Anjana Pillai, MD, reflects on the first annual HCC-TAG Conference, her journey into treating patients with liver cancer, and remaining challenges in the paradigm
Anjana Pillai, MD
In the past few years, a slew of novel agents has been positioned in the pipeline of hepatocellular carcinoma (HCC) and will likely enter the treatment paradigm for patients in the coming year.
With this comes a need to refine treatment plans, discuss sequencing options, and investigate alternative therapy options. The 2020 HCC-TAG Conference aimed to bring experts in oncology, transplant, surgery, interventional radiation, and hepatology together to move toward implementing multidisciplinary care for all patients with HCC, explained Anjana Pillai, MD, one of the course directors of the conference.
"We had incredible enthusiasm and lively discussions [at the 2020 HCC-TAG]," said Pillai. "That was what we hoped for. We wanted a group of speakers and an agenda that allowed for live discussions, fluidity, and respect of differing opinions. We achieved that."
In an interview with OncLive during the 2020 HCC-TAG Conference, Pillai, an associate professor of medicine, medical director of the Liver Tumor Program, co-director of the Living Donor Liver Transplant Program, and associate program director of the Gastroenterology Fellowship Program at University of Chicago Medicine, reflected on the first annual HCC-TAG Conference, her journey into treating patients with liver cancer, and remaining challenges in the paradigm.
OncLive: What was the rationale for the 2020 HCC-TAG Conference?
Pillai: This conference started as a pipedream. Michael R. Charlton, MBBS, MD, [is on the faculty for] NASH-TAG, which is Therapeutic Agents for Non-Alcoholics Steatohepatitis and Liver Fibrosis. I thought that it would be great if we did an HCC-TAG conference, and Charlton agreed. We were both very excited about it and hoped we could also get others excited.
Therefore, we reached out to 4 other course directors: Amit Singal, MD, MS; Anthony El-Khoueiry, MD; Julie K. Heimbach, MD; and Riad Salem, MD, MBA. They are all well-known experts in interventional radiology, surgery, oncology, and hepatology. When they all said yes, [we knew] this was actually going to happen.
The impetus for the conference was the changing landscape of HCC and the importance of establishing a multidisciplinary team in the implementation of treatment strategies. There isn't another single-topic conference like HCC-TAG in the United States.
What is the benefit of a multidisciplinary approach in HCC treatment?
Unlike many cancers, which occur in healthy tissue, often in liver cancer the patient has a damaged, cirrhotic liver on top of the cancer. There are 2 competing mortalities [to manage].
Additionally, there are multiple treatment options. Chemotherapy is not the only treatment. There is locoregional therapy, resection, and transplant, as well as systemic therapy. If you are [treating patients] in a multidisciplinary format, you may realize that what you can offer based on your specialty is not what is best for the patient.
Every patient with HCC we see at University of Chicago Medicine is presented at our tumor board. The first question we pose is regarding curative options. If a patient is eligible for [resection or transplant], we go with the curative option. If the patient is not eligible, we ask if their performance status [makes them eligible for therapy]. If the answer is “Yes,” we look to the best data to give the [optimal] therapy while preserving quality of life (QoL). That is our algorithm. We take everyone's advice into account and try to develop the best treatment plan.
What are the next steps for this conference?
Going forward, we would like to make this an annual conference. We didn't explore image guidance or radiomics, so there are many other topics to discuss. Plus, many of the speakers are doing high-level research and have interim data.
We want this to be a multidisciplinary conference where innovators can come to discuss their passions and research—that way, they can report back to their respective centers and discuss [what they learned] with colleagues.
What else is important to highlight regarding this conference?
What I loved most about this conference was the collegiality and the respect all of the disciplines had for one another. We have a group of outstanding oncologists, surgeons, interventional radiologists, transplant hepatologists, and gastroenterologists who are truly experts in their fields. It was nice to see high-level discussions between people with completely differing opinions who also understand that, “This is how you move the field forward.” I am really proud we were able to do it.
Reflecting on your career, why did you choose practice HCC?
I've always been drawn to complicated cases, even in residency and fellowship. I gravitated toward the liver because it is a complex topic. When I was a fellow, the patients [with HCC] were so sick, and I loved taking care of them.
