J Gastrointest Canc (2011) 42:228–235

DOI 10.1007/s12029-010-9200-x

ORIGINAL RESEARCH

Comparison of Cancer Care for Hepatocellular Carcinoma

at Two Tertiary-Care Referral Centers from High and Low
Endemic Regions for Viral Hepatitis
Fahad Alsohaibani & Geoffrey Porter &
Hamad Al-Ashgar & Mark Walsh & Robert Berry &
Michele Molinari & Kevork Minas Peltekian

Published online: 1 September 2010

# Springer Science+Business Media, LLC 2010

Abstract
Background Risk factors for hepatocellular carcinoma
(HCC) have geographic variability but differences in care
have not been described. We reviewed the presentation,
management, and outcomes of HCC patients from two
tertiary-referral centers in Central Saudi Arabia and Atlantic
Canada during 1997–2002.
Methods Data were extracted from health records of 96
Saudi and 80 Canadian consecutive patients with HCC.
F. Alsohaibani : K. M. Peltekian
Department of Medicine, Dalhousie University,
Halifax, Nova Scotia, Canada
F. Alsohaibani : H. Al-Ashgar
Department of Medicine,
King Faisal Specialist Hospital and Research Center,
Riyadh, Saudi Arabia
G. Porter : M. Walsh : M. Molinari : K. M. Peltekian
Department of Surgery, Dalhousie University,
Halifax, Nova Scotia, Canada
G. Porter
Cancer Care Nova Scotia,
Halifax, Nova Scotia, Canada
M. Walsh : M. Molinari : K. M. Peltekian
Atlantic Multi-Organ Transplantation Program,
Queen Elizabeth II Health Sciences Centre,
Halifax, Nova Scotia, Canada
Results Mean age (±SEM) of the two groups were similar
(64+1 and 65+1 years) with 93% versus 75% males
amongst Canadian and Saudi patients, respectively. In
Canada, underlying disease was alcohol-related cirrhosis
(45%), cryptogenic cirrhosis (26%), or hepatitis C (13%).
For Saudis, HCC cases were attributed to hepatitis C (47%),
cryptogenic cirrhosis (27%), and hepatitis B (21%). At
initial presentation, Saudi patients had more vascular
invasion and distant metastases while Canadians had more
advanced liver disease. The tumor-specific prognostic
classifications were comparable. Due to center-specific
expertise or preference, symptomatic treatment was more
common amongst Saudi patients (83% versus 42%) while
more Canadians underwent local palliative interventions
(52% versus 12%). Frequency of potentially curative
therapies including resection and transplantation were
similar at both centers. There was no difference in overall
median survival (14 versus 10 months) amongst Canadian
and Saudi patients.
Conclusions This study validates divergence in HCC
presentation between low and high endemic regions for
viral hepatitis. In addition, for the first time, differences in
cancer care of HCC are documented.
Keywords Cancer care . Cirrhosis . Viral hepatitis .
Canada . Saudi Arabia . Health service delivery

