Editorial Note: China bears a significant burden of liver cancer. To prevent its onset and progression, the country, society, and countless physicians have undertaken extensive measures under the framework of "three-level prevention," achieving remarkable progress. With the increasing proportion of early diagnosis and treatment of liver cancer in recent years, a key focus for radiotherapy specialists has been how to precisely select appropriate radiotherapy methods for early-stage liver cancer patients to improve their prognosis. Oncology Frontier interviewed Dr. Zhaochong Zeng from Zhongshan Hospital, Fudan University, to discuss liver cancer prevention and control in China, explore strategies and advantages of proton therapy, brachytherapy, and combined radiotherapy with interventional treatments for early-stage liver cancer, and outline the role of the radiotherapy department in multidisciplinary team (MDT) development for liver cancer.

01

Oncology Frontier: Could you provide an overview of the current state of early diagnosis and treatment for liver cancer in China? What areas need improvement?

Dr. Zhaochong Zeng:Liver cancer prevention and control in China mainly follow the “three-level prevention strategy”:

• Primary prevention aims to reduce risk factors and lower incidence rates.
• Secondary prevention focuses on early detection, early diagnosis, and early treatment.
• Tertiary prevention involves providing personalized treatments for diagnosed patients to delay disease progression and improve outcomes.

In China, screening programs enable early diagnosis and treatment, targeting high-risk groups such as individuals with a history of hepatitis, those older than 40, and those with a family history of liver cancer. Liver cancer screening in China has been relatively successful compared to other cancer types, primarily due to the availability of biomarkers such as alpha-fetoprotein (AFP) and des-gamma-carboxy prothrombin (DCP), as well as periodic imaging measures like ultrasound, which facilitate the detection of liver lesions.

If ultrasound reveals liver lesions alongside elevated tumor markers or a history of hepatitis B, further diagnostic evaluation is required.

However, there is still room for improvement. One significant issue is raising awareness among high-risk groups about the importance of regular screenings. Many individuals tend to neglect the necessity of periodic examinations. After a few normal results, they may discontinue screenings, leading to delayed diagnosis. This is an area that demands urgent attention.

02

Oncology Frontier: What are the outcomes of combining radiotherapy with interventional treatments for early-stage liver cancer? Which patient groups benefit most from this strategy?

Dr. Zhaochong Zeng:Early-stage liver cancer generally refers to tumors of 2–3 nodules with a maximum diameter of ≤3 cm or single tumors, regardless of whether they exceed 5 cm, with Child-Pugh class A/B liver function, and no imaging evidence of vascular invasion or extrahepatic metastasis.

Treatment strategies for early-stage liver cancer depend on tumor size and location and are categorized into surgical and non-surgical options.

• Surgical Candidates: Patients eligible for surgery generally achieve favorable outcomes through surgical resection.
• Non-Surgical Candidates: For tumors ≤5 cm, options like radiofrequency ablation (RFA) or stereotactic body radiotherapy (SBRT) can achieve curative results. For tumors >5 cm, RFA might not achieve complete eradication, and SBRT could face challenges, necessitating comprehensive approaches such as combined radiotherapy with interventional therapy, RFA, or pharmacological treatments.

In summary, surgery should be prioritized whenever feasible. For non-surgical cases, treatment approaches such as RFA, radiotherapy, or combination therapies should be considered.

03

Oncology Frontier: What are the advantages of proton therapy and brachytherapy for early-stage liver cancer patients?

Dr. Zhaochong Zeng:Studies have demonstrated that proton therapy combined with interventional treatments yields favorable outcomes. Proton therapy can be considered a specialized form of SBRT. Similar to photon SBRT, it is applicable for early-stage liver cancer patients.

Brachytherapy involves implanting radioactive particles within liver lesions, such as Yttrium-90 microspheres administered via hepatic artery injection. This approach is generally suitable for single lesions >5 cm in diameter in early-stage liver cancer patients.

• For large, unresectable lesions, Yttrium-90 microsphere brachytherapy is an option.
• For smaller tumors, brachytherapy is not recommended; instead, surgery, RFA, or proton/photon SBRT are preferable.

04

Oncology Frontier: In recent years, multidisciplinary team (MDT) approaches have significantly advanced liver cancer treatment. How should radiotherapy departments strengthen MDT development to maximize patient benefits?

Dr. Zhaochong Zeng:I often emphasize that radiotherapy is highly effective for liver cancer. However, due to limited MDT integration, radiotherapy remains underutilized, and access to it for liver cancer patients is restricted.

