Dr. El-Khoueiry on Choosing Between Immunotherapy Agents and TKIs in HCC

Anthony B. El-Khoueiry, MD, associate professor of clinical medicine, Keck School of Medicine, USC Norris Comprehensive Cancer Center, discusses choosing between immunotherapy agents and TKIs in hepatocellular carcinoma (HCC).

According to data from phase I/II studies, nivolumab (Opdivo) and pembrolizumab (Keytruda) can be used in the second-line setting as well as in the third-line setting. The trial eligibility did not limit the number of prior lines of therapy; however, patients must have had prior exposure to sorafenib (Nexavar), says El-Khoueiry. It can be difficult to decide between a TKI and a PD-1 inhibitor in the second-line setting as there are no head-to-head trials that have compared these agents directly. Therefore, a lot of the decision comes down to patient characteristics.

PD-1 inhibitors may induce a long-lasting response. However, not all patients will reach third- or fourth-line treatment. In those cases, giving these agents as second-line therapy may be the patient’s best chance of deriving benefit from them. For patients who are progressing rapidly or have high-risk disease, giving them immunotherapy may also be preferable in the second-line setting as opposed to a TKI. However, the TKIs are FDA approved based on phase III data and level 1 evidence. For example, data regarding the sequence of frontline sorafenib and second-line regorafenib (Stivarga) indicate a median overall survival of 26 months.