R. Berry
Department of Diagnostic Imaging, Dalhousie University,
Halifax, Nova Scotia, Canada Abbreviations
HCC Hepatocellular carcinoma
K. M. Peltekian (*)
QEII Queen Elizabeth II Health Science Centre
Atlantic Hepatology Services,
P. O. Box 60010, B3H 4R7 Halifax, Nova Scotia, Canada KFSH King Faisal Specialist Hospital and Research Center
e-mail: Kevork.Peltekian@dal.ca ASR Age standardized rate
J Gastrointest Canc (2011) 42:228–235
ICD International Classification of Disease
AFP α-Fetoprotein CTP, Child–Turcotte–Pugh
CLIP Cancer of the Liver Italian Program
BCLC Barcelona Clinic Liver Cancer
HBV Hepatitis B virus
HCV Hepatitis C virus
TACE Trans-arterial chemo-embolization
PILI Percutaneous intra-lesional injection
IQR Inter-quartile range
Introduction
Hepatocellular carcinoma, the most common primary
malignancy of the liver, is observed characteristically as
a complication of chronic liver disease. It accounts for
6% of all cancers worldwide. Hepatocellular carcinoma
(HCC) is considered to be the fifth most common
cancer in the world and the third most common cause
of cancer mortality with a 5-year survival rate of less
than 5% without treatment (1).
The incidence of HCC is characterized by marked
geographic and demographic variations that correlate
with the prevalence of HBV and HCV. The great
majority of HCC occurs in either Southeast Asia or in
sub-Saharan Africa (2). Epidemiologic and laboratory
studies have firmly established a strong and specific
association between HBV and HCC. In addition, cirrhosis,
regardless of its etiology, is the most significant risk factor
for HCC (3). In North America, although alcohol and
persistent HCV infection are well-documented etiologic
factors for HCC, recent epidemiologic observations
indicate that non-alcoholic fatty liver disease leading to
cryptogenic cirrhosis also contributes to the cases of HCC
(4).
In spite of the well-described geographic variation in the
global epidemiology of HCC, differences in cancer care
between regions are unknown. Atlantic Canada is considered
to have low incidence for HCC, however, over the last 25 years
the incidence of HCC has increased significantly, from 0.20
per 100.000 (1974–1978) to 1.13 per 100.000 (1994–1998)
(5). In Saudi Arabia, the overall age standardized rate (ASR)
for HCC between January 1999 and December 2000 was
estimated to be 4.5/100.000 (6.5/100.000 in males and 2.6/
100.000 in females) with the highest ASR in the Central
Region at 10.4/100.000 (6).
We reviewed and compared the clinical presentation,
management and outcomes of patients referred from
Atlantic Canada (low endemic area for viral hepatitis) and
from Central Saudi Arabian Region (high endemic area for
viral hepatitis).
229
Methods
Study Population
Nova Scotia is the most populated of the four provinces in
Atlantic Canada with an estimated population of 950,000.
Queen Elizabeth II Health Science Center (QEII) is the
main teaching hospital for Dalhousie University and the
province’s largest healthcare center with 1,100 beds—175
dedicated to Veterans. It is also the tertiary-referral center
for cancer care in the Maritimes and hosts the Atlantic
Multi-Organ Transplantation Program, which provides
advanced liver care and transplantation to approximately
2,500,000 Atlantic Canadians. King Faisal Specialist
Hospital and Research Center (KFSH) is situated in
Riyadh, the capital of Saudi Arabia. KFSH is a
government-funded tertiary medical and research facility
operating 894 beds and serve mainly the central part of
Saudi Arabia and the surrounding regions (with population
of 4,250,000 as of September 2004). Similar to QEII, it is
one of the main teaching hospitals in the Central Region
providing cancer care and advanced hepato-biliary surgery
and liver transplantation.
Inclusion Criteria
All patients diagnosed with HCC between 1997 and 2002 at
QEII and KFH were included. Although in recent years, there
has been emphasis for outpatient investigation and manage-
ment of patients with HCC and even home-based palliative
care for those with advanced disease, during the study period,
most subjects diagnosed with HCC were hospitalized in both
medical (oncology or gastroenterology) and surgical services
for investigations, interventions, and palliation. In both
centers, often consultation was provided by hepatologists to
patients in both hospital and outpatient settings.
We used established criteria for the diagnosis of HCC (7).
HCC is a highly vascular neoplasm that usually arises in a
cirrhotic liver. Based on this concept, we used noninvasive
diagnostic criteria whenever biopsy was not available. The
diagnostic imaging criteria required that the liver mass be
characterized by at least two imaging modalities with contrast
enhancement on computerized tomography, magnetic reso-
nance imaging, or angiography. The presence of elevated
serum α-fetoprotein (AFP) greater than 400 ng/dl in cirrhotic
patients who had a liver mass was also considered diagnostic.
If the purposes of this study when lesion mass size was less
than 2 cm in diameter, to be included in the study, histological
confirmation was necessary (7). There were six out of 86
patients from QEII and four out of 100 patients from KFSH