Liver cancer MDTs can adopt two models:

1. Hospital-Based MDT Teams:These include hepatobiliary surgery, oncology (liver cancer), gastroenterology, interventional radiology, radiotherapy, imaging, and pathology departments. Strengthening and organizing these teams within hospitals can increase patient access to comprehensive treatments. MDT meetings serve as platforms for evidence-based discussions and decision-making. Effective MDT collaboration enhances understanding between specialties, helping identify patients who are genuinely suitable for radiotherapy.
2. Internal MDT Teams within Radiotherapy Departments:These teams should consist of radiation oncologists, medical physicists, dosimetrists, and technicians. They need to focus on precise target delineation, dose planning, and patient condition assessments to optimize radiotherapy outcomes.

In summary, hospital-wide MDTs are essential for determining the most appropriate treatment strategies for patients, while internal MDTs within radiotherapy departments are crucial for ensuring precise and effective radiotherapy. Therefore, the future development of radiotherapy departments does not solely rely on advanced equipment but also on active participation in hospital-wide MDTs and building strong internal MDTs to deliver optimal radiotherapy for liver cancer patients.

Dr. Zhaochong Zeng

• Titles: Second-level Professor Chief Physician Doctoral Supervisor at Zhongshan Hospital, Fudan University
• Professional Roles: Vice Chair, Radiotherapy Oncology Branch, Chinese Research Hospital Association Vice Chair, Integrated Diagnosis and Treatment Branch, Chinese Anti-Cancer Association Vice Chair, Tumor Radiobiology and Multimodal Therapy Committee Standing Member, CSCO Liver Cancer Committee Standing Member, Liver Cancer Committee, Chinese Medical Doctor Association
• Publications and Achievements: Published 130 SCI papers and 70 Chinese-language articles as the first or corresponding author. Editor-in-Chief of Clinical Practice of Radiotherapy for Primary Liver Cancer (1st and 2nd Editions) and Atlas of Precise Radiotherapy Target Delineation for Primary Liver Cancer. Lead author of Consensus for SBRT for HCC from the 7th APPLE and the 2016 and 2020 Consensus on Radiotherapy for Primary Liver Cancer. Recipient of one national second prize for scientific and technological progress and four provincial and ministerial science and technology awards. Principal investigator of nine national research projects. Recognized as an outstanding academic leader and top talent in Shanghai; awarded the title of Shanghai’s Excellent Doctor in 2023.

Editorial Note: China bears a significant burden of liver cancer. To prevent its onset and progression, the country, society, and countless physicians have undertaken extensive measures under the framework of “three-level prevention,” achieving remarkable progress. With the increasing proportion of early diagnosis and treatment of liver cancer in recent years, a key focus for radiotherapy specialists has been how to precisely select appropriate radiotherapy methods for early-stage liver cancer patients to improve their prognosis. Oncology Frontier interviewed Dr. Zhaochong Zeng from Zhongshan Hospital, Fudan University, to discuss liver cancer prevention and control in China, explore strategies and advantages of proton therapy, brachytherapy, and combined radiotherapy with interventional treatments for early-stage liver cancer, and outline the role of the radiotherapy department in multidisciplinary team (MDT) development for liver cancer.

01

Oncology Frontier: Could you provide an overview of the current state of early diagnosis and treatment for liver cancer in China? What areas need improvement?

Dr. Zhaochong Zeng:Liver cancer prevention and control in China mainly follow the “three-level prevention strategy”:

• Primary prevention aims to reduce risk factors and lower incidence rates.
• Secondary prevention focuses on early detection, early diagnosis, and early treatment.
• Tertiary prevention involves providing personalized treatments for diagnosed patients to delay disease progression and improve outcomes.

In China, screening programs enable early diagnosis and treatment, targeting high-risk groups such as individuals with a history of hepatitis, those older than 40, and those with a family history of liver cancer. Liver cancer screening in China has been relatively successful compared to other cancer types, primarily due to the availability of biomarkers such as alpha-fetoprotein (AFP) and des-gamma-carboxy prothrombin (DCP), as well as periodic imaging measures like ultrasound, which facilitate the detection of liver lesions.

If ultrasound reveals liver lesions alongside elevated tumor markers or a history of hepatitis B, further diagnostic evaluation is required.

However, there is still room for improvement. One significant issue is raising awareness among high-risk groups about the importance of regular screenings. Many individuals tend to neglect the necessity of periodic examinations. After a few normal results, they may discontinue screenings, leading to delayed diagnosis. This is an area that demands urgent attention.

02

Oncology Frontier: What are the outcomes of combining radiotherapy with interventional treatments for early-stage liver cancer? Which patient groups benefit most from this strategy?

