Candice Roth (00:08.526)
Welcome to the heart and soul of oncology navigation. My name is Candice Roth, executive director for the Academy of Oncology Nurse and Patient Navigators, and I will be moderating our discussion today. We are excited to facilitate this discussion on behalf of AONN+ and the Society of Interventional Oncology. Today's podcast will introduce hepatocellular carcinoma, also known as HCC, and the multidisciplinary team, which we may shorten to MDT during the conversation. We will also review key information on tumor biology and risk factors, introduce the MDT model, and share examples of cross-collaboration from the University of California, San Diego. It's now my pleasure to introduce our faculty for this conversation, and I will kick it over to Dr. Berman to begin.

Zach Berman (00:58.862)
Hi, thank you so much for having me. My name is Zach Berman. I'm an interventional radiologist at UC San Diego and specializing in HCC.

Adam Burgoyne (01:07.36)
My name is Adam Burgoyne. I am a medical oncologist here at UC San Diego, and I work with the rest of the team and also specialize in HCC.

Yuko Kono (01:15.488)
My name is Yuko Kono. I'm a hepatologist at UC San Diego, also specializing in HCC care in multidisciplinary team and work with everybody. Thank you for having me.

Sam Myers (01:28.568)
Thanks Candice so much. My name is Sam Myers and I'm a registered nurse at the Cancer Center specializing in HCC and GI cancers and also working as a new patient nurse navigator for liver mass referrals here at UCSD.

Candice (01:45.196)
Wonderful. Thank you all for being here. Sam, I would love to kick it over to you to get things started.

Sam (01:51.606)
Absolutely. Just to help the team connect with our listeners, I'm wondering if each of you could share a bit of your personal background, how you came to work in the field of oncology and/or what you find most inspiring about working on HCC or with HCC patients. So go ahead and start with you, Dr. Kono.

Yuko (02:14.688)
Okay, well, thank you so much. So, like I said, I'm a hepatologist trained in Japan, where actually hepatologists may also serve as a radiologist and interventional radiologist, depending on the practice. And from early in my training, I was involved not only in ultrasound and telescopic procedures, but also in liver biopsy, tumor ablation, and trans-arterial chemoembolization. And it was really fascinating to me that I could be involved in all spectrum of liver care, HCC care, from diagnosing, managing current liver disease to screening, diagnosing HCC and ultimately treating it. I ultimately came to San Diego in 98 for my research. And now I've been practicing here as a hepatologist and specializing in HCC.

Sam (03:09.046)
Awesome, thank you so much. And you, Dr. Berman.

Zach (03:12.098)
Yeah, definitely. Like others, life always finds a way to get you where you need to be. But I went to med school thinking I wanted to be an orthopedic surgeon. And then my first year of medical school, I had a chance to see one of the trans-arterial procedures Dr. Kono just mentioned in a patient. And as soon as I saw that, I knew that's exactly what I wanted to be doing for the rest of my life. And so I got kind of lucky and serendipitously found this specialty and have been excited to be here ever since.

Sam (03:41.698)
Great, so glad you're here. And you, Dr. Burgoyne?

Adam (03:44.59)
Thanks again for inviting me to share my story and experience here. I am a medical oncologist, as I mentioned, and I've been a researcher at heart throughout the majority of my training. I was always interested in cancer biology and understanding tumorigenesis. And then as my career has evolved, translating that interest into clinical trials and developing new therapies for our patients. So that's been a natural fit for me across cancer in general.

I did fall into liver cancer care a bit by accident as part of my training. So I've been here at UC San Diego since 2011. I did my residency and fellowship training here. And when I was doing postdoctoral research as a fellow, I started working on some preclinical liver cancer related projects. And that in terms of the era of history was just when immunotherapy was coming to the forefront of cancer and how we're using immunotherapy in HCC. And the field has really exploded since that time and all the advances that we've made. So it's been an exciting time for me to be a part of that and to dedicate my career to HCC patient care and research. And then maybe I'll turn things back to you, Sam, and ask you how you got inspired to be a part of this team.

