Hepatocellular carcinoma (HCC) is a primary malignancy of the liver that occurs predominantly in patients with underlying chronic liver disease and cirrhosis. Treatments exist for patients with HCC, but only orthotopic liver transplantation or liver resection are potentially curative. However, with the nationwide shortage of organ donors, other minimally invasive treatment options may be offered. These include transarterial chemoembolization (TACE), radiofrequency ablation (RFA), microwave ablation (MWA), and systemic chemotherapy. Currently, a patient with a diagnosis of HCC is reviewed at a multidisciplinary tumor board comprised of a panel of physicians who are experts in different medical specialties; these specialists determine the treatment plan that can produce optimal outcomes for patients.
TACE is the initial locoregional treatment used most frequently for HCC as well as for the downstaging of tumors. Given that HCC is mostly dependent on hepatic arterial blood supply, embolization of the hepatic artery branch leads to selective tumor hypoxia and eventually tumor necrosis by reducing arterial blood flow. This technique involves image-guided catheter-based infusion of particles, such as polyvinyl alcohol beads, alcohol, starch microspheres, metallic coils, autologous blood clots, and gelfoam. Prior to embolization, a chemotherapeutic agent including doxorubicin, cisplatin, mitomycin, and epirubicin is injected. Yttrium 90 delivers a more targeted delivery of effective dose radiation directly to the liver in much the same manner as TACE. Microscopic glass beads that contain radioactive material become trapped in blood vessels that feed the tumor and deliver radiation to the lesion.
RFA is considered the most frequently used minimally invasive treatment for HCC. RFA delivers a rapid electromagnetic pulse that causes thermal injury leading to necrosis of the lesion, which is dependent on both the temperature achieved and the duration of heating. MWA is similar to RFA and utilizes electromagnetic waves with high frequencies that lead to rapid elevation of temperatures within the MWA field, leading to a more rapid and uniform ablation.
In terms of systemic therapies, the oral tyrosine kinase inhibitor sorafenib has become the systemic therapy standard of treatment for advanced HCC. Current treatment options are only modestly associated with increased survival, however, highlighting the need for novel strategies and agents. Future studies are needed to further investigate biomarkers, treatment modalities, and newer systemic treatments for HCC.
The following case studies illustrate the varied roles of the nurse navigator in improving outcomes in patients with HCC.
Case Study 1
A 43-year-old male presented with right lower quadrant abdominal pain. He underwent exploratory laparotomy, liver biopsy, and intraoperative ultrasound for diagnosis. The final pathology revealed moderately to poorly differentiated HCC. Navigation was initiated at the time of diagnosis. The oncology nurse navigator educated the patient on HCC, explained the diagnostic test results, and discussed the treatment options available. A multidisciplinary team approach was utilized to care for the patient. This included internal medicine, gastroenterology, surgery, medical oncology, pain management, and nurse navigation.
Since the patient’s disease was localized to the liver, he was offered outpatient therapy with sorafenib. He was hesitant to begin any treatment because of his cultural beliefs, so the oncology nurse navigator referred him to a pastoral counselor, who helped him make the decision to start sorafenib treatment. At this juncture, the nurse navigator educated the patient on potential side effects that may occur with the drug, including diarrhea, fatigue, hand–foot skin reaction, and hypertension. She also provided information on the management of common side effects associated with sorafenib and provided printed materials for the patient’s reference. The patient indicated that he would not continue sorafenib therapy if his quality of life began to deteriorate.
The oncology nurse navigator stressed the importance of compliance with the prescribed schedule and dose of sorafenib to achieve optimal results of the treatment and provided tools to help the patient stay adherent. She followed up with the patient regularly and provided appropriate interventions as needed to manage side effects related to sorafenib treatment. With the support of his nurse navigator, the patient was able to complete the full course of sorafenib treatment.
Case Study 2
A 59-year-old African American male was diagnosed with HCC. The medical oncologist decided to initiate TACE treatments, which involved working in conjunction with the interventional radiology specialist. The patient was referred to a gastrointestinal nurse navigator at diagnosis.
At the outset, the nurse navigator made efforts to understand the patient’s social history and build a rapport with him. As a result, the patient shared that he had a history of alcohol and drug abuse in his younger years. He shared that his wife had helped him mend his ways and change his life; he had promised her that he would support her for the rest of her life. However, because of his HCC diagnosis and treatment-related side effects, he was unable to keep up with the demands of work.
At his medical oncology visit before his second TACE treatment, the patient was emotional and expressed that he was fearful that he would be unable to keep his promise to his wife. Moreover, the patient shared that he had experienced severe vomiting after the first TACE treatment and was unsure if he would be able to continue the prescribed treatments. In anticipation of his upcoming treatment, the patient expressed that he was feeling anxious, depressed, and hesitant to continue TACE therapy.
His nurse navigator recognized that the patient needed emotional support and referred him to a psychiatrist, to address his feelings of guilt surrounding his inability to keep his promise to his wife. Next, the nurse navigator referred the patient to a social worker to assist him with financial resources, to address the financial situation that was causing him stress and anxiety. After this, the patient was referred to a palliative medicine specialist for managing the pain, fatigue, and nausea that he was experiencing. Finally, the nurse navigator referred the patient to a dietitian since he had experienced significant weight loss.
Nurse navigators build rapport with their patients and can identify barriers to treatment, thereby allowing them to provide appropriate and prompt interventions. In this case, the patient shared his feelings and experiences with his nurse navigator, which he would have been hesitant to share with his provider.
