Al B. Benson, MD, professor of medicine, Hematology and Oncology, Northwestern University Feinberg School of Medicine, discusses the complexity of up-front treatment in hepatocellular carcinoma (HCC).

The treatment paradigm of HCC has become more diverse with the approval of novel therapies, explains Benson. 

Typically, a hepatologist is involved in the multidisciplinary management of patients with HCC because patients often have underlying liver disease, Benson says. This comorbidity can significantly alter or complicate treatment decisions. 

Additionally, an overall multidisciplinary team should be consulted when treating patients with HCC to determine if the patient is eligible for transplant, Benson says.

Alternatively, patients may be considered for other localized therapies, such as liver resection, ablation, radioembolization, bland embolization, or chemoembolization, concludes Benson.

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Al B. Benson, MD, discusses the complexity of up-front treatment in hepatocellular carcinoma.  



Dr. Benson on the Complexity of Up-front Treatment in HCC

Al B. Benson, MD, professor of medicine, Hematology and Oncology, Northwestern University Feinberg School of Medicine, discusses treatment for patients with resectable colorectal cancer.

If a patient presents with potentially resectable disease, a multidisciplinary team should be brought in so that the surgeon and the radiologist can help determine whether the tumor is resectable.

If the disease is deemed resectable, Benson recommends giving a limited course of neoadjuvant therapy, which typically ranges between 2 and 4 months. It’s not as important to shrink the tumor because the disease is already resectable, adds Benson. By administering chemotherapy, the patient’s chemosensitivity can be assessed, which could then guide treatment decisions down the line, says Benson.

The use of chemotherapy in the newly-diagnosed setting is included in the National Comprehensive Cancer Network guidelines, and reinforced by data from the phase III CALGB/SWOG 80405 trial (NCT00265850). Common regimens include FOLFOX, CAPOX, or FOLFIRI plus a biologic. If the patient has a 

 mutation, bevacizumab (Avastin) would be considered, whereas if the patient has 

 wild-type disease, either cetuximab (Erbitux) or panitumumab (Vectibix) could serve as potential options, concludes Benson.

Al B. Benson, MD, professor of medicine, Hematology and Oncology, Northwestern University Feinberg School of Medicine, discusses treatment for patients with resectable colorectal cancer (CRC).

Dr. Benson on Treatment for Patients With Resectable Colorectal Cancer

Al B. Benson, MD, professor of medicine, Hematology and Oncology, Northwestern University Feinberg School of Medicine, discusses the implications of microsatellite instability (MSI) testing on patients with colorectal cancer (CRC).

It is important, according to Benson, to perform tumor testing to determine whether a patient with CRC has an alteration, as that may inform treatment decisions. MSI testing should be done on every patient with CRC to ensure the patient does not have a genetic component, such as Lynch syndrome, explains Benson.

Patients with microsatellite instability—high (MSI-H) tumors are candidates for immunotherapy, which is generally given after progression on first-line chemotherapy, adds Benson. However, ongoing clinical trials are also examining first-line immunotherapy in this patient population. MSI testing is necessary regardless of the stage of disease, concludes Benson.

Al B. Benson, MD, discusses the implications of microsatellite instability testing on patients with colorectal cancer.

Dr. Benson on MSI Testing in Colorectal Cancer

Al B. Benson, MD, professor of medicine, Hematology and Oncology, Northwestern University Feinberg School of Medicine, discusses ongoing research with immunotherapy in metastatic colorectal cancer (mCRC).

Currently, research with immunotherapy is limited to patients with microsatellite instability—high (MSI–H) tumors, says Benson. Studies have shown the activity of pembrolizumab (Keytruda) and nivolumab (Opdivo), as well as the combination of nivolumab and ipilimumab (Yervoy). Whether checkpoint inhibitors should be used alone or in combination is an area of active investigation, explains Benson. A patient with MSI-H mCRC has a worse prognosis. If the patient progressed on frontline therapy, a combination therapy could induce a quicker response compared with single-agent therapy.

Investigators are also evaluating immunotherapy in the adjuvant setting, says Benson. The challenge is making the approach effective for the majority of patients who are not MSI-H. Potential strategies to overcome the limitations of single-agent immunotherapy in patients with microsatellite stable disease population include combinations of immunotherapy with radiation, liver-directed therapy, chemotherapy, targeted agents, and vaccines, says Benson.

Dr. Benson on the Ongoing Research With Immunotherapy in mCRC

Al B. Benson, MD, professor of medicine, Hematology and Oncology, Northwestern University Feinberg School of Medicine, discusses key considerations in the frontline treatment of patients with metastatic colorectal cancer (mCRC). 