Sam (05:04.014)
Thank you. I also fell into HCC by accident, but my first job out of nursing school way back when was in oncology. So I've always been an oncology nurse at heart, but was a travel nurse during the pandemic and ultimately ended in San Diego in GI, which I never thought I would do, but fell in love with liver cancer patients. Their stories, saw an opportunity to really help a population that has historically been potentially underserved and under-resourced. So, HCC for life.

So, before we dive a little deeper, wondering if Dr. Burgoyne, you could give just a brief overview of HCC and sort of outline the differences that makes it different from other solid tumors.

Adam (05:55.534)
Sure. Thanks, Sam. I'm happy to kind of kick us off with some discussion on HCC and what makes it unique. So I'm a GI medical oncologist, and we do treat, of course, all cancers with the gastrointestinal tract. But there are some pretty unique differences for HCC in terms of the tumor biology, diagnosis, treatment, and even just the composition of the multidisciplinary team. So of course, we have Dr. Kono here from hepatology because we're talking exclusively about the liver. And hepatocellular carcinoma is the most common cancer of the liver. Dr. Kono can maybe elaborate on risk factors throughout the discussion today, but it does tend to arise most commonly in people that have underlying liver disease. And we'll talk about the importance of that from a tumor biology and treatment perspective, as well as complications in the management.

A few other unique features of HCC that make it different than the other tumors that we typically treat in the GI tract or across all of oncology is we do have very robust imaging tools for both diagnosis and response monitoring for HCC. And those are very well standardized. And HCC is one of the few tumor types where our diagnostic imaging tools are so robust that sometimes we don't even need to do a biopsy to confirm diagnosis, which is something that is a bit unique to the field and sometimes even surprises patients sometimes that they don't always need that biopsy for a tissue diagnosis. There are other unique aspects of HCC that maybe Dr. Berman can touch on later in our discussion in that we have some unique tools in our toolkit that we use specifically for liver-directed therapies that other tumor types don't always have at their fingertips. So it's for those reasons that we're here all to talk about our relevant specialties and how we work together to take care of cancer patients using all the different tools that we bring to the table.

Sam (07:59.906)
Great, thank you so much. And that sort of leads us into a great segue of, you know, with all of these different tools in the toolbox, how do you pick which ones and use them simultaneously to help patients? So Dr. Berman, could you speak to why a multidisciplinary team approach is essential in managing HCC?

Zach (08:21.196)
Yeah, of course. And just like Dr. Burgoyne mentioned with a lot of options that we have available for HCC that other tumors may not have, as was briefly mentioned, a lot of the patients have cirrhosis that causes them to have or develop HCC. And the only way for them to be quote unquote cured from the HCC is to usually get a liver transplant. So liver transplantation for patients with HCC is fairly unique, you know, endeavor, where some other cancers do are capable of getting liver transplantation, but that's a little bit more novel and experimental where for HCC liver transplantation is kind of the bread and butter. And so a lot of our patients are, you know, going to not only have treatment of their cancer, but then also treatment of what's causing the cancer at the same time too. So you may have, you know, myself or someone from my team, someone for Dr. Burgoyne's team, et cetera, all treating the cancer, but at the same time too, they also might be undergoing a liver transplant evaluation workup. You know, obviously Dr. Kono can touch a lot more on that, but it's quite involved. It has to do with, you know, financial background. Do they have a support network to help them after a liver transplantation, et cetera? Not necessarily related to the cancer itself, but it is part of their cancer care. So, you know, you need a whole team to kind of cover all facets of this where, you know, if someone had colorectal cancer, for instance, they may just need a medical oncologist to be kind of the hub of, you know, the hub and spokes model. But with HCC, given that there's so many different things going on, different people are needed for different things.

Adam (10:01.966)
Thanks.

