Dr Akkus on Making Second-Line HCC Decisions Without Randomized Data

Calling a colleague in another city, or even another country, is, I think, a multidisciplinary evaluation.

In the second segment of an interview with OncLive, Erman Akkus, MD, a medical oncologist at Ankara University, discussed how oncologists should weigh cross-trial comparisons and approach second-line decisions in advanced hepatocellular carcinoma (HCC) when randomized data are absent.

No randomized controlled trial has defined second-line therapy in advanced HCC after contemporary first-line immunotherapy, leaving clinicians to extrapolate from real-world series and single-arm data. That gap shapes how Akkus approaches both his own evidence-synthesis work and everyday treatment decisions. He examined the gap itself and his group's reconstructed patient-data analysis in the first segment of his OncLive discussion.

Cross-trial comparison should be avoided in principle, Akkus acknowledged, but he argued that oncology is not governed by the fixed relationships of physics or mathematics, and that a clinician facing a patient has to act on the best available data. Continuing to analyze, interpret, and draw conclusions from imperfect evidence is worthwhile, he said, as long as its limitations and strengths are kept in view. In his own papers, he added, the aim is to address clinical questions that carry practical meaning rather than analysis for its own sake.

For a community oncologist managing HCC without an on-site liver tumor board, Akkus advised starting with eligibility — performance status, liver function and reserve, decompensation, and toxicity profile determine whether systemic treatment is appropriate at all. For patients who qualify, he uses an available TKI, favoring lenvatinib. Multidisciplinary input no longer requires a shared room, he emphasized that a call to a colleague in another city or country counts, and should be used.

Looking ahead, Akkus identified two questions he considers central because they will shape every subsequent line: which patients should receive systemic therapy in intermediate-stage disease and which should receive dual immunotherapy versus an immunotherapy–TKI combination in the first line.