Anjana Child Care Clinic

[Olympia Brackin]

AnjanaPillai, MD, is a board-certified gastroenterologist and transplant hepatologist who specializes in managing chronic liver diseases, liver transplant and hepatobiliary malignancies. As the medical director of our liver tumor program, Dr. Pillai leads a team of specialists with expertise in benign and malignant liver tumors who together see patients in one location to avoid multiple visits and to enhance the patient experience. This is followed by a weekly liver tumor board to discuss patient treatment plans with insight from multiple specialties. As a professor of medicine and surgery and a full member of the University of Chicago Medicine Comprehensive Cancer Center, she collaborates with the cancer center to provide individualized treatment options to her patients.

Dr. Pillai is also active in national and international societies that focus on advancing research and setting industry standards, including the UNOS National Liver Review Board for adult HCC and the Governing Board for the International Liver Cancer Association (ILCA). She previously chaired the Liver and Intestinal Community of Practice (LICOP) Executive Committee of the American Society of Transplant and currently co-chairs the Liver Cancer SIG of the American Association for the Study of Liver Diseases (AASLD). Additionally, she is the co-founder and course director of HCC-LIVE, an annual conference dedicated to advancing liver cancer care. Her contributions to these organizations help shape the future of liver cancer treatment and ensure her patients benefit from the latest medical research.

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Liver cancer has become the fastest increasing cause of cancer death in the United States. Now, several types of cancer can form in the liver. But the good news is, there are multiple treatment options.

We'll talk about those treatment options, prevention methods, and management of chronic liver diseases with a group of experts who are at the forefront of liver care. We'll take your questions and answer as many as possible. That's coming up now on At The Forefront Live.

We'll get to your questions in just a moment. But first, we need to remind our viewers, the program is not designed it take the place of a visit with your physician. And let's just get started. And we can have each one of you tell us a little bit about yourself and what exactly you do here at UChicago Medicine.

Sure, of course. My name is Anjana Pillai. I'm a transplant hepatologist with the Transplant Institute. I direct-- I'm the Medical Director of our Liver Tumor Program, and I'm also the Co-director of our Living Donor Liver Transplant Program.

Absolutely. So many people may not know this, but your liver is actually your largest internal organ. It's pretty remarkable, and can sustain life when only about 10% to 20% of it is working, which is why many people actually don't know that they have advanced liver disease until they have symptoms.

Your liver does-- it actually does the most jobs of any organ in your body. It takes food and it breaks down the nutrients for energy. It stores many of your essential nutrients and minerals. It helps regulate blood sugar and produces blood sugar.

It helps-- it produces many of your clotting factors so that you heal from surgery or when you get a cut. It produces bile, which helps you metabolize fat. It helps you fight infections. And just as importantly, it also helps detoxify your body. So it helps break down chemicals and drugs you may injest, as well as alcohol.

And so we have definitely noticed a rise in its incidence over all 50 states. It is the number 1 reason that patients are listed for liver transplant now in the United States. And in our own center, over 50% of our patients that are listed for transplant, it's due to primary liver cancer, or HCC.

So there can be many different types of cancer that happen in the liver. There can be primary liver cancer, meaning cancer arising from the liver cells. But inside your liver, there are also millions of bile ducts that help drain out the bile to help you digest. And there can be cancer arising from these bile duct cells.

And that's what's called bile duct cancer, or cholangiocarcinoma. And actually, the most common type of cancer that can go to the liver is actually-- it comes from somewhere else. For instance, colon cancer that goes to the liver, or lung cancer, or breast cancer, et cetera.

Yeah, I think there's a few reasons. So just so we all orient ourselves, liver cancer, I'll refer to as HCC, is the primary liver cancer. Because Dr. Liao did mention there's several types of cancers that occur in the liver. But HCC often occurs in the background of cirrhosis, which is advanced liver disease.

So about 80% to 90% of cases occur because you have end-stage liver disease. And the most common reasons are alcoholic liver disease, hepatitis C, or fatty liver disease. So the reasons that we're seeing an increase is also-- because there's an increase in cirrhosis.

