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The Management of HCC: Moving Forward

Panelists: Ghassan K. Abou-Alfa, MD, Weill Cornell Medical College; Peter Galle, MD, PhD Johannes Gutenberg University, Mainz; Riad Salem, MD, Northwestern University; Amit Singal, MD UT Southwestern Medical Center
Published: Wednesday, Jan 09, 2019



Transcript: 

Ghassan K. Abou-Alfa, MD: With this, I would like to ask for any final thoughts about all the different things that we have discussed. Peter?

Peter Galle, MD, PhD: One aspect that might be stressed that we haven’t been talking about so much is the relevance of side effects. Side effects are something we and the patient are afraid of. They result in stopping the treatment. However, in recent years, we have learned that in TKI [tyrosine kinase inhibitor]–related side effects, there’s also a positive. All of these side effects are related to better outcomes. So patients who, for example, develop hand-foot skin reaction do benefit more on therapy. What does that mean? It means that we have a way to discriminate those who are responding better than others. It tells us that it’s very relevant to keep patients on a drug. We have to play around much more with our TKIs than we thought in the past. In the beginning, we felt that we should either give at a full dose or not give at all. We should not be flexible about that because patients will be, in the end, undertreated, and the tumor will become resistant. This is not the case.

We can go up and down and adjust it according to the needs of our patients. I think that is very relevant. Particularly when we talk about combinations, it’s all about toxicity. The only way to guide a patient through therapy is to adapt therapy according to the patient’s needs. That means having a fine understanding of side effects and doing a tapering or an adaption of the dosing.

Ghassan K. Abou-Alfa, MD: I totally agree. I’m glad you brought this up because checkpoint inhibitors, like TKIs, have side effects. Thankfully, we don’t see too many side effects with the checkpoint inhibitors, but they can happen. We have to be very vigilant.

Riad, any final thoughts?

Riad Salem, MD: Yes, just a couple of things. I think we have to continue to think about combination therapy. The reality is that everybody gets combination therapy. We have to figure out what the optimal way is to treat them. If you treat earlier or intermediate disease, how can you maximize that without having the issue of side effects and start the systemic therapies early?

The other thing I would say is response matters. This is something that matters to patients. It matters to physicians. It’s probably the most talked about issue in follow-up clinic. Frankly, what is causing a lot of excitement in the HCC [hepatocellular carcinoma] field are these responses that people are seeing.

I think overall survival, as an endpoint, is a clear one for very advanced disease. It’s much more challenging to perform clinical trials in earlier disease and intermediate disease, and I think investigators and thought leaders have to really figure out endpoints that are relevant that will move the field forward, get incorporated into guidelines, and be enough for scientists and physicians to act on. I think that’s very important.

And ultimately for me, as an interventional radiologist, I deal with a lot of different conditions. HCC continues, after 15 years, to be the most exciting one, in my opinion. It’s the most exciting field that I work in, and I’m always sort of proud to be a part of that tumor board.

Ghassan K. Abou-Alfa, MD: Well, I’m honored to have you as well. Number 1, we still definitely have change, in regard to the endpoints. We all agree that response rates definitely, as we discussed, have evolved quite a bit, in regard to not only the response but also the extent of the response or how long the response will be. But on the other hand, we put this in perspective with regard to the intent to treat that we brought up a little bit, especially with atezolizumab-bevacizumab.

And No 3 is the point about the criticality of the overall survival. Whenever something happens in a patient, whatever happens on a certain dimension, is actually a part of that patient’s care. As such, the overall survival has quite a bit of critical importance in this regard.

But I like what you have said. If anything, the most important great news is actually for the patients. We have a lot of opportunities for patients and can offer things that hopefully will extend life and hopefully, of course, lead to cure.

Amit, final thoughts?

Amit Singal, MD: Yes, I have 2 closing thoughts. The first is that we’ve seen a lot of advances in terms of locoregional therapy and systemic therapy. But at the end of the day, it goes back to where we started. The best survival is likely if you’re found at an early stage. So it’s important that we know the at-risk population. It’s important that we really promote HCC surveillance and find these patients at an early stage. When they are found at an early stage, it is important to refer them for curative therapies. At the end of the day, the best survival is with resection, transplantation, and local ablation.

The second point is that with all of these advances, HCC is exciting, but it’s increasingly complex. The BCLC [Barcelona Clinic Liver Cancer] makes this seem as if you can just follow the lines down and say that this is the therapy, but these lines are becoming much more blurred. You’re seeing more transition between therapies and more combination therapies. The difference is that these therapies are all delivered by different providers. There is increasing data on multidisciplinary care in expert centers. You’ve already heard this several times—a radioembolization is not a radioembolization, and a chemoembolization is not a chemoembolization. And so, it’s really important that patients are referred in to get multidisciplinary care in high-volume expert centers whenever possible.

Ghassan K. Abou-Alfa, MD: October is Liver Cancer Awareness month. It’s very important that we present that discussion and that effort that we’ve put together over here to all patients and caring physicians for patients with HCC, as we really look forward with these new events that will hopefully improve outcomes.

This really brings up a very important point: Screening and prevention are critical, as Amit said. If a patient has hepatitis B or hepatitis C, or even any concern or potential risk factor for developing HCC, they better be checked by their doctors. They need to be followed with a well-proved, well-documented screening approach or system that we have in place. This is very, very critical.
          