Candice (10:03.018)
Dr. Berman, thank you for sharing that. Sam, I would love to understand how oncology nurses, nurse navigators, patient navigators, how they are part of that multidisciplinary team in terms of coordinating and supporting those patients with HCC.

Sam (10:18.51)
Yeah, they're absolutely essential. I've done this for several years now and you have patients coming from a wide variety of backgrounds. And historically, HCC, especially in Southern California, has disproportionately impacted patients of Hispanic and Asian ethnicities. And so with that comes a lot of potential barriers, including language, health literacy, distance to an academic medical center. Dr. Berman touched on social and caregiving support. You know, patients are battling not only a cancer, but also a significant chronic disease. So there's a lot of caregiving burden that comes along with these diagnoses. So not only are clinical oncology nurses needed, but non-clinical patient navigators are certainly part of this picture and helping with transportation, financial resources, medication coverage. It really runs the gamut.

Candice (11:24.386)
Thank you. And I'm glad you mentioned barriers. I mean, as you know, that's one major role of navigation is to assess and address those barriers. So I appreciate you bringing that up and including our non-clinical team members as they're equally as important, I think, in some ways because of the work that they do and where their focus lies. So thank you, Sam.

Sam (11:45.132)
Yeah, absolutely. And I did want to mention too that our social workers here at the Cancer Center are also instrumental. They have like a wide breadth of knowledge and, you know, specifically knowing resources that are geared towards HCC is really helpful in helping overcome some of these barriers to get patients treatment.

Candice (12:06.658)
Lots of collaboration.

Sam (12:09.144)

Definitely. And so, you know, we talked about how these patients have sort of two different diagnoses happening at the same time. So I'm wondering if Dr. Kono as a hepatologist, you may be able to speak to how underlying cirrhosis really kind of complicates decision-making and navigating treatment plans for these patients.

Yuko (12:30.434)
Right, so for other cancers, like we've been talking about, it's really cancer staging and oncologists will determine what type of treatment, what type of course, but because of the underlying cirrhosis, there are mainly two things we need to consider on top of tumor staging: the liver function and liver transplant candidacy. You know, for example, poor liver function limits treatment options, and we really need to balance HCC and liver function. If the patient has more HCC but very poor function, she or he would likely die from cirrhosis, not from HCC. So we will prioritize the transplant. Or if the patient has more advanced HCC but with good liver function, we will be very aggressive treating HCC as the patient will likely die from HCC. And these combinations will be, you know, many different ways, come in many different ways. So, you know, basically we are dealing with two life-threatening conditions simultaneously, cancer and cirrhosis and its complications that makes this decision making really complicated.

Sam (13:53.016)
Thank you so much. Yeah, it sounds like we've got a basis now of sort of understanding HCC and cirrhosis and their overlap. So, want to dive in a little bit more into the multidisciplinary team model that we use here at UCSD. So wondering Dr. Berman, if you'd be able to speak to sort of what the ideal MDT model for HCC looks like and who that involves.

Zach (14:16.846)
Of course, you know, like I said before, patients with HCC are going to have a lot of kind of players on the field at the same time. And so it's usually ideal to have all those players in the same room at the same time talking to each other. Right. So, you know, let's say someone has early stage HCC and they're going to be undergoing transplant evaluation at the same time. Being in there with the hepatology team is incredibly important. So if a patient needs to have imaging coordinated so that you don't have repeat imaging because the needs from the cancer therapy treatment might be different than that needed for liver transplantation. Making sure that you get the imaging at the right time, making sure the labs aren't being duplicated unnecessarily, and then making sure the patient understands all of these appointments they need to have. As patients start to get a little bit more advanced, the whole field right now is starting to experiment and I think experiment is too aggressive a word we're starting to see a lot more usage of combination therapy of local regional therapies with systemic therapies. And so there's a lot of coordination that needs to go into that. If a patient's on Bevacizumab or Avastin, that might need to be held for procedures and coordinating, making sure that everyone is on the same page from that is incredibly important. And then again, as we'll kind of touch upon in a little bit, all therapies do come with some toxicities. And so making sure everyone's there together, managing the toxicities together, you know, if they decompensate, any paracenteses can we expedite that? Or instead of having multiple people managing diuretics and stuff like that, having everyone in the same room together talking at the same time. Ideally in a multidisciplinary care team, you can have all of the right players in the room at the same time. And I think at a minimum for HCC, you're talking about hepatology, medical oncology, surgical oncology, and interventional radiology.