There's an increase in the number of patients that are now living with hepatitis C that have progressed to cirrhosis. We have better medications available, so people with cirrhosis are living longer. And also, because of the rise of fatty liver disease, alcohol, and diabetes, which also contribute to cirrhosis, there's an increase in all those different ideologies that all lead to the risk of liver cancer.

So a lot of times, it's kind of non-specific, vague symptoms like feeling more tired, fatigued. Unexplained weight loss, or loss of appetite. Sometimes, if the liver function is impaired, patients might notice symptoms like swelling in their legs and having bloating in their abdomen, so fluid filled up inside their abdominal cavity, et cetera.

And I know we're going to talk more in detail about that. So this is why-- where surveillance comes in. It's important to undergo surveillance and look for risk factors that may potentially put you at risk for liver cancer.

Yeah, absolutely. So 90% of liver cancer happens in the background of cirrhosis. So anyone with cirrhosis, which is advanced liver disease, or scarring of the liver, should undergo liver cancer screening.

There is guidelines from the US societies, from societies around the world, including Europe, Asia-Pacific, and they all recommend an ultrasound every six months for anyone with cirrhosis. Also, that includes patients with hepatitis B, many of whom, or at least 20% of whom, don't necessarily need cirrhosis to have liver cancer. So that subset of patients should also undergo regular screening. And there's guidelines for age related to that and when they should go undergo screening.

So there-- we've actually come a long way in how we treat liver cancer, how we treat primary liver cancer, hepatocellular carcinoma. So for patients with localized disease, options include surgery or even a liver transplant, which we'll talk about in a little bit. And then there are ways to directly treat the liver.

For instance, they can go in and burn off with our-- we call it radiofrequency ablation, but burn off small liver tumors. There are ways to microwave the small liver tumor. And then there's ways to go indirectly the liver with a catheter and plant radiation seeds in there to treat localized liver tumors that way. And then there are a lot of new treatments that treat the whole body for patients with more advanced cancers, cancers that spread outside the liver. These include targeted therapies and also immunotherapies.

So immunotherapy is a very different way of treating cancer, and it's been-- has generated quite a lot of excitement in cancer treatment. And not just liver cancer, but in many different other kinds of cancer. And it's actually been approved in liver cancer and other kinds of cancer by the FDA.

So the way, in general, it works is that it tricks your body to go after-- so essentially, it's like your body doing the job of attacking the cancer cells. So normally, your body's immune system is very good at detecting bad cells.

So if you go out to the beach and get a sunburn, you don't immediately get skin cancer. And that's because your body's immune system recognizes that there are damage cells, and sends those damaged cells to go away. So for a cancer to grow in your body undetected by your immune system, it must have somehow come up with ways to escape from your immune system's surveillance.

And so a lot of these new immunotherapy treatments that we have essentially un-hides this cancer from your immune system. And then your immune system goes after it. And studies in liver cancer have shown that it's provided significant benefits in liver cancer patients.

That's fascinating. And I love the sunburn analogy. I've never really thought of it that way, but that makes perfect sense. I mean, your body does do a lot of the work to prevent some of these things--

--you can't always. That's fantastic. So let's talk about some of the other treatment options. You mentioned them briefly, but what are the more common treatment options? And what should people expect?

So I think, as Dr. Liao said, it really depends at the stage in which you're diagnosed. So again, just going back to the importance of surveillance, by the time-- if you present with symptoms, some of the symptoms that Dr. Liao. described earlier, oftentimes, your cancer is advanced. And oftentimes, it's not curable.

So this is why we have surveillance for liver cancer, because the whole idea of surveillance for any cancer, really, is if you have the options of curative options if the cancer is detected early. So if you undergo proper surveillance, if you have cirrhosis or if you have hepatitis B and you detect a small lesion that's localized, meaning it hasn't spread, it's a certain size or a certain number, the curative option includes resection. So taking-- removing that tumor, which we work very closely with our transplant surgeons, our hepatobiliary surgeons, and then transplant.

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