ASCO Updates Guidelines for Advanced HCC

The American Society of Clinical Oncology (ASCO) has updated its guidelines on the use of systemic therapy for advanced hepatocellular carcinoma (HCC). The guidelines were published in the Journal of Clinical Oncology.

First-Line Therapy

For patients with Child-Pugh class A advanced HCC who have an ECOG performance status score of 0 or 1, the guidelines recommend atezolizumab plus bevacizumab or durvalumab plus tremelimumab as first-line treatment (a strong recommendation based on moderate- to high-quality evidence).

Patients with contraindications to atezolizumab plus bevacizumab or durvalumab plus tremelimumab can receive sorafenib, lenvatinib, or durvalumab as alternatives (a strong recommendation based on moderate-quality evidence).

Second-Line Therapy

For patients with Child-Pugh class A advanced HCC who have good performance status, recommendations for second-line treatment vary based on the first-line treatment a patient received.

Patients who received first-line atezolizumab plus bevacizumab can receive any of the following second-line treatments:

• A tyrosine kinase inhibitor (TKI) — such as sorafenib, lenvatinib, or cabozantinib — or ramucirumab (a weak recommendation based on low-quality evidence)
• Nivolumab plus ipilimumab (supported by data from case series)
• Durvalumab plus tremelimumab. (There are no data to support this recommendation.)

If durvalumab plus tremelimumab is given in the first line, second-line therapy with a TKI is recommended (a weak recommendation based on low-quality evidence). Atezolizumab plus bevacizumab may also be considered, but there are no data to support this recommendation.

If a patient received sorafenib or lenvatinib in the first line, second-line therapy may consist of any of the following (a weak recommendation based on low-quality evidence):

• Another TKI (cabozantinib or regorafenib)
• Ramucirumab
• Nivolumab plus ipilimumab
• Durvalumab
• Atezolizumab plus bevacizumab (for patients who did not have access to this combination in the first line)
• Durvalumab plus tremelimumab (for patients who did not have access to this combination in the first line).

Pembrolizumab and nivolumab may also be options for patients who previously received sorafenib or lenvatinib.

Third-Line Therapy and Child-Pugh Class B HCC

For third-line therapy, patients with Child-Pugh class A disease and good performance status can receive any of the aforementioned agents, as long as they do not have an identical mechanism of action to prior therapies (weak recommendation based on low-quality evidence).

For patients with Child-Pugh class B disease and good performance status, health care providers should consider the patients’ underlying liver function, bleeding risk, presence of portal hypertension, extent of extrahepatic spread, tumor burden, and major vascular invasion. There are limited data to suggest that regimens typically used for Child-Pugh A disease can be beneficial in untreated patients with Child-Pugh B cirrhosis (weak recommendation based on low-quality evidence).

Disclosures: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of disclosures.

This article originally appeared on Cancer Therapy Advisor