Expert Stresses Early Detection, Multidisciplinary Care for HCC

Amit Singal, MD

With the success of regorafenib (Stivarga) in the phase III RESORCE trial and the promise of immunotherapy agents such as nivolumab (Opdivo), hepatocellular carcinoma (HCC) seems to be coming into a new era of therapeutic development after almost a decade of failed trials.

Challenges remain though, namely in detection. According to Amit Singal, MD, the biggest limitation in the field of HCC is the high population of patients who are diagnosed at a late stage.

“It is extremely frustrating, because if we find these patients at an early stage, we actually have highly effective curative therapies available—whereas, if you find them at a late stage, the median survival is pretty poor,” said Singal.

In addition to early detection, Singal said that patients with HCC need multidisciplinary care or at the very least, better communication. Physicians should be considering all treatment options for patients, not just what falls within their specialty, said Singal.

OncLive: Sorafenib has been established as a frontline therapy for nearly 10 years, do you see this changing in the near future?

In an interview with OncLive, Singal, associate professor, UT Southwestern Medical Center, discussed the recent successes in the HCC treatment landscape and the challenges that still remain.Singal: I think it is an exciting time for HCC. Sorafenib (Nexavar) has been the only agent we have had in a decade. When it first came out, we thought that there would be something right around the corner, but then all we had was negative trial after negative trial. I think this is the first time in HCC that we are starting to see truly promising phase II data. We will see what the phase III data show in the next year or 2, but I think that this is a time where we will see a lot of progression in terms of new therapies becoming available.

How has regorafenib impacted the field?

Do you believe there is a future for immunotherapy in HCC?

What is the biggest challenge in treating HCC?

We just had our second positive trial, with regorafenib showing benefit as a second-line agent. I think we are going to see more and more new drugs coming to the market. So, it will be an interesting time to be involved in the field, as we may go from 1 agent to potentially multiple in a very short period of time.The RESORCE trial evaluated regorafenib versus placebo as a second-line therapy and showed a significant survival benefit in these patients. It is important, clinically, because it was an unmet need—we did not really have anything for these patients who had progressed on sorafenib. I think that what was most surprising was the degree of survival benefit in this very difficult to treat patient population, which I think speaks to not only the drug itself, but also how these patients were selected.Yes, I think those are some of the most promising medications. The most exciting part of this is that we are seeing some partial responders and even some complete responders. To offer patients with advanced tumors a good chance with this is really exciting. I think you already are seeing excitement not only among providers, but among patients, with the possibility of immunotherapy. We are going to see a lot more solid phase II data coming out at the next few meetings and some early phase III results.I think the biggest thing that I see as a limitation in this field is the continued high proportion of patients who are diagnosed at a late stage. The possibility of new agents may shift that toward having slightly better survival but I do not think it will be anything close to what we have with curative therapies. What is frustrating is that HCC surveillance is fairly easy to do, it is just not being done. If we were able to increase rates of surveillance, we would dramatically improve prognosis.

What do you think is important to understand about the treatment landscape of this disease?

Most of my research focuses on how we can improve early detection. We have done some work in terms of interventions to increase early detection, including population health management interventions to identify patients with cirrhosis earlier and make them go out and get their surveillance testing done. I think this is something where if all of us pitch in with patient education and provider education, we can make a big difference.The important thing for not only oncologists, but anyone treating HCC, is to remember that there are several different treatment options available. One of the things that I have seen is that you consider your small piece of the pie, but HCC is a cancer that can be treated by several different subspecialties, ranging from transplant hematology and surgery to intervention radiology to medical oncology. We are very good at considering what we do, but not at considering what other treatment options are available.

I think it is very important for all of us to keep in mind that there are other options that may be more effective for that patient sitting in front of you. We have to communicate with each other. You see this in the data that shows that benefits of multidisciplinary care, which is showing that communication is vital in maximizing the benefit for these patients. While multidisciplinary care is not necessarily possible in each setting, communication is.