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The Future of HCC Treatment

Panelists: Ghassan K. Abou-Alfa, MD, Memorial Sloan Kettering Cancer Center; Richard S. Finn, MD, UCLA; Laura M. Kulik, MD, Northwestern University Feinberg School of Medicine; R. Kate Kelley, MD, University of California-San Francisco; Riad Salem, MD, Northwestern University Feinberg School of Medicine
Published: Tuesday, Apr 04, 2017



Transcript:

Ghassan K. Abou-Alfa, MD:
I come to one important point. There is no question that immune checkpoint inhibitors might already be looked at in the locally advanced disease, local therapies. Your thoughts, Riad?

Riad Salem, MD: I know that we have a few clinical trials that we’re trying to do in this spirit of combination therapy. So, we’re really looking at that. Those are the results that we’ve seen that have really allowed you to pass the barriers of expected response rates. We’ve seen that with some of the local therapies on sorafenib. We’re hoping to see that with some of the immunotherapies, but we’re clearly studying that to make sure that the safety profile is there. And, again, we want to keep moving that bar forward.

Ghassan K. Abou-Alfa, MD: Great. To summarize that, there is no doubt that a lot is going on. As we heard, the precision medicine in HCC is an evolving field, but really, we don’t have, yet, that understanding, especially in the distribution of the different risk factors and what they allude to in regard to that genetic makeup of the tumors. In regard to what we’re waiting for as data in the first-line setting, lenvatinib, obviously, is the last bastion—if you want to call it that—that we’re waiting for the results of.

In the second-line setting, ramucirumab and the high AFP level is still awaiting recognition. In terms of c-MET inhibitors, I have to admit that before the checkpoint inhibitors came on board, they were really like the ASPIRE-4 results, and I would say we still have to recognize them as such. While the advent of the immune checkpoint inhibitors are ongoing, the c-MET inhibitors probably represent that “Back to the Future” kind of look. And we’re waiting for the results of tivantinib and cabozantinib as well.

Lastly, of course, with the checkpoint inhibitors, there’s a lot going on in the field. It’s mushrooming beyond reality at this point in time, and this is, again, good news. We like that, and we’re waiting for all the results of those studies to better define any role they might play in regard to HCC. With this said, this was a fascinating discussion with everybody, and it’s extremely informative. I’d like to really carry on with some final thoughts from our panelists. We’ll start with Dr. Finn.

Richard S. Finn, MD: I think one thing I would like to leave clinicians with is the fact that in an academic center multidisciplinary program, we’re all interacting in a very coordinated way. But it’s important in the community that clinicians stay engaged with their patients. Medical oncologists, or hepatologists, or gastroenterologists should engage with the interventionalists. It’s important that they be engaged in patients with early stage disease, or intermediate disease, so as to capture patients who can benefit from systemic treatment. There are now strong phase III studies in the frontline with sorafenib, and in second-line with regorafenib, and the only way we’ll reach the true benefit that’s been demonstrated in clinical studies with these molecules is to capture the patients that are eligible to receive them.

Ghassan K. Abou-Alfa, MD: Fair enough. Thank you for saying that. Dr. Kulik, your thoughts?

Laura M. Kulik, MD: I would say for patients who are in the community that if they have HCC, they should be seen at least once in an academic center. I think the target is moving to, “Who is a candidate for, for example, resection, or some of the liver-directed therapies—specifically radioembolization that may make somebody a candidate for resection, and even candidates for transplant?” And we won’t know that until they’re seen and evaluated.

Ghassan K. Abou-Alfa, MD: Absolutely. If I can comment on that, patients who are seen by the different disciplines have really shown an improvement in outcome. It’s really, very highly-evidenced and published. Dr. Kelley, your thoughts?

R. Kate Kelley, MD: I think that one of my key points to emphasize is that this is really a disease on the move. Not only is the incidence dramatically on the rise, and liver cancer is reaching really enormous proportions worldwide as the second leading cause of death, but, finally, we’re seeing momentum following along in drug development, a huge amount of interest in finding new therapies, and promise for many of these therapies to make a difference. So, it is important that we don’t give up on this population. I echo, completely, what Laura said—to refer patients to an academic center at least once to make sure that there aren’t new therapies popping up along the way, whether they’re liver-directed, surgical, interventional radiology, or, we hope, systemic. That can make a big difference down the road.

Ghassan K. Abou-Alfa, MD: A beautiful message of hope, of course, and especially for our patients’ loved ones. Dr. Salem?

Riad Salem, MD: I would say that HCC is, clearly, a very dynamic field. It’s a very exciting field. As an interventional radiologist, it is my favorite disease entity to work with. It allows me to interact with experts like yourselves—from oncology to hepatology—and it’s really something that is extremely fulfilling, from my aspect. You have to know the literature. These are things that are so dynamic from the discussions that you moderated on today. It’s so dynamic. There’s all sorts of new things that are going on, so I would say to be knowledgeable about the literature and engage all of the disciplines. You’ll maximize outcomes. I think that the future is very bright, and again, it’s a very, very exciting field to be a part of. I’m certainly proud of that. But I would encourage people to really engage quite a bit.