who were excluded because of insufficient data or non-
conclusive results.
230
Data Source
In this retrospective analysis, health records of 80 consecutive
patients diagnosed and hospitalized with HCC between 1997
and 2002 at QEII were reviewed and compared with 96
consecutive patients hospitalized during the same time period
at KFSH with the diagnosis of HCC. One of the authors (FA)
performed all the chart reviews and data extraction in
standardized fashion to ensure comparable interpretation of
results among the two distant study centers.
Diagnostic Codes
Our data included patients diagnosed with primary liver
cancer, using the International Classification of Disease
(ICD-9 code 155.0 and ICD-10 code C22) for HCC.
The main database included age, gender, performance
status, clinical and laboratory including serum AFP as a tumor
marker for HCC, and platelet counts as a reflection on the
presence of portal hypertension. Since the Child–Turcotte–
Pugh (CTP) classification is one of the most commonly used
systems to evaluate liver function in cirrhotic patients we
made every effort to extract the presentation data from charts
to be able to calculate it. We then reviewed all the relevant
radiological and histological data at presentation to determine
tumor size, presence of vascular invasion or metastasis. Data
relating to various treatment modalities administered to each
patient and the final outcomes, when available, including
death were also extracted from patient charts and entered into
data for later analysis.
Currently, there are many available prognostic staging or
classification systems for HCC including (8). In our study,
we extracted data to determine each patient’s Okuda staging
(9) and Cancer of the Liver Italian Program (CLIP) score
(10) at the time of initial HCC diagnosis. CLIP score is
easily computed and consisted of four variables: CTP stage,
tumor morphology and extension, serum AFP levels, and
presence of portal vein thrombosis. Since one of the main
objectives of our study was to compare the type of
intervention in the management of HCC, we also gathered
data to categorize the patient in the appropriate Barcelona
Clinic Liver Cancer (BCLC) staging classification (11). The
latter has been incorporated into clinical practice guidelines
since it stratifies patients according to HCC staging and
degree of liver disease in a process leading to a specific
treatment; BCLC staging classification has shown the best
results in terms of survival (12).
Center-Specific Interventions
During study period, both centers provided hepatic resection
and liver transplantation. These two surgical interventions
J Gastrointest Canc (2011) 42:228–235
were considered potentially curative and all subjects under-
going hepatic resection or transplantation were grouped as
receiving curative therapy even if they received local
palliative therapies such as trans-arterial chemo-embolization
(TACE) prior to liver transplantation.
The main approach for managing non-resectable focal
lesions less than 3 cm differed between QEII and KFSH
during the study period. In spite of the availability of
radiofrequency ablation, in Atlantic Canada the primary
modality of intervention was percutaneous 99% ethanol or
50% acetic acid injection; radiofrequency ablation (RFA) at
QEII was being utilized mainly for metastatic cancers
involving the liver rather than primary HCC. On the other
hand, in Central Saudi Arabia, RFA was used primarily to
control focal HCC. In addition, in Atlantic Canada because
of early successful experience, chemo-embolization via
hepatic artery was often used in subjects with non-
resectable large tumors or while on the wait list for liver
transplantation. This intervention was not available at
KFSH during the study period. These three interventions:
percutaneous intra-lesional injection (PILI) with ethanol or
acetic acid, RFA whether percutaneous or intra-operative,
and TACE were all considered local intervention modes for
management of HCC. For the purposes of this study,
patients undergoing these procedures were grouped as
receiving palliative therapy.
In addition, during the study period, at QEII subjects
with non-resectable and advanced HCC were often tried on
tamoxifen. However, large controlled-trial (13) and later a
systematic review with meta-analysis confirmed the lack of
efficacy for tamoxifen in HCC (14). For the purpose of this
study, all patients referred for hospice or comfort care, those
treated with systemic chemotherapy or hormonal therapy
such as tamoxifen were grouped together as having only
symptomatic therapy.
Statistical Analysis
Descriptive statistics (mean, standard deviation, range, and
proportions) were used to describe each variable. Comparisons
between groups were made with Student t-test for continuous
variables and χ2 test for frequencies of categorical variables.
A Kaplan–Meier plot was constructed for visual representa-
tion of the deaths. Statistical significance was demonstrated
by a p-value<0.05. Statistical analysis was performed with
Minitab version 14 (Minitab, State College, PA).
Results
At QEII the mean (±SEM) age of patients was 64+1 years
with 93% males compared to 75% males, and 65+1 years
J Gastrointest Canc (2011) 42:228–235 231

