Current Status of Management of Hepatocellular Carcinoma in The Gulf Region: Challenges and Recommendations

SIMPLE SUMMARY: The incidence of liver cancer is rising globally and is estimated to reach >1 million cases by 2025. Hepatocellular carcinoma (HCC) accounts for ~90% of the cases of liver cancer and is associated with a high healthcare expenditure and death rate. The most prominent risk factors for HCC include hepatitis B and C viral infections and non-alcoholic steatohepatitis associated with metabolic syndrome or type 2 diabetes. There has been a steady increase in the diagnosis of liver cancer in the Arabian Gulf region, possibly due to the high incidence of obesity, diabetes, and viral hepatitis. The diversity of the Gulf population makes it imperative to develop and implement effective screening programs for the early diagnosis and treatment of HCC. In this review, we discuss the available literature on the epidemiology, screening, and management of HCC in the Gulf region. ABSTRACT: The burden of hepatocellular carcinoma (HCC) is on the rise in the Gulf region, with most patients being diagnosed in the intermediate or advanced stages. Surgery is a treatment option for only a few, and the majority of patients receive either locoregional treatment (percutaneous ethanol injection, radiofrequency ablation, transarterial chemoembolization [TACE], radioembolization, radiotherapy, or transarterial radioembolization) or systemic therapy (for those ineligible for locoregional treatments or who do not benefit from TACE). The recent emergence of novel immunotherapies such as immune checkpoint inhibitors has begun to change the landscape of systemic HCC treatment in the Gulf. The combination of atezolizumab and bevacizumab is currently the preferred first-line therapy in patients not at risk of bleeding. Additionally, the HIMALAYA trial has demonstrated the superiority of the durvalumab plus tremelimumab combination (STRIDE regimen) therapy in efficacy and safety compared with sorafenib in patients with unresectable HCC. However, there is a lack of data on post-progression treatment after first-line therapy with either atezolizumab plus bevacizumab or durvalumab plus tremelimumab regimens, highlighting the need for better-designed studies for improved management of patients with unresectable HCC in the Gulf region.