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Sequencing With I-O Combinations in Unresectable HCC

Insights From: Richard S. Finn, MD, University of California Los Angeles
Published: Friday, Jan 31, 2020



Transcript: 

Richard S. Finn, MD: In the past 2 years, we’ve seen a lot of new data and approvals in the liver cancer space happen very fast. Frontline, we have lenvatinib and sorafenib based on noninferiority data. And then we have several second-line agents approved. All of them, though, took patients who had prior sorafenib. And that’s progress. As new drugs become available, we need to be able to integrate new data into our practice paradigms. If the IMbrave150 data lead to regulatory approval, which I think most of us suspect it will, then we will have a new frontline regimen for the majority of our patients. That would be bevacizumab and atezolizumab. This is helpful because the field has been trying to figure out where I/O [immuno-oncology] agents will fit in. Currently they’re approved in the second line based on accelerated approval mechanisms for nivolumab and pembrolizumab. But now, I/O will probably be moved to the frontline in combination with atezolizumab. Then I think we’ll probably be sequencing TKIs—the first-line TKI, perhaps sorafenib, lenvatinib. Then sequencing cabozantinib or regorafenib, and ramucirumab for patients who have elevated alpha-fetoprotein.

But now we’re talking about potentially 3 lines of therapy. That means patients need to be in good condition, right? It is really important for us to get the message out that we have systemic treatments that are improving survival, and that to continue doing locoregional treatments for patients who have liver-confined disease or vascular invasion should not be the standard practice. A patient should be transitioned to systemic treatment once they have evidence of progression after locoregional treatment. That will be an important education point for practitioners, because we now have very high-level evidence that we can improve survival with systemic treatment. There are a number of them available for patients. And in order to get patients these sequences, they need to be well enough. Liver function cannot be decompensated to get these treatments, because then we won’t get benefits and we’ll see more toxicity.

Transcript Edited for Clarity
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Transcript: 

Richard S. Finn, MD: In the past 2 years, we’ve seen a lot of new data and approvals in the liver cancer space happen very fast. Frontline, we have lenvatinib and sorafenib based on noninferiority data. And then we have several second-line agents approved. All of them, though, took patients who had prior sorafenib. And that’s progress. As new drugs become available, we need to be able to integrate new data into our practice paradigms. If the IMbrave150 data lead to regulatory approval, which I think most of us suspect it will, then we will have a new frontline regimen for the majority of our patients. That would be bevacizumab and atezolizumab. This is helpful because the field has been trying to figure out where I/O [immuno-oncology] agents will fit in. Currently they’re approved in the second line based on accelerated approval mechanisms for nivolumab and pembrolizumab. But now, I/O will probably be moved to the frontline in combination with atezolizumab. Then I think we’ll probably be sequencing TKIs—the first-line TKI, perhaps sorafenib, lenvatinib. Then sequencing cabozantinib or regorafenib, and ramucirumab for patients who have elevated alpha-fetoprotein.

But now we’re talking about potentially 3 lines of therapy. That means patients need to be in good condition, right? It is really important for us to get the message out that we have systemic treatments that are improving survival, and that to continue doing locoregional treatments for patients who have liver-confined disease or vascular invasion should not be the standard practice. A patient should be transitioned to systemic treatment once they have evidence of progression after locoregional treatment. That will be an important education point for practitioners, because we now have very high-level evidence that we can improve survival with systemic treatment. There are a number of them available for patients. And in order to get patients these sequences, they need to be well enough. Liver function cannot be decompensated to get these treatments, because then we won’t get benefits and we’ll see more toxicity.

Transcript Edited for Clarity
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