Understanding the broad picture of the patient is a key part of creating an optimal treatment course for the patient, explains Benson, especially as patient-specific characteristics can influence later-line therapies. 

Notable characteristics includes sites of disease, patient performance status, and patient preference, explains Benson. Genomic characteristics such as microsatellite instability status and 

With a thorough patient profile, the optimal treatment strategies can be selected for the individual, concludes Benson. 

Al B. Benson, MD, discusses key considerations in the frontline treatment of patients with metastatic colorectal cancer. 
 

Dr. Benson on Frontline Treatment Considerations in mCRC

Al B. Benson, MD, professor of medicine, Hematology and Oncology, Northwestern University Feinberg School of Medicine, discusses the optimal sequencing of the EGFR inhibitor cetuximab (Erbitux) for patients with 

There are several ways to sequence EGFR inhibitors in patients with 

 wild-type CRC, explains Benson. Some use cetuximab upfront, often in combination with FOLFIRI. 

However, this strategy may not maximize treatment options, Benson says. Instead, upfront FOLFOX in combination with bevacizumab (Avastin), followed by FOLFIRI and bevacizumab at the time of progression may be more efficient. 

If further progression occurs, cetuximab or panitumumab (Vectibix) could be used in combination with irinotecan or FOLFIRI. If patients progress on either of these regimens, TAS-102 (trifluridine/tipiracil; FTD/TPI; Lonsurf) or regorafenib (Stivarga) are available options, says Benson. 

Beyond this, clinical trials also provide a potential option for patients in any line of therapy.

Al B. Benson, MD, discusses the optimal sequencing of the EGFR inhibitor cetuximab for patients with RAS wild-type colorectal cancer. 
 

Dr. Benson on Sequencing Strategies with Cetuximab in CRC

Al B. Benson, MD, professor of medicine, Hematology and Oncology, Northwestern University Feinberg School of Medicine, discusses the use of genomic testing in patients with newly diagnosed metastatic colorectal cancer (mCRC). 

Genomic testing can shed light on optimal targeted treatment strategies for individual patients. As such, genomic testing should be performed at diagnosis, says Benson. Moreover, understanding the optimal first-line option for a patient is a key part of sequencing the most beneficial continuum of care.

 mutations, Benson explains. If a patient is 

 alterations should be considered. Microsatellite instability status should also be evaluated because it can shed light on later-line treatment decisions, concludes Benson. 

Al B. Benson, MD, discusses the use of genomic testing in patients with newly diagnosed metastatic colorectal cancer. 
 

Dr. Benson on the Use of Genomic Testing in Newly Diagnosed mCRC

Al B. Benson, MD, professor of medicine, Hematology and Oncology, Northwestern University Feinberg School of Medicine, discusses the factors to consider when approaching treatment for a patient with advanced colorectal cancer (CRC).

Benson says that it is important to emphasize the multiple aspects of advanced CRC treatment, including patient comorbidities and molecular characteristics. For each patient, their

 and microsatellite instability (MSI) status should be identified before treatment is considered. HER2 is also being explored as a target in ongoing clinical trials of patients with metastatic CRC, suggesting it should also be sequenced for along with the more common markers.

Tumor characteristics and patient preference should also be taken into account when deciding on treatment, Benson says. With multiple opportunities for treatment, it is critical to look at these factors to optimize treatment sequencing, he adds.

Another factor to consider is location. The location of the tumor is based on important molecular characteristics, explains Benson. For example, more MSI-high and BRAF-positive tumors are seen in patients with right-sided CRC.

Al B. Benson, MD, professor of medicine, Hematology and Oncology, Northwestern University Feinberg School of Medicine, discusses the factors to consider when approaching treatment for a patient with advanced colorectal cancer. 

Dr. Benson on Considerations for Advanced CRC Treatment

Al B. Benson, MD, professor of medicine, Hematology and Oncology, Northwestern University Feinberg School of Medicine, discusses the clinical utility of cell-free DNA (cfDNA) in guiding treatment decisions for patients with colorectal cancer (CRC).

Ongoing research is investigating the use of cfDNA in CRC, explains Benson. The presence of cfDNA in patients who have had complete resection of their tumor may indicate that the individual has a higher risk of recurrence. Therefore, researchers are looking to open a study that will randomize patients with stage II disease to chemotherapy. After receiving treatment, patients’ cfDNA will be analyzed to see whether the addition of chemotherapy to a patient’s course of treatment can reduce their risk of recurrence.

Moreover, cfDNA is being investigated in patients with metastatic CRC to see if there is a benefit with particular treatment strategies, concludes Benson.

Al B. Benson, MD

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