Recent Approvals, Collaborative Care Model Spark Change in HCC Treatment

Michael R. Charlton, MD, MBBS

Among an explosion of new data, novel therapies, potential biomarker breakthroughs, and improved technology, the field of hepatocellular carcinoma (HCC) is moving toward a more comprehensive, personalized, and optimistic approach in treatment, said Michael R. Charlton, MD, MBBS.

"This is a time to be more optimistic in HCC," said Charlton. "We are seeing patients who had seemingly hopeless situations now develop into [having] a chronic disease. Our tools are getting better and, in turn, we are getting better at understanding how to use them. We are in as good of spirits as you can be in a difficult situation."

Importantly, the field has adopted a multidisciplinary approach for patient care to include efforts of those working in oncology, interventional radiation, surgery, and hepatology, said Charlton.

"It's our responsibility to come together and push the field forward in a team-based approach," he explained. "We have all of these different tools and each of us sees them a bit differently. What we saw at the 2020 HCC-TAG Conference is that, when we are under the same roof, new ideas and perspectives emerge."

In an interview with OncLive during the 2020 HCC-TAG Conference, Charlton, professor of medicine, director of the Center for Liver Diseases, and co-director of the Transplant Institute at the University of Chicago Medicine, discussed the evolution of HCC treatment.

OncLive: What was the rationale for starting the HCC-TAG Conference?

Charlton: HCC is the most rapidly increasing cancer in the United States—and probably worldwide. It's been a very exciting time for therapy. Some of the developments are happening in interventional radiology, some in surgery, some in hepatology, and many in oncology.

We thought we would try to bring all of those elite, key opinion formers, scientists, and clinicians under 1 roof to develop ideas to move the field forward quicker and in a more organized way.

Why is it essential to utilize multidisciplinary care in HCC?

Medicine is [getting] increasingly complicated. I often tell patients that they should think of their healthcare team as an orchestra. There is likely a conductor to that orchestra, but there is also an oncologist, a radiologist, and a surgeon [as part of the orchestra].

The best decisions are made when each of these experts sit around the table thinking about a particular case and deciding what's the best way forward for a particular patient. It could be a standard of care, exploring a clinical trial, surgery, interventional radiology, or something else. It is easily the best way to treat patients.

What is the benefit of early detection of disease for patients with liver cancer?

By the time most people with liver cancer are diagnosed, they have progressed to the point that they are not curable with our current tools. We would love to see more people be screened and surveyed, so they are diagnosed when they have resectable disease or that we can treat with locoregional therapies.

Sadly, only a minority of patients present with curable disease using our current tools. Hopefully in 5 to 10 years, that group of patients will greatly expand, but as we sit here today, the majority of patients are not curable because they present with late-stage disease.

That being said, could you discuss the recent explosion of systemic therapy options in HCC?

There are different groups of therapies available, such as the TKIs and checkpoint inhibitors. These drugs are often being used in combination.

Cabozantinib (Cabometyx) is being used with the checkpoint inhibitor nivolumab (Opdivo). The IMbrave150 study was a combination of bevacizumab (Avastin) and atezolizumab (Tecentriq). [These combinations are showing] improved outcomes for progression-free and overall survival.

We have struggled to move this field forward, and now it is definitely improving. Guidelines that were written 1 year ago are no longer current. We need guidelines that reflect [more recent] data that have emerged.

How do you use routine biopsy in HCC? How do you see biomarker innovation impacting this space?

If you asked me a few years ago what the role of biopsies in HCC would be now, I would have said it was diminishing. Now, I have to rethink that.

We heard a great presentation [at HCC-TAG] about different biomarkers and how the behavior of cells within a particular patient's liver cancer can help to direct therapy at initial diagnosis or at recurrence.

It's not quite ready for primetime, but it's clearly emerging as something that has meaning. Retrospective data showed that if transforming growth factor—ß levels fell during therapy, that was an important sign of response.

I could see treatment decisions changing based on biomarker response, or using different forms of therapy based on histological biomarkers. It is a very intriguing time, and we hope for more personalized medicine going forward.

What does the future of HCC treatment look like to you?

Going forward, we will see an interaction between industries. The National Institute of Health has a lot of resources, but the pharmaceutical industry has more. Investigators have ideas. Of course, patient advocates are an important group. Listening to them all to see the way forward makes the most sense. That collaborative sense of moving the field forward is the best thing about today compared with 1 year ago [in this field].

What is the take-home message from this year’s HCC-TAG conference?

I only see liver disease; that is all I have been doing for 25 years. Yet, I am surprised by how many new things I have learned at the 2020 HCC-TAG Conference. No one person can have a comprehensive understanding of the field, even if it is their specialty.

Make sure that you are seeing patients in a team setting. You're so much more likely to get ideas that are best for the patient [that way].

What advice would you give a community oncologist who may not regularly see patients with HCC?

There are updated guidelines to reference, but those guidelines become outdated quickly. Stay abreast through medical meetings, such as the HCC-TAG Conference and ASCO Annual Meetings.

Also, perhaps there is 1 person in [a community practice] who is a champion of HCC. There are so many types of cancer, so no one person can be on top of all of them. Having 1 person who can stay up to the minute with HCC [may be beneficial]. That is how I would approach it if I was a community oncologist.

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