Chemoembolization for hepatocellular carcinoma: where does the truth lie?

Hepatocellular carcinoma (HCC) remains one of the most highly lethal cancers in the world. It continues to be plagued by a shortage of effective therapeutic options and consequently is a major cause of death, especially in eastern Asia and sub-Saharan Africa. In the United States, the incidence of HCC has been rapidly and steadily increasing in the past 20 years because of the concomitant epidemic rise in hepatitis C virus infection. Surgical resection and liver transplantation offer the only chance for a cure, but, unfortunately, tumors in most patients are found to be unresectable at presentation and the patients are therefore left with palliative options only. Of those, transcatheter arterial chemoembolization has been the most widely used over the years and has become the mainstay of therapy for patients with unresectable HCC. Yet, controversy has surrounded its efficacy and impact on patient survival. After a period of initial enthusiasm followed by encouraging results from retrospective and prospective studies, several randomized trials failed to show any survival advantage of chemoembolization over supportive care. So where does the truth lie? The publication this year of two separate high-quality randomized trials, one in Hepatology from Hong Kong and the other in Lancet from Spain, should help answer this question and finally establish the usefulness of chemoembolization as an effective palliative therapy against HCC.