Sam (16:06.19)
Great, and I would add having an oncology nurse case manager can also be incredibly helpful in the MDT model as well. So Dr. Kono, Dr. Berman has mentioned the role of transplant in early stage HCC. Is there a specific time point or when would you start to involve the transplant teams in that patient's care?

Yuko (16:28.6)
So I would say in early time, the reason being, like Dr. Berman, Dr. Burgoyne mentioned, liver transplant is really the ultimate treatment for both cirrhosis and HCC. And if that's a cure for a patient and not only early stage HCC, nowadays we have downstaging, meaning we treat the HCC, advanced HCC, who are not eligible for transplant but may be eligible after being treated by either local regional treatment or even with systemic treatment. So if there is a possibility to become a transplant candidate, we definitely want to evaluate and give patients a chance for survival, for cure. And it is critical to involve transplant team from the beginning and we have transplant surgeons, hepatologists all the time in a multidisciplinary discussion as well.

Sam (17:36.312)
Great, thank you. And just one follow-up question just for the team members listening who may be not as familiar with HCC treatments. Is there ever an opportunity for transplant down the line after a patient has started treatment or maybe was initially deemed ineligible for transplant?

Yuko (17:56.51)
Correct. So usually, or traditionally, early stage HCCs called T2 stage HCC, you know, very small or up to three lesions were eligible, are eligible for transplant. And these patients can get what's called exception points for transplant priority it's called MELD points. But like Sam mentioned, when a patient has more advanced HCC but gets treated and downstaged within this T2 stage criteria, then they can also receive a transplant.

Candice (18:46.006)
You had mentioned the importance of the oncology case manager as part of the team, Sam. So I'd love to hear from your perspective, what role does the oncology nurse play in connecting all of those disciplines that were just mentioned?

Sam (18:58.382)
Yeah, thanks so much, Candice. There obviously are a lot of moving parts, right? And I think the biggest role we can play is always putting the patient at the center of all this care. There's a lot of to-dos on the list, but if we can keep the patient in mind including what is their financial status and insurance status like? How far do they have to drive to the cancer center? Do they come by themselves or with someone else who can help them with information and medication management? All of those things are really gonna help determine the trajectory for that patient in terms of going through various treatments. So, for example, here, the MDT model is really whenever a patient is able to see two or more providers from different disciplines, we try to coordinate those visits for the same day. It reduces transportation toxicity, financial toxicity, and helps the patient be more compliant with treatment plans of care. I really think just sort of remembering to bring it all back to the patient as much as we can is where we can really step in and help.

Candice (20:10.21)
That's great. Thank you.

Sam (20:11.938)
So getting more into some of the clinical decision-making that happens once we see a patient here in the MDT HCC clinic. Dr. Berman, can you speak to how staging sort of guides which specialty will take the lead in terms of treatment?

Zach (20:28.066)
Of course. And I think this is something that's incredibly unique and special to HCC. So there's a bunch of different staging models. I think, you know, most people might be familiar with the TNM staging for other kinds of cancer. While that does exist for HCC, in general, we tend not to use that. I think most people these days are using something called the BCLC or Barcelona Clinic Liver Cancer criteria, which essentially breaks patients down into, I would say, three main categories. The first one being early, the second one being intermediate, and the third one being advanced. There's some other categories in there too, but I think for simplicity, let's say those three. The early one that's where we're talking a lot more local regional therapies, whether that be surgery or something called percutaneous ablation or other trans-arterial therapies. The advanced stage is usually patients who have, you know, extensive vascular invasion from their cancer or metastatic disease from their cancer. And then usually we're talking about medical oncology with Dr. Burgoyne and his colleagues. Everything in between is called intermediate traditionally has gone to local regional therapy, although there's being a lot more push towards combination therapy of combining local regional with systemic therapy. And again, the whole goal is always trying to get patients to curative intent therapies if they can. So if we can somehow downstage them to transplant like Dr. Kono mentioned, at any stage of their treatment, if we can downstage them to transplant, that's always the goal.

