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Liver cancers

About

What is covered

This interactive flowchart covers liver and bile duct cancers.

Updates

Updates to this interactive flowchart

22 May 2018 Endoscopic bipolar radiofrequency ablation for treating biliary obstruction caused by cancer (NICE interventional procedures guidance 614) added to treating cholangiocarcinoma.
20 March 2018 Regorafenib for previously treated advanced hepatocellular carcinoma (NICE technology appraisal guidance 514) added to treating hepatocellular carcinoma.
5 September 2017 Sorafenib for treating advanced hepatocellular carcinoma (NICE technology appraisal guidance 474) added to treating hepatocellular carcinoma.
26 April 2016 Microwave ablation for treating liver metastases (NICE interventional procedures guidance 553) added to treating liver metastases.
24 November 2015 Living-donor liver transplantation (NICE interventional procedures guidance 535) added to liver transplantation.
21 July 2015 Everolimus for preventing organ rejection in liver transplantation (NICE technology appraisal guidance 348) added to liver transplantation.
27 May 2014 Chemosaturation via percutaneous hepatic artery perfusion and hepatic vein isolation for primary or metastatic liver cancer (NICE interventional procedures guidance 488) added to treating all types of liver cancer.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on liver and bile duct cancers in an interactive flowchart

What is covered

This interactive flowchart covers liver and bile duct cancers.

Updates

Updates to this interactive flowchart

22 May 2018 Endoscopic bipolar radiofrequency ablation for treating biliary obstruction caused by cancer (NICE interventional procedures guidance 614) added to treating cholangiocarcinoma.
20 March 2018 Regorafenib for previously treated advanced hepatocellular carcinoma (NICE technology appraisal guidance 514) added to treating hepatocellular carcinoma.
5 September 2017 Sorafenib for treating advanced hepatocellular carcinoma (NICE technology appraisal guidance 474) added to treating hepatocellular carcinoma.
26 April 2016 Microwave ablation for treating liver metastases (NICE interventional procedures guidance 553) added to treating liver metastases.
24 November 2015 Living-donor liver transplantation (NICE interventional procedures guidance 535) added to liver transplantation.
21 July 2015 Everolimus for preventing organ rejection in liver transplantation (NICE technology appraisal guidance 348) added to liver transplantation.
27 May 2014 Chemosaturation via percutaneous hepatic artery perfusion and hepatic vein isolation for primary or metastatic liver cancer (NICE interventional procedures guidance 488) added to treating all types of liver cancer.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Regorafenib for previously treated advanced hepatocellular carcinoma (2018) NICE technology appraisal guidance 514
Sorafenib for treating advanced hepatocellular carcinoma (2017) NICE technology appraisal guidance 474
Everolimus for preventing organ rejection in liver transplantation (2015) NICE technology appraisal guidance 348
Microwave ablation for treating liver metastases (2016) NICE interventional procedures guidance 553
Living-donor liver transplantation (2015) NICE interventional procedures guidance 535
Selective internal radiation therapy for primary hepatocellular carcinoma (2013) NICE interventional procedures guidance 460
Irreversible electroporation for treating liver metastases (2013) NICE interventional procedures guidance 445
Irreversible electroporation for treating primary liver cancer (2013) NICE interventional procedures guidance 444
Cryotherapy for the treatment of liver metastases (2010) NICE interventional procedures guidance 369
Radiofrequency ablation for colorectal liver metastases (2009) NICE interventional procedures guidance 327
Ex-vivo hepatic resection and reimplantation for liver cancer (2009) NICE interventional procedures guidance 298
Microwave ablation of hepatocellular carcinoma (2007) NICE interventional procedures guidance 214
Radiofrequency-assisted liver resection (2007) NICE interventional procedures guidance 211
Laparoscopic liver resection (2005) NICE interventional procedures guidance 135
Photodynamic therapy for bile duct cancer (2005) NICE interventional procedures guidance 134
Radiofrequency ablation of hepatocellular carcinoma (2003) NICE interventional procedures guidance 2
SIR-Spheres for treating inoperable hepatocellular carcinoma (2016) NICE medtech innovation briefing 63

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Regorafenib

In the NHS, advanced unresectable hepatocellular carcinoma is mostly treated with sorafenib. For people who cannot tolerate sorafenib, or whose disease progresses with sorafenib, the only current option is best supportive care. Regorafenib is a possible treatment option after sorafenib instead of best supportive care, in line with its marketing authorisation.
Clinical trial evidence in people with advanced hepatocellular carcinoma who have already had sorafenib, have an ECOG performance status score of either 0 or 1, and Child-Pugh grade A liver impairment shows that people having regorafenib live longer than people having best supportive care. However, the survival benefit with regorafenib is unclear in people who cannot tolerate sorafenib, have a poorer ECOG performance status or more severe liver disease. These people were not included in the trial so it is uncertain whether the results of the trial would translate into similar benefits in the NHS.
The company responded to the committee's preferred assumptions after consultation and submitted a further model incorporating these assumptions for overall survival extrapolation, full dose and pooled resource use surveys.
Regorafenib meets NICE's criteria to be considered a life-extending treatment at the end of life. The most plausible cost-effectiveness estimates are higher than those NICE normally considers an acceptable use of NHS resources for end-of-life treatments. Therefore regorafenib cannot be recommended for routine use in the NHS.
Regorafenib is not recommended through the Cancer Drugs Fund because the uncertainties in the clinical and cost effectiveness cannot be resolved by data collection in the Cancer Drugs Fund, and regorafenib does not have plausible potential to be cost effective.
For more information see the committee discussion in the NICE technology appraisal guidance on regorafenib for previously treated advanced hepatocellular carcinoma.

Glossary

Eastern Cooperative Oncology Group

Paths in this pathway

Pathway created: November 2013 Last updated: May 2018

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