Tanios Bekaii-Saab, MD: Arndt, TKIs [tyrosine kinase inhibitors], IO [immune-oncology], all that stuff. This is great. We’re playing with those, but what else? Where do we need to move? How many TKIs can we have? How many PD-1-CTLA-4 combinations? I think we’re pretty maxed out there and everything is looking relatively similar. What next?

Arndt Vogel, MD: That’s a good question. We have touched on most points already to which extent can we use combinations, and to which extent we do treatment beyond progression; IO beyond progression. There are a couple of clinical trials that evaluate this—phase 3 studies, IITs [investigator-initiated trials], phase 2 studies—so we will get an answer to this. We have a lot of options as we have discussed—first line, second line, sometimes evidence free. One would be more combinations, but we have learned with COSMIC [NCT03755791], we cannot combine everything with everything, it does not work out. The next point is something you mentioned at the beginning, having a biomarker would be a good thing in HCC [hepatocellular carcinoma] to select patients on biomarkers. As pointed out, we do not have anything. A lot of research is ongoing but this is something we clearly need. Something we have not discussed, and I’m not really a fan of, but to an extent we can also use chemotherapy. We now have all these data from China, completely different patient population, young hepatitis B patient with excellent liver function, which suggests that intra-arterial chemotherapy could be an option. I’m not convinced. Maybe I’m also looking forward to any comments here.

Tanios Bekaii-Saab, MD: Back to the future, anytime we talk about chemotherapy.

Arndt Vogel, MD: Absolutely, you’re hesitant. I was not sure whether I should mention it.

Tanios Bekaii-Saab, MD: I tell you, I’ve never seen a response.

Arndt Vogel, MD: Me neither. We had small phase 2 studies, like 10 years ago, we did it already and it did not work, so I’m not sure, but it’s worthwhile to go back to the future as you pointed out. We need to have new ideas.

Tanios Bekaii-Saab, MD: I want to ask all of you about anything that you’ve seen at ASCO [American Society of Clinical Oncology] that popped out to you in HCC. HCC tends to be not as represented.

Pierre Gholam, MD: Subdued.

Tanios Bekaii-Saab, MD: Although previous ASCOs and ASCOs GIs, it was everywhere.

Anthony El-Khoueiry, MD: It’s a reflection of the enormous body of data that has emerged, and we need to let the dust settle a bit, understand the landscape, let some of the new agents evolve in knowledge, and then we’ll see.

Tanios Bekaii-Saab, MD: Rather than to fire from the hip, just add things, I’m going to start with Pierre. Dr Gholam, what clinical pers can you offer for community practitioners treating patients with HCC at a high level?

Pierre Gholam, MD: The field is evolving at such a high pace that not only is it important to understand how to use these drugs safely and effectively, but also what is a rational order to use them in. I think that is going to be our task in the next few years, to understand what works before or after what, and when do we decide the transition of care from one regimen to the other? Those who treat HCC at a high level have a lot of work on their hands. There’s going to be a lot more reported in this coming year and it’s only going to get more complicated, but that’s not a reason not to dive into it and help patients as much as we can.

Tanios Bekaii-Saab, MD: Thank you, Pierre. Dr Yarchoan?

Mark Yarchoan, MD: The field has evolved incredibly rapidly with all of these combinations, and with potentially more on the way. For the first time talking about triplet therapy, which is exciting. What advice would I have for community-based oncologists? HCC is extremely complicated and multidisciplinary, and it’s important to think about referring patients with liver-only HCC because there’s a lot that can be done in MDT [with a multidisciplinary team] that can’t be done with a solo practitioner. That would be my advice.

Tanios Bekaii-Saab, MD: It’s a multidisciplinary disease. Dr El-Khoueiry?

Anthony El-Khoueiry, MD: I would mention one thing. We have great systemic options that are effective. We have many of them, so the transition from liver-directed therapy to systemic therapy is a critical point. The old days of continuing to do liver-directed therapy until liver function deteriorates or the patient misses the opportunity of systemic therapy are long gone. The transition is critical.

Tanios Bekaii-Saab, MD: I think that’s why our hepatology colleagues are our best allies in that. Dr Vogel?

Arndt Vogel, MD: I don’t want to repeat something that has been said before, but in this case, I really would like to do it because I agree that the multidisciplinary discussion is critically important. What I see is that with the availability of more systemic therapies, they are used more in the community, and they are not discussed in the multidisciplinary tumor board. This is something we urgently need to prevent. In the past, we have used the local therapies too much, but we should not use them in the future. We still need to identify those patients in which potentially curative treatments could be available, including liver transplantation, risk section, SBLT [stereotactic body radiation therapy], and everything we have discussed, and therefore MDT not only at first diagnosis but also during treatment is critically important.

Tanios Bekaii-Saab, MD: Which makes quite a bit of sense. We’re not just treating the cancer, we’re treating the disease and the liver as well, it’s not a simple issue. It requires that multidisciplinary team in every aspect of care from stage 0 to stage V. I want to thank our panel for this rich and informative discussion and to our viewing audience, thank you for joining us. We hope that you found this OncLive Peer Exchange® discussion to be useful and valuable to the treatment of your patients with hepatocellular carcinoma.

Transcript edited for clarity.