Sam (21:59.586)
Great, that's very helpful. Thank you, Dr. Berman. So say we have a patient who has seen the great Dr. Berman for a local regional treatment, and it's determined that they need more systemic treatment. What is that transition like, Dr. Burgoyne? How do you come to see that patient?

Adam (22:20.398)
Thanks, Sam, that's a great question. And there's certainly been a pretty substantial evolution on how we think about transitioning these patients who maybe were benefiting from local regional therapy for some time, but something has now changed in their tumor biology or their clinical staging such that systemic therapy might be warranted either because they are becoming more advanced and that's the best option for them to treat their cancer, which has become more of a systemic process. Or as Dr. Berman alluded to, are there ways that we can introduce systemic therapy earlier to try to what we use this term of pushing people to the left on the BCLC staging system moving them towards curative intent therapies. And I'd be remiss not to note that this process has changed a lot. You know, 10 years ago when I was first starting to take care of advanced HCC patients and we were at the sort of end of the TKI era, we didn't have a lot of great options and there wasn't a strong push to transition someone from local regional therapy into the systemic arena. Our local regional therapy has also evolved substantially since that time too, as we're using radioembolization more frequently, which Dr. Berman can certainly tell us more about, and higher doses of radioembolization and seeing better outcomes there. So as our systemic therapy options have now included immunotherapy as our mainstay in terms of our backbone, which tend to be fairly well tolerated therapies, they don't work against local therapy. Sometimes they can work with local approaches, which is why as Dr. Berman mentioned, sometimes we're using combination therapies. Sometimes it is appropriate to get that patient evaluated for immunotherapy and either adding that on top of their local approach or making the decision that we're going to move forward, you know, targeting the whole body. In our experience and in my experience working with this team, that's really not one person working in a silo making that decision. That's a conversation that happens at tumor board. That's a conversation that happens offline between any members of the care team to make sure that we are serving the patient best when that transition might need to happen. And then of course, they're engaging people like Sam to help educate that patient on how that transition can be the smoothest because some of those handoffs can be disconcerting for patients. If they're used to Dr. Berman, to bring a new team member onto the scene can be obviously something that we need to make sure happens smoothly.

Candice (24:55.512)
Thank you, Dr. Burgoyne. I think that's helpful to think about those transitions and how the entire team can be involved. Sam, I would love to understand how nurses can help differentiate the treatment toxicity from liver decompensation.

Sam (25:10.318)
Yeah, it's a great question, Candice, and definitely an arena where oncology nurses can be really helpful to the multidisciplinary team. So as we talked about, these patients have two different processes happening both the liver cirrhosis or underlying liver disease, and then now are likely receiving an immunotherapy or a TKI or other liver cancer directed therapy. The best way to differentiate is to educate yourself on sort of the pathophysiology how cirrhosis comes to be, how it impacts other systems, complications that can happen like esophageal variceal bleeding, ascites, hepatic encephalopathy. We'll talk about some of those in a bit. Versus the immunotherapy adverse events that we see such as thyroiditis, colitis, dermatitis you know, all those things that we see from more of an overactive immune system. So sometimes it overlaps and it's hard to know, especially when it comes to liver function labs, right? Is this a hepatitis from immunotherapy or is this decompensating liver function? And again, that's where the multidisciplinary team approach really comes into play. Nurses communicating even with one another. Sometimes patients don't know who to reach out to, right? So you may be receiving a call from a patient complaining about worsening ascites that may be from their cirrhosis. Can you help connect that patient expeditiously to the correct department to help manage that? And I think being that touch point is really key there, which kind of goes into probably your next question.

