Liao Emphasizes the Importance of Multidisciplinary Collaboration in HCC

A critical member of the modern-day multidisciplinary team tasked with the treatment of patients with hepatocellular carcinoma (HCC) is the interventional radiologist, according to Chih-Yi Liao, MD, who added that these specialists can help the team best navigate whether locoregional therapy is an appropriate treatment option.

“We have a multidisciplinary liver tumor program with a dedicated tumor board,” Liao explained. “That consists of a hepatology transplant [clinician], transplant surgery [clinician], interventional radiologist, medical oncologist, radiation oncologist, pathologist, and radiologist. We review all the cases together and [evaluate] who are the best patients to consider for combinations of local regional therapy plus systemic therapy. We have seen patients down stage to become candidates for curative resection or transplant with this approach.”

In the interview, Liao, associate director, Gastrointestinal Oncology, co-director, Neuroendocrine Tumor Program, and assistant professor of medicine at UChicago Medicine in Illinois, discussed key takeaways from the Treatment Crossroads in HCC workshop during a recent OncLive® State of the Science Summit™ on gastrointestinal cancer, which he chaired.

OncLive: What is the take home message for your colleagues from the Treatment Crossroads workshop on treatment options in intermediate and advanced HCC?

Liao: The main takeaway message [is that] it’s so important to work in a multidisciplinary team. As we saw in the presentation, traditionally we think of the HCC treatment landscape via the Barcelona Clinic Liver Classification [staging system], but we are beginning to see it’s not just unidirectional, it’s dynamic. [This means that] by combining different modalities of treatment in patients with more advanced stage disease, if they respond well, they can be potentially down staged and then they may have curative treatment options available.This is especially true for intermediate-stage patients, where we have traditionally [administered] embolization therapy [with] transarterial chemoembolization or transarterial radioembolization. Now we also have systemic therapies, and we have ongoing trials investigating the combination of locoregional therapies plus systemic therapies specifically for intermediate-stage patients. To make that determination, we need to work in a multidisciplinary team.

How do you establish patient eligibility for locoregional therapy?

It is done via our multidisciplinary tumor board. We review our cases every week and, especially for intermediate-stage patients, we think about which patients will benefit the most from locoregional therapy vs systemic therapy vs a combination of both.

What’s the role of the interventional radiologist in initiating locoregional therapy?

We’re fortunate that we have a very close and collaborative relationship with our interventional radiologists here at the University of Chicago. We have a multidisciplinary liver tumor clinic where the patients physically see all of us at the same time. In one visit they will see an oncologist, a hepatologist, surgeon, and an [interventional radiologist]; it’s like four visits in one.

It’s great because many times we have already discussed the patient’s case in the tumor board preceding the clinic visit and we all walk in with the same message. In working with our interventional radiologists, we coordinate different aspects of care. We have our support staff also aligned with each other to make sure nothing is lost in the transition of care. Our interventional radiologists will help manage the immediate adverse effects of the liver-directed therapies [all the while] oncologists will continue to manage the symptoms of the overall cancer. We still oversee everything, but it’s a close, collaborative relationship to help our patients move in and out of the different phases of their treatment.

How do you select patients for monotherapy vs combination therapy in the frontline setting of metastatic HCC?

We have seen many doublet regimens approved in the first-line setting, [including] atezolizumab [Tecentriq] and bevacizumab [Avastin], [as well as] durvalumab [Imfinzi] and tremelimumab [Imjudo]. At the 2024 ASCO Annual Meeting we learned the results of the [phase 3] CheckMate-9DW study [NCT04039607] of ipilimumab [Yervoy] and nivolumab [Opdivo], which were positive; I believe that [regimen] will probably also be FDA approved.

We will have multiple regimens to choose from. In general, for patients who are fit, with good liver function, who are Child-Pugh A, and who otherwise don’t have any contraindication, I generally would [administer] a doublet therapy as opposed to monotherapy. Sometimes patients may have a contraindication to one of the two drugs, sometimes they are more frail, or have poor liver function. That may be a situation where I may go for monotherapy, but in general, if there’s no contraindication, I will go for doublet therapy, because the data show that it’s more effective than monotherapy.

In terms of [deciding between] immunotherapy/TKI vs immunotherapy/immunotherapy, I tend to think about what’s a better fit for the patient, taking into account their other comorbidities. If a patient has a lot of cardiovascular comorbidities, [such as] uncontrolled hypertension, they may not be a good candidate for anti-VEGF therapy. In that situation, immunotherapy plus immunotherapy may be a better fit for the patient. We don’t have head-to-head comparison for the two [approaches], so for now we individualize [our decision] based on the fit for the patient.

How are you selecting a second-line therapy for patients with HCC?

We don’t have prospective clinical trial data to help us answer that [question] because the currently approved second-line agents were all approved when sorafenib [Nexavar] was the first-line therapy. What we should do after atezolizumab/bevacizumab or durvalumab/tremelimumab remains unknown, or at least not answered by [data from] prospective clinical trials.

There are some smaller published data using second-line therapy with a TKI, even with ipilimumab/nivolumab following first-line immunotherapy. For now, [the decision comes down to] the treating physician’s judgment. I have sometimes [administered] ipilimumab/nivolumab following first-line immunotherapy. I have also used a TKI, [such as] cabozantinib [Cabometyx] following atezolizumab/bevacizumab, for example. We need prospective clinical trials to help us answer that [treatment sequencing] question. We are a big clinical trial center, so my preference is to enroll patients in a clinical trial.