Riccardo Lencioni, MD
Although it has been nearly 10 years since a new systemic drug has been approved for the treatment of patients with hepatocellular carcinoma (HCC), the field is changing rapidly due to new therapies for a prime underlying cause of the disease and advances in interventional radiology.
That was the picture painted by HCC experts during a wide-ranging OncLive
Peer Exchange® panel discussion entitled “Update on Treatment of Advanced Liver Cancer.” The program brought together experts in medical oncology, hepatology, and radiology who stressed the necessity of cooperation among specialists in their fields due to the complex nature of managing patients with HCC.
Riccardo Lencioni, MD, noted there is a “broad spectrum” of options for treating patients with HCC. “Sometimes we may have the feeling that there are competitors like surgery versus ablation, chemoembolization versus sorafenib [Nexavar],” he said.
“… In reality, when it comes to discussing individual patients, there is much more synergy and complementarity rather than competition among these different options. So this is the key for the management of HCC—personalized decisions.”
There are so many “gray zones between the different types of therapy” that specialists should participate in multi disciplinary team meetings, said moderator Ghassan K. Abou-Alfa, MD.
Ghassan K. Abou-Alfa, MD
“For the general community oncologist, they maybe see a handful of patients with liver cancer a year,” observed Richard S. Finn, MD. “… I think that it really behooves them to have a patient seen at a large transplant-based multidisciplinary setting. Even if the patient ends up coming back to them for care, the optimal approach would probably be developed in that setting, and it’s certainly a way to get them access to clinical trials.”
Finn, a translational researcher, also noted a frustrating lack of progress since the FDA approved sorafenib, a VEGF inhibitor, for patients with unresectable HCC in 2007. It remains the only systemic drug specifically approved for HCC, according to the National Cancer Institute. “It’s very easy to become discouraged by all the negative data that have occurred over the past several years, but we owe it to our patients to continue trying to move forward,” said Finn.
The panelists said several promising novel options are being explored in clinical trials including agents targeting the MET pathway, immunotherapies aimed at the PD-1/PD-L1 checkpoint, and a vaccina virus that expresses GM-CSF.
HCC Profile in Flux
The most prevalent risk factor for HCC in the United States is chronic hepatitis C, accounting for at least 50% and, in some US centers, up to 65% to 70% of the HCC cases, said Amit Singal, MD.
Amit Singal, MD
However, the explosion of highly effective therapies for patients with the virus is an important medical advance that is changing the face of the population likely to develop liver cancer.
Singal said hepatitis C treatment significantly reduces liver-related mortality and the risk of HCC. “In patients who do not already have cirrhosis, you can essentially almost universally prevent the progression of cirrhosis and prevent HCC,” he said. “In those who have already developed cirrhosis, you have about a 75% reduction in the risk of developing future HCC as well as liver-related mortality. So you can have a substantial benefit in reducing future HCC burden.”
At the same time, the HCC risk factors of obesity and diabetes pose a growing threat. “Patients who have an underlying metabolic syndrome are at high risk for developing nonalcoholic steatohepatitis,” said Singal. “It’s currently estimated that 30% of Americans actually have nonalcoholic steatohepatitis with approximately 2% to 3% of the population having the form that can progress to cirrhosis and HCC.”
“When you look at this from a population-attributable fraction, nonalcoholic fatty liver disease is one of the most common reasons that we’re going to be seeing HCC,” Singal said. “I think that this is really the future of HCC.”