Ghassan K. Abou-Alfa, MD: Great. Thank you all for your contributions for this discussion. On behalf of our panel, we thank you for joining us, and we hope you found this Peer Exchange® discussion to be useful and informative.

Transcript Edited for Clarity

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Transcript:

Ghassan K. Abou-Alfa, MD:
I come to one important point. There is no question that immune checkpoint inhibitors might already be looked at in the locally advanced disease, local therapies. Your thoughts, Riad?

Riad Salem, MD: I know that we have a few clinical trials that we’re trying to do in this spirit of combination therapy. So, we’re really looking at that. Those are the results that we’ve seen that have really allowed you to pass the barriers of expected response rates. We’ve seen that with some of the local therapies on sorafenib. We’re hoping to see that with some of the immunotherapies, but we’re clearly studying that to make sure that the safety profile is there. And, again, we want to keep moving that bar forward.

Ghassan K. Abou-Alfa, MD: Great. To summarize that, there is no doubt that a lot is going on. As we heard, the precision medicine in HCC is an evolving field, but really, we don’t have, yet, that understanding, especially in the distribution of the different risk factors and what they allude to in regard to that genetic makeup of the tumors. In regard to what we’re waiting for as data in the first-line setting, lenvatinib, obviously, is the last bastion—if you want to call it that—that we’re waiting for the results of.

In the second-line setting, ramucirumab and the high AFP level is still awaiting recognition. In terms of c-MET inhibitors, I have to admit that before the checkpoint inhibitors came on board, they were really like the ASPIRE-4 results, and I would say we still have to recognize them as such. While the advent of the immune checkpoint inhibitors are ongoing, the c-MET inhibitors probably represent that “Back to the Future” kind of look. And we’re waiting for the results of tivantinib and cabozantinib as well.

Lastly, of course, with the checkpoint inhibitors, there’s a lot going on in the field. It’s mushrooming beyond reality at this point in time, and this is, again, good news. We like that, and we’re waiting for all the results of those studies to better define any role they might play in regard to HCC. With this said, this was a fascinating discussion with everybody, and it’s extremely informative. I’d like to really carry on with some final thoughts from our panelists. We’ll start with Dr. Finn.

Richard S. Finn, MD: I think one thing I would like to leave clinicians with is the fact that in an academic center multidisciplinary program, we’re all interacting in a very coordinated way. But it’s important in the community that clinicians stay engaged with their patients. Medical oncologists, or hepatologists, or gastroenterologists should engage with the interventionalists. It’s important that they be engaged in patients with early stage disease, or intermediate disease, so as to capture patients who can benefit from systemic treatment. There are now strong phase III studies in the frontline with sorafenib, and in second-line with regorafenib, and the only way we’ll reach the true benefit that’s been demonstrated in clinical studies with these molecules is to capture the patients that are eligible to receive them.

Ghassan K. Abou-Alfa, MD: Fair enough. Thank you for saying that. Dr. Kulik, your thoughts?

Laura M. Kulik, MD: I would say for patients who are in the community that if they have HCC, they should be seen at least once in an academic center. I think the target is moving to, “Who is a candidate for, for example, resection, or some of the liver-directed therapies—specifically radioembolization that may make somebody a candidate for resection, and even candidates for transplant?” And we won’t know that until they’re seen and evaluated.

Ghassan K. Abou-Alfa, MD: Absolutely. If I can comment on that, patients who are seen by the different disciplines have really shown an improvement in outcome. It’s really, very highly-evidenced and published. Dr. Kelley, your thoughts?

R. Kate Kelley, MD: I think that one of my key points to emphasize is that this is really a disease on the move. Not only is the incidence dramatically on the rise, and liver cancer is reaching really enormous proportions worldwide as the second leading cause of death, but, finally, we’re seeing momentum following along in drug development, a huge amount of interest in finding new therapies, and promise for many of these therapies to make a difference. So, it is important that we don’t give up on this population. I echo, completely, what Laura said—to refer patients to an academic center at least once to make sure that there aren’t new therapies popping up along the way, whether they’re liver-directed, surgical, interventional radiology, or, we hope, systemic. That can make a big difference down the road.

Ghassan K. Abou-Alfa, MD: A beautiful message of hope, of course, and especially for our patients’ loved ones. Dr. Salem?

Riad Salem, MD: I would say that HCC is, clearly, a very dynamic field. It’s a very exciting field. As an interventional radiologist, it is my favorite disease entity to work with. It allows me to interact with experts like yourselves—from oncology to hepatology—and it’s really something that is extremely fulfilling, from my aspect. You have to know the literature. These are things that are so dynamic from the discussions that you moderated on today. It’s so dynamic. There’s all sorts of new things that are going on, so I would say to be knowledgeable about the literature and engage all of the disciplines. You’ll maximize outcomes. I think that the future is very bright, and again, it’s a very, very exciting field to be a part of. I’m certainly proud of that. But I would encourage people to really engage quite a bit.

Ghassan K. Abou-Alfa, MD: Great. Thank you all for your contributions for this discussion. On behalf of our panel, we thank you for joining us, and we hope you found this Peer Exchange® discussion to be useful and informative.

Transcript Edited for Clarity
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