Dr. Zhaochong Zeng:Early-stage liver cancer generally refers to tumors of 2–3 nodules with a maximum diameter of ≤3 cm or single tumors, regardless of whether they exceed 5 cm, with Child-Pugh class A/B liver function, and no imaging evidence of vascular invasion or extrahepatic metastasis.

Treatment strategies for early-stage liver cancer depend on tumor size and location and are categorized into surgical and non-surgical options.

• Surgical Candidates: Patients eligible for surgery generally achieve favorable outcomes through surgical resection.
• Non-Surgical Candidates: For tumors ≤5 cm, options like radiofrequency ablation (RFA) or stereotactic body radiotherapy (SBRT) can achieve curative results. For tumors >5 cm, RFA might not achieve complete eradication, and SBRT could face challenges, necessitating comprehensive approaches such as combined radiotherapy with interventional therapy, RFA, or pharmacological treatments.

In summary, surgery should be prioritized whenever feasible. For non-surgical cases, treatment approaches such as RFA, radiotherapy, or combination therapies should be considered.

03

Oncology Frontier: What are the advantages of proton therapy and brachytherapy for early-stage liver cancer patients?

Dr. Zhaochong Zeng:Studies have demonstrated that proton therapy combined with interventional treatments yields favorable outcomes. Proton therapy can be considered a specialized form of SBRT. Similar to photon SBRT, it is applicable for early-stage liver cancer patients.

Brachytherapy involves implanting radioactive particles within liver lesions, such as Yttrium-90 microspheres administered via hepatic artery injection. This approach is generally suitable for single lesions >5 cm in diameter in early-stage liver cancer patients.

• For large, unresectable lesions, Yttrium-90 microsphere brachytherapy is an option.
• For smaller tumors, brachytherapy is not recommended; instead, surgery, RFA, or proton/photon SBRT are preferable.

04

Oncology Frontier: In recent years, multidisciplinary team (MDT) approaches have significantly advanced liver cancer treatment. How should radiotherapy departments strengthen MDT development to maximize patient benefits?

Dr. Zhaochong Zeng:I often emphasize that radiotherapy is highly effective for liver cancer. However, due to limited MDT integration, radiotherapy remains underutilized, and access to it for liver cancer patients is restricted.

Liver cancer MDTs can adopt two models:

1. Hospital-Based MDT Teams:These include hepatobiliary surgery, oncology (liver cancer), gastroenterology, interventional radiology, radiotherapy, imaging, and pathology departments. Strengthening and organizing these teams within hospitals can increase patient access to comprehensive treatments. MDT meetings serve as platforms for evidence-based discussions and decision-making. Effective MDT collaboration enhances understanding between specialties, helping identify patients who are genuinely suitable for radiotherapy.
2. Internal MDT Teams within Radiotherapy Departments:These teams should consist of radiation oncologists, medical physicists, dosimetrists, and technicians. They need to focus on precise target delineation, dose planning, and patient condition assessments to optimize radiotherapy outcomes.

In summary, hospital-wide MDTs are essential for determining the most appropriate treatment strategies for patients, while internal MDTs within radiotherapy departments are crucial for ensuring precise and effective radiotherapy. Therefore, the future development of radiotherapy departments does not solely rely on advanced equipment but also on active participation in hospital-wide MDTs and building strong internal MDTs to deliver optimal radiotherapy for liver cancer patients.

Dr. Zhaochong Zeng

• Titles: Second-level Professor Chief Physician Doctoral Supervisor at Zhongshan Hospital, Fudan University
• Professional Roles: Vice Chair, Radiotherapy Oncology Branch, Chinese Research Hospital Association Vice Chair, Integrated Diagnosis and Treatment Branch, Chinese Anti-Cancer Association Vice Chair, Tumor Radiobiology and Multimodal Therapy Committee Standing Member, CSCO Liver Cancer Committee Standing Member, Liver Cancer Committee, Chinese Medical Doctor Association
• Publications and Achievements: Published 130 SCI papers and 70 Chinese-language articles as the first or corresponding author. Editor-in-Chief of Clinical Practice of Radiotherapy for Primary Liver Cancer (1st and 2nd Editions) and Atlas of Precise Radiotherapy Target Delineation for Primary Liver Cancer. Lead author of Consensus for SBRT for HCC from the 7th APPLE and the 2016 and 2020 Consensus on Radiotherapy for Primary Liver Cancer. Recipient of one national second prize for scientific and technological progress and four provincial and ministerial science and technology awards. Principal investigator of nine national research projects. Recognized as an outstanding academic leader and top talent in Shanghai; awarded the title of Shanghai’s Excellent Doctor in 2023.