With this said, I would like to thank you all for joining us for this discussion. This was terrific. On behalf of the panel, we thank you very much for joining us. We hope you found this OncLive® Peer Exchange to be useful and informative.

Transcript Edited for Clarity 

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Transcript: 

Ghassan K. Abou-Alfa, MD: With this, I would like to ask for any final thoughts about all the different things that we have discussed. Peter?

Peter Galle, MD, PhD: One aspect that might be stressed that we haven’t been talking about so much is the relevance of side effects. Side effects are something we and the patient are afraid of. They result in stopping the treatment. However, in recent years, we have learned that in TKI [tyrosine kinase inhibitor]–related side effects, there’s also a positive. All of these side effects are related to better outcomes. So patients who, for example, develop hand-foot skin reaction do benefit more on therapy. What does that mean? It means that we have a way to discriminate those who are responding better than others. It tells us that it’s very relevant to keep patients on a drug. We have to play around much more with our TKIs than we thought in the past. In the beginning, we felt that we should either give at a full dose or not give at all. We should not be flexible about that because patients will be, in the end, undertreated, and the tumor will become resistant. This is not the case.

We can go up and down and adjust it according to the needs of our patients. I think that is very relevant. Particularly when we talk about combinations, it’s all about toxicity. The only way to guide a patient through therapy is to adapt therapy according to the patient’s needs. That means having a fine understanding of side effects and doing a tapering or an adaption of the dosing.

Ghassan K. Abou-Alfa, MD: I totally agree. I’m glad you brought this up because checkpoint inhibitors, like TKIs, have side effects. Thankfully, we don’t see too many side effects with the checkpoint inhibitors, but they can happen. We have to be very vigilant.

Riad, any final thoughts?

Riad Salem, MD: Yes, just a couple of things. I think we have to continue to think about combination therapy. The reality is that everybody gets combination therapy. We have to figure out what the optimal way is to treat them. If you treat earlier or intermediate disease, how can you maximize that without having the issue of side effects and start the systemic therapies early?

The other thing I would say is response matters. This is something that matters to patients. It matters to physicians. It’s probably the most talked about issue in follow-up clinic. Frankly, what is causing a lot of excitement in the HCC [hepatocellular carcinoma] field are these responses that people are seeing.

I think overall survival, as an endpoint, is a clear one for very advanced disease. It’s much more challenging to perform clinical trials in earlier disease and intermediate disease, and I think investigators and thought leaders have to really figure out endpoints that are relevant that will move the field forward, get incorporated into guidelines, and be enough for scientists and physicians to act on. I think that’s very important.

And ultimately for me, as an interventional radiologist, I deal with a lot of different conditions. HCC continues, after 15 years, to be the most exciting one, in my opinion. It’s the most exciting field that I work in, and I’m always sort of proud to be a part of that tumor board.

Ghassan K. Abou-Alfa, MD: Well, I’m honored to have you as well. Number 1, we still definitely have change, in regard to the endpoints. We all agree that response rates definitely, as we discussed, have evolved quite a bit, in regard to not only the response but also the extent of the response or how long the response will be. But on the other hand, we put this in perspective with regard to the intent to treat that we brought up a little bit, especially with atezolizumab-bevacizumab.

And No 3 is the point about the criticality of the overall survival. Whenever something happens in a patient, whatever happens on a certain dimension, is actually a part of that patient’s care. As such, the overall survival has quite a bit of critical importance in this regard.

But I like what you have said. If anything, the most important great news is actually for the patients. We have a lot of opportunities for patients and can offer things that hopefully will extend life and hopefully, of course, lead to cure.

Amit, final thoughts?

Amit Singal, MD: Yes, I have 2 closing thoughts. The first is that we’ve seen a lot of advances in terms of locoregional therapy and systemic therapy. But at the end of the day, it goes back to where we started. The best survival is likely if you’re found at an early stage. So it’s important that we know the at-risk population. It’s important that we really promote HCC surveillance and find these patients at an early stage. When they are found at an early stage, it is important to refer them for curative therapies. At the end of the day, the best survival is with resection, transplantation, and local ablation.

The second point is that with all of these advances, HCC is exciting, but it’s increasingly complex. The BCLC [Barcelona Clinic Liver Cancer] makes this seem as if you can just follow the lines down and say that this is the therapy, but these lines are becoming much more blurred. You’re seeing more transition between therapies and more combination therapies. The difference is that these therapies are all delivered by different providers. There is increasing data on multidisciplinary care in expert centers. You’ve already heard this several times—a radioembolization is not a radioembolization, and a chemoembolization is not a chemoembolization. And so, it’s really important that patients are referred in to get multidisciplinary care in high-volume expert centers whenever possible.

Ghassan K. Abou-Alfa, MD: October is Liver Cancer Awareness month. It’s very important that we present that discussion and that effort that we’ve put together over here to all patients and caring physicians for patients with HCC, as we really look forward with these new events that will hopefully improve outcomes.

This really brings up a very important point: Screening and prevention are critical, as Amit said. If a patient has hepatitis B or hepatitis C, or even any concern or potential risk factor for developing HCC, they better be checked by their doctors. They need to be followed with a well-proved, well-documented screening approach or system that we have in place. This is very, very critical.
          
With this said, I would like to thank you all for joining us for this discussion. This was terrific. On behalf of the panel, we thank you very much for joining us. We hope you found this OncLive® Peer Exchange to be useful and informative.

Transcript Edited for Clarity 
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