The Challenge of Liver Disease

A multidisciplinary team is needed to treat this complex—and growing—health problem.

The liver, the body's largest internal organ, is an important player in digestion, energy storage and toxin filtration. It’s also the center of a new health care focus. Liver diseases such as hepatitis C, nonalcoholic fatty liver disease and liver cancer are all on the rise, according to the Centers for Disease Control and Prevention (CDC). More than 30 million people—10 percent of the U.S. population—have liver disease. Each year, about 21,000 Americans are diagnosed with primary liver cancer—one of the few cancers that are increasing in the U.S.

In response to this unsettling trend, major health care centers like Saint Barnabas Medical Center have, in recent years, created new, dedicated comprehensive liver disease teams to bring together experts to treat these complex patients. Liver disease in general, and specifically liver cancer, is a challenging area of health care, and medical authorities have found that its treatment requires a team of highly skilled and well-trained physicians.

Two factors probably help explain the rise in liver disease, says Russell C. Langan, M.D., a surgical oncologist who specializes in hepatopancreatobiliary surgery—that includes the liver, pancreas, gallbladder and bile ducts—at Saint Barnabas Medical Center and Rutgers Cancer Institute of New Jersey. One is the increase in nonalcoholic fatty liver disease, which is believed to be directly related to a recent surge in obesity in the U.S and the standard American diet. Up to 25 percent of Americans may have nonalcoholic fatty liver disease, the CDC reports. The second factor is the number of people, especially baby boomers, who carry hepatitis viruses. Four million Americans are infected with hepatitis C and more than 1 million are infected with hepatitis B. Three-quarters of those infected with hepatitis C don’t know they have it because the disease can be present for years without showing symptoms. It often lies undetected for 20 to 30 years and is a leading cause of cirrhosis and liver failure. For these reasons, Dr. Langan says, “more people today are living with chronic inflammation of the liver.” That can progress to liver failure and cancer.

One cancer, intrahepatic cholangiocarcinoma, causes about 5,000 deaths a year, says the doctor, who explains that this type is “exponentially on the rise. Over the past 20 years, it has become the leading cause of liver tumor-related death.”

Surgery is often recommended as the first treatment for patients with intrahepatic cholangiocarcinoma as well as other types of liver cancer. The next question is whether the patient needs postsurgical treatment as well. At Saint Barnabas Medical Center, that decision often falls to Delia Radovich, M.D., a medical oncologist. “Historically there have been few large clinical trials for patients with cholangiocarcinoma, so there are not always clear recommendations for treatment after potentially curative cancer surgery,” she says.

“Some patients require chemotherapy for a period of time. Some require radiation. Experience is an important guide,” she adds. The team feels that it is exceptionally important to be cared for at a center that deals with liver disease and cancers often and has individuals specifically trained in that area. Saint Barnabas Medical Center is an institution with a dedicated liver team and a center for liver diseases and tumors.

In a case in which there is no spread of cholangiocarcinoma outside the tumor, doctors can either give chemotherapy alone or choose “watchful waiting.” When chemotherapy is chosen, says Dr. Radovich, it is common to use either oral or IV agents for a period of several months. For some types of liver cancers, immunotherapy can be administered—it is a therapy given at Saint Barnabas Medical Center. In other situations, the disease may be treated with an infusion of radioactive particles directly into the liver.

Dr. Radovich explains that the complexity of many cases of liver cancer and other liver disease illustrates the need for a comprehensive, multidisciplinary approach. “To do liver surgery requires expertise, and it should be done at a center where the surgical team does a lot of it,” she says. “The liver is one of the more complicated sites for surgery, and you don’t want just any surgeon.”

After surgery, effecting a cure requires a well-coordinated team of specialists. “Medical oncology used to be ‘one size fits all,’” she says. “We are all trained to treat all types of cancers.” But as the field has grown, more and more, oncologists have been subspecializing. “At Saint Barnabas Medical Center we have eight medical oncologists. All of us are capable of treating all types of cancer, but within the group, some physicians focus on breast, some on lung, some on gastrointestinal (GI), etc. There is a great deal to know about each of these cancer types.”

Dr. Radovich moderates the multidisciplinary gastrointestinal tumor board meeting, at which the team of providers discusses each case and comes to consensus on a treatment plan. Additionally, there is a liver-specific multidisciplinary management meeting that takes place at Robert Wood Johnson (RWJ) University Hospital and Rutgers Cancer Institute of New Jersey. The Saint Barnabas liver doctors participate in this meeting electronically. “It is held at RWJ in New Brunswick, but we can link in, and our patients get presented there,” Dr. Langan says. “Here at Saint Barnabas Medical Center, we really stress the importance of having a large team of physicians working together to care for our patients.” He stresses that liver disease requires this type of care. “If you have liver disease, you should be seen in a proper system by a team of specialists who see it and treat it often and can manage it appropriately,” he says.

Deaths from most cancers are declining. NOT SO WITH LIVER CANCER.

In recent years, deaths from most cancers have been going down. But the National Cancer Institute reports that those from cancer of the liver and intrahepatic bile duct increased by an annual average of 2.6 percent from 2005 to 2014—and that an estimated 28,920 Americans lost their lives to these cancers in 2017. The American Cancer Society says liver cancer incidence (which of course is different from deaths) “continues to increase rapidly in women, but appears to be stabilizing in men.”

For more information about the Liver Center at Saint Barnabas Medical Center, call 973.322.6777.

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