After I finished my gastrointestinal fellowship, I did my transplant fellowship at Northwestern University. Laura M. Kulik, MD, who was a speaker and moderator [at the 2020 HCC-TAG Conference] was the first person who got me interested in this field. I would go to see patients with her and attend multidisciplinary tumor board. She started my passion for liver cancer.
Afterward, I started the Liver Tumor Program at both Emory University and University of Chicago Medicine. I learned how to best serve patients from working with different specialists.
Therefore, it came gradually. I liked the patient population, had some good mentors, and realized I could run a program. That is how I got here.
How would you define your practice?
I am a clinician, not a basic scientist or translational researcher. When a patient comes to our tumor program at University of Chicago Medicine, we want to personalize medicine for that patient. Also, we want to educate patients, their families, and the community around us about liver cancer.
I've been very lucky to have leaders at University of Chicago Medicine who support us, as well as colleagues in interventional radiology, oncology, and transplant surgery, who all support our clinic.
Similarly, we have a multidisciplinary tumor board where we evaluate patients and truly listen to one another. We often agree but when we don't we always come to the conclusion that this is the right treatment for the patient.
How has the treatment of liver cancer evolved since your career began?
I finished my fellowship in 2009 around the time when sorafenib (Nexavar) was approved. Then, there was no movement in the field until 2017.
In my first job, I would offer my patients sorafenib as treatment because we also treated hepatitis C patients with pegylated interferon and ribavirin. We were used to drugs with toxicities.
Now with the influx of systemic therapies, it is very difficult to stay up to date. There are so much data coming out that it is hard to understand how to appropriately [apply the data to practice]. Again, having a close working relationship with our oncology colleagues becomes important in keeping up with the data to understand the mechanisms of action with these medications.
At the end of the day, we want to do no harm and preserve the patients' liver function the best we can.
The IMbrave150 study has garnered a lot of excitement. What implications do the results of this trial have on practice?
The difference with the IMbrave150 trial is that though [atezolizumab (Tecentriq) and bevacizumab (Avastin)] are not new to the oncology world, they are new to the cirrhotic world. We have to be careful of the indications in which these medications hopefully receive approval for soon.
There are patients with HCC who have underlying liver disease. We have to ensure that we appreciate that, as the IMbrave150 trial was done in patients with preserved liver function.
What exciting research are you currently involved in?
I am fortunate enough to be part of a group of researchers often led by Signal or Neehar Parikh, MD. Recently, Parikh submitted a National Institute of Health grant to look at transarterial chemoembolization versus transarterial radioembolization in patients with advanced HCC. Currently, there is no level I evidence comparing the 2 approaches. University of Chicago Medicine is 1 of 5 centers that will be enrolling patients on this trial.
We also have several industry-sponsored trials looking at first- and second-line therapies for liver cancer.
What is your take-home message that drives your passion to continue treating patients with HCC?
You have to have a passion for what you do. I have a lot of empathy for my patients and for people with liver disease. Many of those people did not know they had liver disease and have now developed cancer. Additionally, I am seeing more younger patients being diagnosed with advanced liver cancer.
[It is] wonderful when we are fortunate enough to walk patients through a curative cancer journey by taking them to transplant. However, many times that is not the case and we see patients with very advanced disease. Nonetheless, there is something about walking a patient through that journey even if you can't offer them much. We are going to maximize QoL through palliative services.
As providers, we want our patients to have trust in us and believe that we want to do what is best for them.
What are some remaining challenges in HCC?
One challenge is identifying patients earlier so we can offer them curative treatments. We are seeing a lot of advanced cases. Even though we know which individuals should undergo surveillance, we are not quite where we should be [with patient selection]. Education is very important in telling providers if you have a patient with cirrhosis or hepatitis B who meet certain criteria that you have to surveil for liver cancer.
Another challenge is that although there have been tremendous improvements in available treatment options, we are not curing patients with advanced HCC. We are offering them longer survival, but we are not curing them.
Liver cancer is such a heterogeneous disease not just between people and their underlying liver disease, but between the cases of liver cancer themselves, and even between regions in a single tumor.
We have not yet identified molecular drivers that we can target to personalize medicine for liver cancer. There is a lot of great work going into it, but we haven't yet translated it into clinical practice.