Liver cancer patients gain clarity on surgery options through precision medicine tool

Duke-NUS alumnus Dr Marjorie Hoang (Class of 2023) and her mentor, Professor Pierce Chow, have brought clarity to the complex decision-making process patients diagnosed with intermediate-stage liver cancer and their doctors face by creating an algorithm that can accurately calculate the likely overall survival and recurrence-free survival following surgery.

Dr Hoang, whose interest in the liver stems from her first year at Duke-NUS, undertook a transformative third-year research project under the guidance of Prof Chow, a senior consultant specialising in liver cancer surgery at the National Cancer Centre Singapore, from which emerged this latest collaboration that lasted well-beyond Dr Hoang's medical school years.

"It was during the Body and Disease course at the end of my first year that I became fascinated with the liver. Knowing how prevalent HCC is in Asia-;particularly in Singapore, and Vietnam, where I'm from-;has given me added purpose as I set out to become a clinician," said Dr Hoang, who hopes to join General Surgery Residency and plans to continue pursuing research in this field. 

Together, they set about how to better predict which patients diagnosed with intermediate-stage liver cancer would benefit from a partial surgical removal of the part of liver affected by the cancer.

Marjorie's work addresses an urgent need that doctors and patients face once a diagnosis of HCC is made: the need for an accurate way to determine if surgical resection is the best treatment for a specific patient."

Pierce Chow, Professor, Duke-NUS Medical School

Liver cancer is the seventh most common cancer and the fourth deadliest cancer in the world. And most patients live in East and Southeast Asia. In fact, Dr Hoang's native Vietnam has one of the highest liver cancer rates in the world.

Notoriously challenging to detect early, eight out of ten diagnoses are made only when the cancer is advanced, while those who are diagnosed earlier fall into one of two broad groups. For those whose cancer is at an early stage, treatment options and their benefits are clearly defined.

However, for those whose cancer is an intermediate stage, the best treatment strategy is less clear as the disease presents in many different forms. And thanks to medical advances, including radiation and immunotherapy, patients also face a range of options, further complicating the decision-making.

"For early-stage HCC patients, the Milan criteria is often used to choose patients who are eligible for surgical resection," explained Dr Hoang. "Surgery also remains a widely used therapy in intermediate-stage HCC although there has been no good model to prognosticate survival after resection among patients in this group."

To address this need, Dr Hoang and Prof Chow, along with their team and collaborators from the Duke University Medical Centre, set about adapting a well-established clinical calculator, called Metroticket, which was previously developed to determine the likely prognosis for a liver cancer patient who received a liver transplant, to offer patients with intermediate-stage HCC greater clarity.

The adapted calculator, which was validated using both local and international datasets, takes into account "the patient's tumour burden, degree of biological aggressiveness of the tumour, liver function and age," summarised Prof Chow.

Called the Modified Metroticket, this algorithm accurately predicted overall survival and recurrence-free survival in the Singapore training cohort and US validation patient cohorts. In the Singapore cohort, the Modified Metroticket even outperformed the standard staging system by the American Joint Committee on Cancer used currently.

"This algorithm, made available in the form of an online calculator, will empower doctors and patients to potentially change clinical practice," Prof Chow added.

When Dr Hoang received the news that the prestigious surgical journal International Journal of Surgery accepted her manuscript, she was elated:

"It was a long and arduous process, from writing the paper to going through many rounds of corrections and replies to reviewers. But finally, we got the paper published!"

And all this, while working as a post-graduate Year 1 house officer.

Dr Hoang's journey-;from medical student to aspiring clinician-scientist and author of a precision medicine tool-;illustrates how passion and precision can combine to create real-world solutions in healthcare. But for her, knowing that her work is now out there to help clinicians and patients alike is all the reward she needs.