Dr Kim on Selecting Between Frontline Immunotherapy-Based Regimens in HCC

Richard Kim, MD, service chief, Medical Gastrointestinal Oncology, senior member, Department of Gastrointestinal Oncology, Moffitt Cancer Center; professor, oncology, the University of South Florida College of Medicine, discusses selecting between frontline immunotherapy-based tegimens in patients with hepatocellular carcinoma (HCC).

There is currently an abundance of FDA-approved drugs for patients with HCC, Kim begins. The primary focus of research in the first-line setting revolves around immunotherapy-based approaches. Two notable studies have demonstrated positive outcomes in this context: the phase 3 HIMALAYA (NCT03298451) and the IMbrave150 (NCT03434379) trials, he explains. The IMbrave150 study evaluated the combination of atezolizumab (Tecentriq) and bevacizumab (Avastin), while the HIMALAYA trial utilized durvalumab (Imfinzi) and tremelimumab (Imjudo), Kim states.

Although cross-comparisons are not ideal, they still occur, Kim expands. Kim adds that it is crucial to note a significant difference in the inclusion criteria for the trials being compared. For example, the IMbrave150 study included more patients with hepatitis and underlying liver cirrhosis compared with the patient population in the HIMALAYA study, where there weremore instances of hepatitis and non-viral liver cirrhosis, he emphasizes. The disease etiology of HCC appears to play a role in this variation, with emerging data suggesting that immunotherapy might be more effective in viral etiology compared to non-viral etiology, Kim notes. However, it's premature to establish this as the standard of care.

In the IMbrave150 study, patients with viral etiology responded better to the combination of atezolizumab and bevacizumab compared with those in the HIMALAYA trial, Kim elucidates. Conversely, the HIMALAYA data showed that patients with either viral or non-viral etiology benefited from durvalumab and tremelimumab, he says. The available data still present a mix of outcomes, making it too early to definitively choose between these first-line regimens based on viral or non-viral etiology, Kim notes.

Both regimens have advantages and limitations that should be considered during treatment selection. Atezolizumab plus bevacizumab, for instance, may offer a higher response rate for patients. However, its use raises concerns about potential bleeding, necessitating endoscopy before treatment initiation, he continues.

Alternatively, the use of durvalumab and tremelimumab involves administering 2 immune checkpoint inhibitors. This may lead to higher rates of intermediate adverse effects, which sometimes require management with steroids. Ultimately, selecting between these regimens is a personalized decision based on the patient's specific situation, Kim concludes.