Dr Noonan on Challenges Regarding the Sequencing and Selection of Therapies in HCC

Anne M. Noonan, MBBCh, assistant professor, the Department of Internal Medicine, chief, Gastrointestinal Medical Oncology Section, The Ohio State University, member, the Translational Therapeutics Program, The Ohio State University Comprehensive Cancer Center–James, discusses unmet needs that remain to be addressed in hepatocellular carcinoma (HCC), including challenges regarding the navigation and sequencing of treatment options.

The expansion of available first- and second-line systemic therapeutics in the HCC armamentarium have greatly improved patient prognosis However, understanding the optimal selection and sequencing of these options presents aunique challenge for clinicians, Noonan begins.

Many of the large, phase 3 trials in HCC treatment are unlikely to be repeated in a setting that includes sequencing evaluations, Noonan says. Additionally, patient characteristics that present in the community setting often do not align with original eligibility criteria for patients being evaluated on clinical trials, Noonan explains. For example, studies supporting the FDA approval of current systemic therapies only included patients with Child-Pugh A disease in their eligibility criteria. As a result, there are a limited number of treatment recommendations for patients with HCC who are classified as having Child-Pugh class B or C cirrhosis, Noonan says. Therefore, identifying viable therapeutics for this population is a significant unmet need, she emphasizes.

Many patients with HCC who have cirrhosis of the liver will also experience comorbid organ dysfunction, Noonan continues. This can include liver dysfunction and hepatorenal syndrome. Hepatorenal syndrome predominantly occurs in patients who have ascites originating from portal hypertension, and thrombocytopenia due to splenomegaly, Noonan details. Advanced chronic liver disease is associated with poorer prognosis, and patients with this condition often have difficulty finding safe and effective therapies, Noonan adds. This presents another unmet need that remains to be addressed through future research, Noonan concludes.