE-refractory patients is a recent paradigm shift in HCC management.

Overview of Asian clinical practice guidelines for the management of hepatocellular carcinoma: An Asian perspective comparison

“…10,15,26 Real-life practice Most Asian guidelines advocate surgical resection in more expanded indications. 10,14,15,17,[27][28][29][30] Even in HCC patients with portal vein invasion, surgical resection has been performed in China, Hong Kong, and Taiwan. 27,28,30 Since surgical resection is more aggressively performed, several methods to improve resectability, such as portal vein embolization or ALPPS, were mentioned.…”

“…10,14,15,17,[27][28][29][30] Even in HCC patients with portal vein invasion, surgical resection has been performed in China, Hong Kong, and Taiwan. 27,28,30 Since surgical resection is more aggressively performed, several methods to improve resectability, such as portal vein embolization or ALPPS, were mentioned. However, ALPPS is limited and is only performed in specialized centers in Hong Kong.…”

Clinical practice guidelines and real-world practice for hepatocellular carcinoma in Taiwan: Bridging the gap

“…In the current issue of Clinical and Molecular Hepatology, Su et al 2 reviewed the current status of HCC management in Taiwan and compared clinical guidelines with real-world practice for HCC treatment. 2 Regular surveillance is crucial in HCC management as it improves the outcomes of patients by increasing the likelihood of receiving curative therapy. 3,4 Risk prediction models for HCC stratify patients into risk groups for HCC, 5 and surveillance in patients at high risk of HCC has been shown to improve prognosis.…”

“…10,14 A wide range of heterogeneity in the combination of systemic agents has been shown in real-world practice in Taiwan. 2 Analyzing the realworld practice data may be valuable for evaluation of treatment and outcomes of HCC, which may facilitate NHI approval and help the development of practice consensus.…”

Challenges in translating clinical guidelines into real-life practice for management of hepatocellular carcinoma in Taiwan

“…However, the implementation of these guidelines in real-life practice remains a challenge. In this editorial, we will discuss the paper by Tung-Hung Su et al, which provided valuable insights into the challenges of translating clinical practice guideline into real-life practice and highlight the need for further research to optimize the management of HCC in Taiwan [1].…”