Anthony B. El-Khoueiry, MD: I start by saying I think we underestimate the prognostic impact of underlying liver disease. But medical oncologists in general need to get more used to assessing liver function and realizing that the Child-Pugh score—the degree of cirrhosis are prognostic, and they impact the approach to the patient.

Just to kind of summarize, again, the Child-Pugh score uses the lab values albumin, bilirubin, and INR [international normalized ratio].

Ghassan K. Abou-Alfa, MD, MBA: So albumin, bilirubin, INR.

Anthony B. El-Khoueiry, MD: And then examining ascites and hepatic encephalopathies.

Ghassan K. Abou-Alfa, MD, MBA: And these are clinical, correct?

Anthony B. El-Khoueiry, MD: Correct. So the ascites is not on scans. It’s clinically detectable ascites.

Ghassan K. Abou-Alfa, MD, MBA: Right, that’s very important. Good.

Anthony B. El-Khoueiry, MD: Actually many registries have shown that, especially in medical oncology clinics, only a minority of patients have a Child-Pugh score noted or calculated.

Ghassan K. Abou-Alfa, MD, MBA: Yes.

Anthony B. El-Khoueiry, MD: Again, I do think it’s important for prognostication and management.

Ghassan K. Abou-Alfa, MD, MBA: What we heard today—and this is very important—is that liver cancer, No. 1, happened because of a “risk factor.” Something that really causes a cancer to develop. As we heard from Dr Kaseb, in his clinic, as in our clinics, we see patients who have the hepatitis-B—related HCC [hepatocellular carcinoma]; hepatitis-C–related HCC; nonalcoholic steatohepatitis, which is newly uncovered as a risk factor; and of course the alcoholic cirrhosis.

On top of that, Dr Gholam said he confirmed the necessity for ensuring that we look not only at the liver cancer but also at the liver functionality. And we heard about different parameters that can be used. Nonetheless, I would say the default has been Child-Pugh.

Understandably this is what has been used for long periods of time. It has certain limitations understandably because only the parameters that are related to the cirrhosis are within. But of course we all know that a certain parameter related to the cancer itself can also contribute to the outcome.

Nonetheless, we like to use the Child-Pugh score. And as we heard from Dr El-Khoueiry, the albumin, bilirubin, PT [prothrombin time]/INR, clinical ascites, and clinical encephalopathy, get out of it a certain number that will guide us where the patient might fall. Very important.

As we continue the program you’ll notice that most if, not all of the clinical trials that were done in liver cancer actually depend on the Child-Pugh scoring system. As such, for practicality purposes, this probably will make perfect sense for us in that regard. If anything, I would like to ask 1 last question to Dr Frenette in regard to Child-Pugh. Is it like A to B to C, like a linear thing? In other words, A, then they move to B, then C? Or is it like something else like experiential?

Catherine T. Frenette, MD: It’s really fluid, and patients will be an A and can absolutely move to B, but I have also seen patients who present as a B, and now we can get them back to an A, where now we’re able to tune them up enough, so to speak, to be able to get them to tolerate systemic therapy appropriately. And that’s really through appropriate medication management, diet management, exercise—all these different things that we can do to really maintain their liver function.

Ghassan K. Abou-Alfa, MD, MBA: If anything, the Child-Pugh is more exponential/fluid. Patients will probably live a long time on A, like an endless straight line, and then B is like a curve, and C is like a shoot. Nonetheless, it’s very important that those edges between A6 and B7. What can we do to keep the patient on the A side exactly as we heard from Dr Frenette?

Another thing that Catherine is suggesting, and we’re not going to necessarily discuss in detail, but the new onset is, what’s the microbiome situation and contribution in regard to the NASH [nonalcoholic steatohepatitis]? Or how can we help the NASH, to improve on the situation through the microbiomes; that is, in expanding findings. Admittedly, we’re not there yet, but it’s something that we’re definitely watching very carefully in that regard.

Transcript Edited for Clarity