Systemic Therapy for HCC: A Rapidly Evolving Landscape - Episode 7
Reactions to recent clinical abstracts that support the use of hepatic arterial infusions for chemotherapy delivery in hepatocellular carcinoma.
Tanios S. Bekaii-Saab, MD, FACP: Talk about something that we can’t shake off our practices. Arndt, this whole concept of using HAI [hepatic arterial infusion] pumps, which has been a concept that’s now 3 decades old. It doesn’t seem to just go away. What are your thoughts?
Arndt Vogel, MD: It’s really amazing that it does not go away. We are surprised that we see it published in such great journals in recent years. We have to rethink here also a little bit. As we have just learned about SIRT [selective internal radiation therapy] with Y90 [yttrium-90] and that we need to better select our patients where we use these local therapies. The idea of combining different treatment modalities is interesting, and probably we will increase cure rate. It’s also very important that we more clearly define what is our aim. Is it downsizing/downstaging? Or is it really neoadjuvant that we would like to have patients that are resectable, that we would like to increase cure rate? That would be the first point that we need to be more precise [on] here. If I come back to the intra-arterial chemotherapy, which was presented at ASCO [American Society of Clinical Oncology annual meeting], there was one interesting study, which used intra-arterial chemotherapy as kind of [a] downsizing approach. And, as you said before, it’s around for more than 20 years. We have done our studies here as well. If you look at the older studies, the response rate was never so impressive. In our own studies here in Germany, it was around 20%, 30% at best. Now at ASCO in the presentation, it was more than 60%. If you have a treatment with a response rate of more than 60% and hardly any patient who has progressive disease, then it’s an interesting modality for downsizing if you have a patient who is not a candidate for surgery upfront. But then I think it’s important. What is the difference between these patients that are presented today to those that we have treated 20 years ago?For me, the main difference is if you just look at the age, these are young, male, Chinese patients with hepatitis B, and most of them probably do not have liver cirrhosis. If you have a healthy Chinese man with hepatitis B, no liver cirrhosis, you have good performance status, obviously you can perform these kinds of treatment. I was a bit surprised about the 60% response rate. This should be confirmed in other populations. I’m cautiously optimistic whether this kind of treatment will make it into the clinic because progression-free survival is still very short. For advanced patients, it’s not really a method I would invest anything. We have more active treatments with the immuno-oncology-based combination. The only area that could consider it would be really in these younger patients, good performance status, no liver cirrhosis for downsizing, not downstaging. Downsizing, if at all.
Tanios S. Bekaii-Saab, MD, FACP: Marc, your take as well on the more advanced setting that we’ve seen in HAI [with] FOLFOX [folinic acid, fluorouracil, and oxaliplatin] versus sorafenib [Nexavar], they looked even interesting mildly by a mile. Any thoughts on this?
Mark Yarchoan, MD: I agree with what was just said. These studies are provocative. They’re certainly interesting, but we really need replication in a global setting or Western population. The studies that were presented at ASCO, 80% of the patients in one of the studies were enrolled at a single center. I think we need global studies before this can really enter routine clinical practice.
Tanios S. Bekaii-Saab, MD, FACP: That’s the question. Do we need a global study? Do we need to spend any more resources on studying the question of HAI pump while we have all these modalities? Anjana, I see you have a thought about this.
Anjana Pillai, MD: I’m very transplant focused. I have seen, as you’ve mentioned, it helps up to a point. But if patients are headed towards transplant, when we’re kind of thinking of these patients on a global sense, it does lead to significant biliary issues and quality of life issues. That’s when we have to pause a little bit and think about long-term. In a subset of patients, it’s quite effective. I don’t disagree. And I agree with you, Tony, I don’t know if we need more study since we have so many more effective treatments, but I would just caution that using HAI in all patients, especially as we’re also moving towards transplanting the subset of cholangiocarcinoma patients as well. It’s just something to keep track of.
Tanios S. Bekaii-Saab, MD, FACP: Even more true. Rachna, as a leader in the co-op of a group world and task force, would you even endorse the idea of moving HAI into studying in the cooperative groups?
Rachna Shroff, MD: My biggest other concern is just the logistics and feasibility of doing a global study. HAI can be done in select centers and to make it a therapeutic approach that has a generalizable applicability. Yes, from a swab like wearing that hat, that would be a really hard study to support and endorse. The logistics of that is really complicated, and that makes it in what are already complicated and sick patients. It’s an exponentially larger problem in that situation.
Tanios S. Bekaii-Saab, MD, FACP: There’s definitely the complexities of how to manage them. Arndt, I’ll give you the final word on this.
Arndt Vogel, MD: Our patients in the Western world are not really candidates for this kind of treatment because they have too many comorbidities for these natural ability patients, and we have very effective treatments as mentioned before—TACE [transarterial chemoembolization], Y90 for these early tumors. For the bigger tumors, the field for systemic therapy is moving rapidly forward so I would not invest.
Transcript Edited for Clarity