Jesse Civan, MD

Question

How has the treatment of hepatocellular carcinoma (HCC) changed in the past decade?

Answer

From the perspective of a transplant hepatologist, the last 10 years have seen some substantial changes in national policy regarding organ allocation for patients whose priority on the transplant list is based on their diagnosis of HCC.

These changes have been geared towards ensuring that prioritization on the liver transplant list is based on a radiographic diagnosis of HCC that is as confident as possible in cases where there is no tissue confirmation, which accounts for the majority of cases. The goal is to achieve equitable balance between prioritizing patients whose threat to life is secondary to liver failure vs tumor progression.

Results of these changes have been the emergence of a set of more stringent radiographic criteria, longer waiting times for HCC patients, and an increasing reliance on loco-regional therapy as a bridge to transplant.

Question

Are PD-1, PD-L1, or CTLA-4 inhibitors effective for HCC? Are there any immunosuppressive features unique to liver cancer that make it less likely checkpoint inhibition will be effective?

Answer

Preliminary data on these checkpoint inhibitor therapies are promising. Multiple trials are ongoing trials that will help determine whether these therapies will be considered as options for first-line systemic therapy for HCC.

The US Food and Drug Administration (FDA) recently announced it would fast-track a review of the PD-1 inhibitor, nivolumab, for the indication of HCC, so I would consider nivolumab to be the most promising of the novel therapies likely to enter routine clinical use in the immediate future.

Question

What treatment regimens do you recommend for patients who present with metastatic HCC?

Answer

For the moment, the standard of care remains sorafenib for metastatic HCC. I am, however, recommending to my patients that they be screened for clinical trials of immunotherapy agents.

Question

Are there any current clinical trials you would recommend for patients with relapsed or refractory HCC? Do you expect any of these trials to change clinical care?

Answer

Preliminary data from immunotherapy trials is promising, so I am recommending that my patients be screened for participation in clinical trials in this arena.

Question

Do you foresee treatment vaccines being used for HCC?

Answer

I do not have any particular experience or knowledge of specific studies in the literature to address this question properly. To my knowledge, such a vaccine, while desirable, is not likely to be clinically available in the short-term future.