Candice (27:02.284)
Yeah, you had mentioned the communication education, but would love to understand where oncology nurses might have the greatest impact in HCC care.

Sam (27:12.044)
Yeah, and Dr. Burgoyne mentioned it a bit about having trust in your care team. I think that is a big barrier for a lot of patients who have not maybe historically been engaged in the healthcare system and really building that rapport with patients of if you call me, I'm going to call you back. If you message me, I'm going to message you back. Here's my number. Call me if anything changes. You're not burdening me or not bothering me, that's why I'm here, is to help. And if I can't help, I'm going to help get you where you need to go. And I think really being that way-finding navigator that also has a clinical background and can decide who is best positioned to help this patient with their issue is where we can really be the compass.

Candice (28:01.058)
That's great. Thank you.

Sam (28:03.17)
We talked a lot about how we have two disease processes happening here. And so we're gonna sort of loop back to who owns treatment toxicity management. it medical oncology? Is it hepatology? Or is it a combination of both? So Dr. Burgoyne, would you like to speak to that?

Adam (28:20.522)
In terms of who owns the toxicity management, I have a bit of a mantra in my clinic, which is if I cause the problem, I'm gonna try to fix it. So if it's something that's clearly related to systemic therapy, and we know that those systemic therapies, although transformative in terms of improving outcomes for patients, can also come with side effects and risk. And some of those are pretty clear things that are low grade and easy for us to manage. Some of the things that that Sam mentioned, dermatitis related to immunotherapy, giving people antihistamines for itch, starting someone on topical steroids for a low grade rash. Those are things that are pretty clearly within our wheelhouse as medical oncologists that are frequently prescribing these agents that have known toxicity profiles. Things do get a little bit trickier though when we're not sure what the chicken or the egg is. Sam mentioned it's a very frequent occurrence in our HTC patients that we see elevations in liver function tests. And that's always when it's important that I'm not making decisions on my own, but I'm including the whole team. So if Dr. Kono is that patient's hepatologist, we are constantly having conversations. Hey, is this from worsening liver function from their cirrhosis? Is this from worsening liver function because their tumor is out of control? Is this a toxicity from immunotherapy?

And we manage those things very differently. So it is always important that not only are we on the same page about how we're managing that patient, but how sick are they? Oftentimes these patients end up needing to go to the emergency room or getting admitted to the hospital for expedited imaging and expedited care coordination from the inpatient teams and starting people on immunosuppression. And then if that first line immunosuppression with steroids is not working, when do we move to moving to second line agents and keeping the toxicity profiles of those drugs in mind if that person has bad side opinions or worried about that could be dangerous and then they have infectious risks. So these are all fairly nuanced conversations and it's always important that we have those conversations together so that we're best serving our patients to make a plan that we agree upon.

Zach (30:32.246)
It can also be tricky, especially as we're starting to combine local, regional with systemic therapies, because local regional therapies do have acute toxicity. And I think that's just more of the benefit of having a multidisciplinary clinic and team. So it can be very quick, because sometimes our patients get confused and they might have a procedure with me within a message you, Sam or Dr. Burgoyne, and say, I'm having these symptoms afterwards and you might not know what to do with it.

But since we have this collaborative teamwork, it's very easy for you to quickly ask me, is this normal, for instance? And then obviously I can help out there. But as the care is getting more complex, the sorts of things that might be happening to patients can be complex, and it's important to have that team.

Sam (31:15.438)
Absolutely. And then from a hepatology perspective, Dr. Kono, sort of how do you co-manage complications of cirrhosis like ascites, and cephalopathy, portal hypertension?

