I’m not sufficiently convinced by the current data that there are any patient factors suggesting you should use one drug or the other. I know that there are data out there suggesting that, for example, that lenvatinib is associated with hypertension—that is not a deciding factor for me. The differences are still relatively minor.
What are the considerations for sequencing therapies for patients with advanced HCC?
At the moment, the only solid sequencing data that we have is the sorafenib–regorafenib (Stivarga) sequence or the sorafenib–cabozantinib (Cabometyx) or sorafenib–ramucirumab (Cyramza). The sorafenib–nivolumab data are a little less convincing, simply because the study was a phase II study, and not a phase III study. For lenvatinib, we don’t really have any data on sequencing therapy at all. The same kinds of considerations will apply post-lenvatinib as you have post-sorafenib, but that still needs to be demonstrated.
What are the most pressing challenges today in treating HCC?
Early diagnosis, or the lack of early diagnosis [is a big challenge]. The majority of patients, even in well-developed countries, present with incurable disease. Yet, theoretically at any rate, all liver cancer is curable at some point. The question is to find those patients when the cancer is treatable—the cure rate is going to go up substantially if we’re able to find those patients.
Are there clinical trials that you’re watching closely?
There are a number of studies out there that are going to report out in the near future. There is the phase III nivolumab study [CheckMate-459]. There is the pembrolizumab study…there are a couple of studies about bevacizumab and atezolizumab, and there was lenvatinib and pembrolizumab. Those are the big studies that are out there. The one that we are most interested in at this point is the phase III nivolumab data. If that’s good, then that’s going to be the first-line drug.
Since this is an international conference, can you discuss some of the areas in which different regions can learn from one another or share ideas?
One of the biggest differences is that treatment in the East is more aggressive than it is in the West. Some data would suggest that more aggressive treatment is associated with better outcomes. However, what is not made clear is whether this more aggressive treatment is also associated with more toxicity. It’s very difficult to assess the toxicities involved in some of these treatments in Asia, for example. I’m not yet ready to advocate for more aggressive treatment in the West.
We also have data from the West that suggest that if you don’t stick to the recommended treatment, results are worse. Those studies obviously do include toxicity, so I’m not sure yet that we should be going the more aggressive route.
The other thing is, in some centers in the East, they cling to the use of chemotherapeutic agents. We know that chemotherapy doesn’t work, and we know it’s toxic, but they continue to use it.
I’m a little disconcerted by the number of different staging systems that are being postulated both in the East and in the West, and somehow the staging systems that are described in the East don’t match the staging systems that are described in the West. There is something there that is not gelling properly.View more from the 2018 International Liver Cancer Association Annual Conference Brought to you in part by Eisai