at KFSH. The mean performance status according to Table 1 Characteristics of HCC patients from Saudi Arabia and
Atlantic Canada
Eastern Cooperative Oncology Group classification was
comparable at time of presentation for KFSH versus Variable KFSH QEII p-value
QEII groups (Table 1). Underlying etiology for HCC at (n=96) (n=80)
QEII was alcohol-related cirrhosis (45%), cryptogenic
Agea, year 65±1 64±1 0.384
cirrhosis (26%), hereditary hemochromatosis (13%),
Male sex 75% 93% 0.002
chronic hepatitis C virus (13%), chronic hepatitis B virus
Primary etiology
(5%), primary biliary cirrhosis (2%), and chronic autoim-
HCV 47% 13% <0.001
mune hepatitis (2%). For KFSH group, most HCC cases
HBV 21% 6% 0.006
were attributed to chronic hepatitis C virus (47%),
Alcohol 2% 45% <0.001
cryptogenic cirrhosis (27%), chronic hepatitis B virus
Cryptogenic 27% 26% 0.901
(21%), schistosomiasis (5%) and alcohol-related cirrhosis
Hemochromatosis 0% 13% <0.001
(2%).
Schistosomiasis 5% 0% 0.038
Fifty percent of QEII patients and 40% of patients at
Others 1% 2% 0.457
KFSH had histological confirmation of tumor based on
Laboratorya
sampling of liver lesion either by percutaneous biopsy
Albumin, g/L 30±1 29±1 0.228
or surgical resection (p = 0.166). Partial portal vein
Bilirubin, μmol/L 48±10 42±6 0.654
thrombosis was observed in 12% at QEII versus 16% in
INR 1.10±0.03 1.32±0.04 <0.001
KFSH, while complete portal vein thrombosis was similar
at 14%. More vascular invasion was documented in Platelet count, × 109/L 193±11 177±12 0.315
patients from KFSH than from QEII with 29% versus Child–Turcotte–Pugh classification 0.021
8% (p<0.001) indicating more advanced presentation for A 59% 39%
HCC among Saudi patients. B 28% 39%
C 13% 22%
Morphological Assessment of HCC Performance statusb <0.001
0 18% 11%
Patients with HCC hospitalized at QEII at presentation 1-2 60% 60%
2% had tumor <2 cm in diameter, 50% between 2-5 cm 3 4% 23%
and in 48% the tumor was greater than 5 cm. In KFSH 4 18% 6%
the respective percentages were 4%, 38% and 58% AFP, ng/mL 0.625
(Table 1). Most of QEII patients had unifocal tumor <20 35% 42%
(51% versus 41% in KFSH), while larger number of 20 – 400 26% 23%
KFSH patients had multifocal tumor (42% versus 36% in > 400 39% 35%
QEII). Eight percent versus 5% had diffuse tumor and 5% Tumor diameter, cm 0.235
versus 12% had metastatic tumor in QEII and KFSH, <2 4% 2%
respectively. 2-5 38% 50%
>5 58% 48%
Liver Disease Staging and HCC Classification Tumor distribution 0.214
Unifocal 41% 51%
Patients at QEII had more advanced liver disease with CTP Multifocal 42% 36%
class B–C 61% versus 41% at KFSH (p=0.021). Half of the Diffuse 5% 8%
patients at QEII presented with ascites while only 28% of Metastatic 12% 5%
KFSH patients ascites was noted at presentation (p=0.009). Portal vein thrombosis
The mean tumor-specific staging scores in patient Complete 14% 14% 0.968
populations at both Centers were comparable with CLIP Partial 16% 12% 0.554
score, and Okuda Staging (Table 1). The latter would be CLIP score 0.23
expected since both CLIP score and Okuda staging 0 19% 14%
combine the stage of liver disease and the stage of HCC 1 21% 29%
to predict prognosis. At QEII 87% of patients were 2 32% 27%
classified at BCLC stages C–D versus 80% of patients at 3 19% 11%
KFSH were at stage C–D. The majority of patients were 4 7% 10%
presenting at stages where no efficacious interventions 5 1% 6%
were available that would prolong survival. 6 1% 3%
232 J Gastrointest Canc (2011) 42:228–235

