Updates in Frontline Treatment of Metastatic Liver Cancer - Episode 9

Future Directions for mHCC

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Richard S. Finn, MD: Certainly, as we answer more questions, more questions are raised. As you said, Rich, we need more data. Speaking of more data, Riad, as you look at these systemic agents, you see that we have high-level evidence changing from the natural history of advanced liver cancer. Where do you see these drugs going in the future with how we manage patients?

Riad Salem, MD: As you mentioned before, there are so many new advances over the last year, and these are all great things for patients. As you highlighted, though, it makes the decision-making in the advanced setting once you progress through the first line quite tricky. I would think, at some point, a refinement of the staging system might be in order, particularly now in the advanced setting.

Not only do we think that the BCLC -B stage needs to be refined—maybe there are certain Cs, the pattern that they progressed, the location of the disease, etc—but maybe there are things we can use to better identify which patient is going to respond to this type of treatment. It’s clear, based on the number of treatments, that a lot of patients are going to cross over from left to right to right to left. You’re getting great responses now, particularly with some of the I/O combinations and some of the LRT combinations, you have exceptional and spectacular responses.

We at our center have resected people who have advanced disease with metastatic disease that has been downstaged, and it has demonstrated such a good response that we re-present them and move things earlier. Now, all of a sudden, we resect them. It’s going to require a lot of rethinking as to the algorithm with which patients are treated. Combining these things is going to be very important. How that’s done, again, I don’t really know. Downstaging these patients to resection and transplantation is something that previously we would never think of, but now we’re seeing these great responses that make you think way outside the box and really represent what is true, individualized care. A patient responded so well, you’d never think of resection in this setting, and now you’re going to resect them.

Richard S. Finn, MD: What about the combination of TACE (transarterial chemoembolization), or locoregional treatment, and these new systemic treatments?

Riad Salem, MD: That’s the natural way to think about things. We know that locoregional therapies have a limited benefit. They’re going to progress anywhere between 6 and 15 to 18 months, depending on the study that you look at, which means they’re going to get something else. What that something else is, again, I leave that up to you guys in terms of best selection in the advanced setting.

The natural tendency and the academic and intellectual curiosity is: How best can I benefit from both things? How can I do a really strong cytotoxic therapy and use something that’s cytostatic and get a long TTP, a long PFS, and prolong the duration of response? The natural tendency is to figure out a way to mix these 2 things because I want my BCLC-B patients not to live 25 to 26 months; I want them to live 50 to 70 months. That’s what I aspire to. The curious thing here is how we can combine them in the proper patient in the earlier setting.

Richard S. Finn, MD: There are a lot of exciting studies looking at all the combinations we touched on today, or most of them, in combination with surgery or ablation as true adjuvant studies, in combination, or to support locoregional studies. It’s very important that we refer our fit patients for clinical studies even if they’re candidates for standard of care. The only way we’ll continue to move forward is with research. This has been an excellent discussion. I’d like to thank my colleagues for joining me today. We hope you found the information to be valuable to your clinical practice, and we welcome your feedback in what we covered here today. Thank you all for watching this OncLive® News Network® broadcast.

Transcript Edited for Clarity