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Older liver cancer patients respond to radioembolization equally as well as younger patients
Results of a new analysis by members of the multi-center European Network on Radioembolization with Yttrium-90 Resin Microspheres (ENRY), published on-line in the Journal of Hepatology, the peer-reviewed official journal of the European Association for the Study of the Liver [1] , may have important implications for older patients with inoperable primary liver cancer (hepatocellular carcinoma, or HCC).

Hepatocellular carcinoma (HCC) occurs in people whose livers have become severely damaged or cirrhotic, due to conditions such as hepatitis and alcoholism. It is one of the ten most-common cancers in the world, with nearly 750,000 cases diagnosed annually, and the third-leading cause of cancer deaths. [2]  It occurs with greatest frequency in regions where hepatitis is most often diagnosed, such as in Asia Pacific and Southern Europe.

Hepatocellular cancer can be cured only by surgery, either by resecting the diseased parts of the liver, or by transplantation with a liver from a healthy donor. These interventions, however, are inappropriate for the great majority of patients, whose survival may range from a few months to two or more years depending largely on the state of their liver at the time of their diagnosis and the extent of tumor invasion.

The analysis found essentially identical long-term treatment outcomes following radioembolization using SIR-Spheres in 128 elderly (age 70 years or older) compared to 197 younger (less than 70 years of age) patients with otherwise similar demographics. “Our findings suggest that age alone should not be a discriminating factor for the management of HCC patients. This is important because there is a trend towards increased age in patients diagnosed with HCC, particularly in developed countries,” said the article's lead author, Rita Golfieri, MD, Professor of Radiology in the Department of Digestive Diseases and Internal Medicine of The University of Bologna.

Professor Golfieri also stated that “While age should not be a barrier to the management of older patients with HCC, physicians should definitely take age and frailty into account when deciding which treatments to use.

“For example, the relative mildness of procedure-related events after radioembolization with SIR-Spheres compared with transarterial chemoembolization, or TACE, suggests that an effective single radioembolization procedure may be more acceptable to elderly patients than the multiple courses of treatment required with TACE.

“In addition, while the tyrosine kinase inhibitor, sorafenib, represents a good treatment option for many elderly patients with HCC, the increased frequency of adverse events associated with its use in patients over 75 years old may require dose-modification,” Professor Golfieri said.

The new study is the most recent report based on an extensive evaluation of 325 HCC patients treated by teams of liver specialists, oncologists, interventional radiologists and nuclear medicine physicians at eight centers in Germany, Italy and Spain, and coordinated by Bruno Sangro, MD, PhD, Director of the Liver Unit at Clinica Universidad de Navarra, Pamplona, Spain, and chair of the ENRY group.

When the consolidated ENRY data were first published in 2011,[3] Professor Sangro noted that: “As ENRY was not a prospective study, our findings must be interpreted conservatively. What we can say, based on our evaluation of a broad range of patients with HCC treated in routine clinical practice, is that radioembolization using SIR-Spheres directly targets tumors and spares viable liver tissue, which enables us to reduce the burden of disease and potentially increase both the patient's survival and quality of life. The greatest survival benefit can be expected in those patients with better performance status, fewer tumour nodules and no occlusion of the portal vein.

“What we can now also say based on Professor Golfieri's analyses, is that the benefits we observed apply as much to older patients as to younger ones, with some potential added value for radioembolization based on its relatively mild side-effect profile compared to other treatments for this very serious disease. These patients have few other treatment options,” Professor Sangro explained.

Other treatment options that have been demonstrated to extend survival for patients with inoperable HCC include TACE, which requires repeated interventional procedures and hospitalization due to the resulting post-embolization syndrome; and sorafenib, an oral medication taken twice daily which can give side effects leading to discontinuation of the drug in more than a third of patients (38%). [4]

“Radioembolization may also be a synergistic option when combined with newer pharmaceutical treatments, such as sorafenib,” Professor Sangro said.

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