Table 1 (continued)
On the other hand, the forms of palliative treatments
Variable KFSH QEII p-value available at QEII included TACE which was delivered to
(n=96) (n=80) 44% of patients and PILI with either alcohol or acetic
acid was performed in 9%. At KFSH, PILI with alcohol
Okuda staging 0.215
was performed in 5% of patients and percutaneous or
0 68% 53%
intra-operative RFA in 7%. The RFA technology was
1-2 16% 22%
available at QEII at the time of the study but its use was
3-4 17% 25%
limited to small metastatic tumors in the liver. Although
BCLC classification 0.143
there was an early trend for better outcomes amongst
A 11% 11%
Atlantic Canadians undergoing local palliative therapies
B 9% 2%
including TACE, the long-term outcomes were similar
C 53% 48%
between the two Centers. Finally potentially curative
D 27% 39%
treatment with surgical resection was achieved in 10% of
a
Mean+SEM QEII group versus 7% of KFSH group. Liver transplantation
b
Assessed by the Eastern Cooperative Oncology Group criteria was performed successful for 10% of QEII patients versus 3%
of KFSH patients with HCC.

Treatment Modalities
Symptomatic treatment was the main modality of therapy at
KFSH (83% versus 42% at QEII). The latter group at QEII
included patients who received hormonal therapy with
tamoxifen and those who received systemic chemotherapy
at KFSH; both these interventions were proven subsequent
to study period not to impact survival and hence were
combined in the same treatment category (Table 2). Unlike
patients at QEII, patients with multifocal HCC who were
not candidates for resection or transplantation were only
offered symptomatic treatments since TACE was not
available during the study period at KFSH. In spite of the
more advanced stage of HCC amongst the Saudi patients at
presentation, there was tendency for better survival
amongst the Saudi patients (median survival 8.3 months
versus 0.9 months amongst Atlantic Canadians—presenting
with more advanced liver disease) but this did not translate
to significant overall differences.
Median Survival
Survival was measured from first day of diagnosis to the
day of last follow up and compared between the two
groups. The median survival for patients at QEII and KFSH
is shown in Fig. 1. This was predictable outcome based on
the CLIP score, the Okuda Stage and BCLC classification.
The patients that underwent curative interventions (either
tumor resection or orthotopic liver transplantation) had the
best survival 78% 5-year survival (Fig. 2). Those patients
with palliative therapies such as TACE, PILI, or RFA had
median survival of 24 months (inter-quartile range (IQR)
14 months) while those who received symptomatic therapy
median survival of 6 months (IQR 14 months; Fig. 2). In
our study, only 10% to 20% of patients diagnosed with
HCC were eligible for curative treatments, which included
surgical resection or orthotopic liver transplantation. Of these
two therapies, liver transplantation has the best long-term
outcomes 1, 3, and 5-year survival rates of 78%, 63%, and
57%, respectively.

