Evolving Approaches for HCC in the Molecular Medicine Era - Episode 9

Choosing Between VEGF TKIs for Frontline HCC Treatment

Richard S. Finn, MD: We have some consensus that we have a lot of options in the frontline setting. I think atezolizumab-bevacizumab stands out because of its significant survival advantage over TKIs [tyrosine kinase inhibitors]. Single-agent PD-1 agents have not succeeded in the frontline setting, although we have seen some safety data with nivolumab and Child-Pugh class B patients. Again, it’s uncontrolled data, but the response rate seems to be maintained and the safety seems to be acceptable.

There are also some interesting studies about antidrug antibodies, right? It’s being reported that the incidence of these are a little higher with atezolizumab than with nivolumab or pembrolizumab. At least from my standpoint, I don’t see the clinical relevance of this just yet. We have data that clearly show that atezolizumab-bevacizumab is effective and superior to sorafenib. We have no clinical tests for these antibodies. And whether that will be responsible for acquired resistance has yet to be seen.

If a patient is not a candidate for atezolizumab-bevacizumab for some of the reasons we’ve discussed, Catherine, how do you decide between lenvatinib and sorafenib?

Catherine Frenette, MD: That’s a really good question, and that’s where experience comes in and patient decision-making and knowing your patient. I have a discussion with my patient about their other medical problems and their life. For instance, if someone has a history of cardiac disease and they’ve got severe hypertension and are on 3 antihypertensives, I’m a bit more reluctant to give them lenvatinib. If they do get hypertension, it’s going to be difficult to control it when they’re already maxing out on medical therapy.

On the other hand, if someone is an avid gardener or an avid golfer, and a hand-food-skin reaction would really affect their ability to do what they love to do, I’m more reluctant to put them on sorafenib. I look at those kinds of things. I also think about the proteinuria. For instance, some patients have a really hard time with the twice-daily medicines, in regard to remembering to take the medicine twice a day. In that case, I might lean more toward lenvatinib because it is only administered once a day. You have to pick out these really little particularities of each patient in making the decision.

Richard S. Finn, MD: Sure. The toxicity comes into play. And then sometimes, also, the activity, for those patients who might need a response, right? We know there’s a good chance of response with I/O [immuno-oncology], but this patient, because of 1 of the reasons mentioned, should not get I/O or a combination, specifically atezolizumab-bevacizumab. But they need a response. They have a bulky tumor. Sometimes that would make me consider lenalidomide over sorafenib.

Transcript edited for clarity.