Yuko (31:27.116)
Yeah, thank you, Sam. So yeah, these are, but as Sam just mentioned, are very common complications of cirrhosis and we encounter those sick patients. And for example, ascites, we start with dietary advice, know, low-salt diet, high protein diet, and then we start diuretics. And diuretics, you know, if diuretics is not enough, then we turn into interventional radiology. Dr. Berman, can you do paracentesis?

And these are really managed, you know, we need to monitor labs and make sure kidney function, actuates are fine. And so we need to kind of manage those as it is. And then those, sepharopathy, hepatic cancer property, mycelial bleed, hypertension, these are, you know, what we do every day. But again, with the multidisciplinary team, we have really close communication, patient might be seeing maybe just Dr. Burgoyne today, but he's a little bit confused and some maybe, you know, talking to me, Dr. Kono, can you just see him? He looks a little bit odd, you know, maybe a little bit confused. You know, it can be a very subtle sign, but we know we pay attention to those things. So that's how we manage patients. And also I think Uncle Gene and Uncle just they are also getting familiar with management of those chronic patients complications. And they may be just seeing patients. I may not be there. They may get started. Well, let's start a load of standards, for example. And then I will follow up something like that.

Sam  (33:13.452)
Definitely a team effort, that's for sure. And I just want to add, you know, sometimes in a non-multidisciplinary model, this could certainly lead to communication breakdowns about if, you know, especially when a patient's liver function starts to decline or they start to decompensate. I think it's important to communicate to patients as a nurse what we think is happening, right? Is this liver function getting worse? Is this cancer getting worse? Are we not sure? But letting them know, reminding them that there are two different processes that are happening. And as Dr. Kono alluded to earlier, you can have cancer under control, liver function can continue to be poor from cirrhosis or vice versa. You can have very well compensated cirrhosis and cancer that's not under great control.

What is the cause of the symptoms? Do we know what the cause is? Do we need to figure out what the cause is? And really communicating that to the patient and their caregivers so they know what's going on. Also want to mention, I think one of the biggest things that has helped me as a liver cancer nurse navigator is just being connected within the healthcare system. So knowing someone from hepatology, knowing someone from IR, knowing someone from even primary care, just being able to expeditiously connect those patients with various providers and then also bringing other providers into the fold, right? A primary care physician may not know what medical oncology is doing or vice versa. So connecting those providers to have a conversation can sometimes be the bridge to really help a patient get the care they need. So in talking about sort of collaborating providers, we do have a...a standing tumor board specific for these liver cancer patients. Dr. Kono, you kind of have spearheaded that for many years. Do you wanna speak to sort of what triggers a multidisciplinary tumor board review of a patient's case and sort of what that review looks like?

Yuko (35:16.408)
Sure, thank you, Sam. So basically, any new HCC cases, we would like to review at the multidisciplinary tumor board so that we can have, you know, discussion with all the team members. And then we then decide what kind of treatment patient will go, you know, early stage, for example, will mainly go to surgery, surgical resection or interventional radiology local regional treatment or advanced case may go to systemic therapy or combination therapy. And then we will review patient will have a full-up imaging and we will review, you know, with either recurrent tumors or new tumors, what will be the next step? Because it's a, again, like we've been discussing, it's a complicated disease, complicated process.

We want to really re-review what will be the next step. Is there a time to go for transplant? Is there a time to go to combination? Is there a time to go to systemic? So we always want to discuss with about multidisciplinary team members.

Candice (36:28.076)
Wonderful, thank you, Dr. Kono. I would love to take a minute just to kind of wrap things up and close and just share that this has been a hugely informative and collaborative discussion. So I would like to personally thank the UCSD faculty and team for joining us today. So on behalf of the Heart and Soul of Oncology Navigation podcast, we appreciate you tuning in for this conversation, introducing hepatocelular carcinoma and the role of the multidisciplinary team. To learn more about interventional oncology and the Society of Interventional Oncology, including its mission to advance the field through research, evidence-based education that supports clinical excellence, and awareness efforts that expand access to life-changing treatment options, please visit the Society of Interventional Oncology website at www.sio-central.org. Thank you.