Table 2 Initial treatment modal-

ities for HCC patients from Saudi Modalitya Intervention KFSH (n=96) QEII (n=80) p-value
Arabia and Atlantic Canada
Curative 10 (10%) 16 (20%)
Surgical resection 7 8 0.522
Liver transplantation 3 8 0.061
Palliative 12 (12%) 42 (52%)
RFAb 7 0 0.014
PILI 5 7 0.353
a
Patients could have received
TACEb 0 35 <0.001
more than one modality (e.g.,
patient receiving TACE while Symptomatic 80 (83%) 34 (42%)
awaiting liver transplantation) Hormonalb 0 33 <0.001
b
Difference due to local preferences Systemic chemotherapy 6 1 0.091
or availability of center-specific Supportive 79 27 <0.001
expertise
J Gastrointest Canc (2011) 42:228–235
Fig. 1 Kaplan–Meier survival curve for patients with HCC referred to
KFSH in Central Saudi Arabia (n=96) and QEII in Atlantic Canada (n=
80). The median survival at KFSH and QEII were 10.1 and 13.6 months,
respectively (Log rank, p-value=0.126)
Discussion
Viral hepatitis is the primary underlying etiology of cirrhosis
with subsequent HCC worldwide. Just as expected, in our
study, viral hepatitis comprises significant portion of etiologic
factor for HCC but cryptogenic cirrhosis (presumably
secondary to fatty liver disease) is the second most common
underlying cause for HCC in both regions. Hemochromatosis
is a significant etiologic factor among Atlantic Canadians who
are largely descendents of Celtics from Scotland, Ireland,
Wales, and Normandy.
The incidence of HCC increases with age and occurs
four to nine times more frequently in males than in females
except in the group without preexistent liver disease, in
whom the ratio is 1:1. In the United States, Caucasians are
two to three times less often affected than African
Americans, who in turn are two to three times less often
Fig. 2 Kaplan–Meier survival curve for patients with all HCC by
treatment categories. The median survival rates for curative interventions,
local palliative interventions, and symptomatic treatments were 25.1,
11.1, and 5.8 months, respectively (Log rank, p-value<0.001)
233
affected than Asians, Pacific Islanders, or Native Americans
(15). It is clear that HCC will become a significant cause of
morbidity and mortality in the near future (16).
The most effective way to decrease the incidence of HCC
is to prevent development of cirrhosis. Although there is no
clear evidence to support the benefit of periodic screening for
detection of HCC using ultrasonography and serum AFP;
consensus guidelines based on expert opinions recommend
ultrasonography every 6 to 12 months in high-risk patients
who are candidates for liver transplantation, surgical resection
or percutaneous therapy (12).
Accurate clinical staging of HCC is important to
determine the prognosis and provide the best treatment for
each patient. Unlike for the majority of solid tumors, the
outcomes in liver cancer are highly dependent on the
residual liver function and general health of the patient (17).
This study also provides a glimpse on how the choice of
interventions depends on center-specific preferences or
availability of interventions. Life expectancy of patient
with HCC is hard to predict and despite a statistically
significant improvement in the survival rates over the last
20 years, patients with HCC continue to have poor
prognosis with a median survival of approximately
7 months (16). When symptomatic, HCC is usually non-
resectable and associated with median survival of less than
6 months (18). Despite many available treatment options,
unfortunately the prognosis remains poor.
In our study, overall patients hospitalized at KFSH had
more advanced pathology for HCC with larger tumor load
and multifocality; however, patients hospitalized at QEII
had more advanced liver disease. Presentation with either
advanced HCC pathology or advanced liver disease is not
surprising since both processes remain asymptomatic until
end-stages. This is one of the rationales for supporting
programs for HCC surveillance. However, the difference in
presentation may be explained by the fact that in Atlantic
Canada liver disease and cirrhosis is usually multi-factorial
with many having two or more risks for cirrhosis such as
HCV, alcohol, and obesity. In these patients, HCC is being
identified because patients have declared themselves as
having advanced liver disease. On the other hand, in Saudi
Arabia where the majority of HCC patients had viral
etiology acquiring it at earlier age with increasing propor-
tions of female patients where HCC becomes symptomatic
on a background of more indolent chronic liver disease the
latter being identified only after HCC has been docu-
mented. These differences in presentation, if proven to be
valid in other studies, will have major impact regional
policies for liver disease screening or HCC surveillance.
We were able to document differences not only in the
initial presentation of patients hospitalized with HCC but
also in the type of intervention between low and high-
intermediate endemic regions for viral hepatitis. The main
234
discrepancy in the approach was due to the more advanced
HCC in the high-intermediate endemic region with often
only symptomatic therapy. Some of the differences were
also related to disparities in acceptance and uptake by
providers for novel interventions. The variations and
inequities between the different countries are being recognized
globally in the inability of patients to access new innovative
cancer drug treatments (19). At KFSH, intra-operative radio-
frequency ablation had been available for many years and
well-accepted procedure. On the other hand, because of
strong interventional radiology group at QEII, both PILI and
TACE of HCC via selective hepatic artery injection were
utilized frequently.
In our study, the best outcomes were those patients
eligible for curative treatments which comprised only 10%
to 20% of patients diagnosed with HCC. With wider use of
HCC surveillance programs the proportion of patients
eligible for curative treatments will increase. Once HCC is
determined not to be resectable or transplantable, no
standard treatment has been shown to be effective;
currently, there is no proven treatment modality that
prolongs survival in those patients (20). One exception to
this is TACE that has been shown to improve survival of
highly selected (Child class A–B) patients with unrespectable
HCC. Survival probabilities at 1 and 2 years were 82% and
63% for TACE, and 63% and 27% for control (21). PILI has
been most widely performed as an attractive alternative to
surgery in patients with small HCC with similar outcomes
(22). In recent years, however, in many centers percutaneous
and intra-operative RFA has been steadily replacing PILI.
For small HCC, outcomes following RFA and hepatic
resection are comparable (23). Although sorafenib has been
shown to be effective in non-resectable HCC, its exact role
in the algorithm of HCC management needs further studies
(24). The overall median survival between the two groups
showed minor advantage for patients in Atlantic Canada.
This difference was mainly related to the utilization of TACE
at QEII. The outcomes of all the other interventions were
similar individually or when grouped into curative, palliative
or symptomatic therapy.
This study emphasizes the differences not only in the
initial presentation of subjects with HCC but also in the
type of intervention between low and high endemic
regions for viral hepatitis. The differences attributed to
cancer care are based on availability of local expertise
but also due to divergence in health care cultures.
Increasingly, investigators are relying on multicenter or
multi-group studies to demonstrate effectiveness and
generalizability (25). Comparative studies such as this
one highlight the necessity for global multicenter trials
because of the existence of local variations in expertise
and delivery of cancer care on a background of differences
in the presentation of patients with HCC.
J Gastrointest Canc (2011) 42:228–235
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