Unresectable Hepatocellular Carcinoma: Selecting the Optimal First-Line ICI Combination

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Dr. Abou-Alfa:
This is CME on ReachMD and I’m Dr. Ghassan Abou-Alfa from Sloan Kettering in New York.

Dr. He:
This is Dr. Ruth He from Georgetown University Hospital from Washington, DC. 

Dr. Abou-Alfa:
Managing patients with unresectable hepatocellular, or HCC, requires collaboration among members of different specialties. Ruth, how can we enhance patient outcomes through integrated multidisciplinary care? 

Dr. He:
I believe it is super important to have a group of doctors from different specialties collaborate on the case. And so, we do need to have a multidisciplinary review of the case, or a discussion of the case. And this is very important from diagnosis to treatment, to manage of side effects. And, so, I think patients with liver cancer, the survival it depends not only on cancer control, also management of the liver disease. So, management symptoms of, liver failure. So, it is super important to collaborate, to provide the best outcome for this patient.

And so, Ghassan, what thoughts do you have on the multidisciplinary care model?

Dr. Abou-Alfa:
Well, thanks Ruth. I totally agree with you. Afterall, it’s teamwork. And no doubt that data has shown that if continued serial referrals can really, number one, lack efficiency, and they can result in poor outcome. So, it's very important to really consider the thoughtful and right approach to the therapy, and management of the disease. 

If anything, we do consider that patients might automatically come up first to hepatologist because they have some liver issue that related to the potential etiology of the disease. Of course, there could be probably touching on in regard to a surgeon or in regard to a transplant surgeon. They might come into the attention of an interventional radiologist for a local therapy. And to be fair, Medical Oncology is relatively a newcomer into the field, but thankfully to the many, many therapies that you and I have discussed today, we can see that their early involvement is very critical. And we make sure that because, it can number one, build the big picture, number two, is of course, encourage and enhance what's necessary on anybody's patient therapy.

And as is though, you and I were already discussed many therapies that are available for patients with advanced HCC. The involvement of Medical Oncology right from the start will be very critical because we know that it will give the opportunity to help build the big picture and ensure that we get the right therapy for the patient at the right time and make sure that the contribution that medical oncology can bring in is well noted right from the start. 

Dr. He:
I agree with you on that. And so, early on, when patient is presented with resection or transplant options, and the medical oncologists can bring in data of systemic therapy, the benefit, especially for those high-risk patients if they have increased risk of recurrence or progression. And later, when the disease progresses, if patients present with more advanced stage disease, I think, with the more treatment options, I feel like the medical oncologists become more and more the captain of the team. And I think we need to collaborate with our hepatologists and GI specialist in managing any possible adverse events from the treatment.

Dr. Abou-Alfa:
As we can see, you can summarize that I totally agree, Dr. He and I, that no doubt that teamwork is very important. Multidisciplinary team approach is very critical.

I will here post two important notes. Data has shown interestingly that patients that are not seen by all these specialties will not fare as well in regard to outcome and in regard to survival. This is published. 

And point number two, please, please, when there is a tumor board, we have noticed, by some observation, that all the players will be there, but sadly, our colleagues in medical oncology are the ones that are less to come to the MDT. Please, please, very critical that you are there because, number one, so we can see where we can help, where we can serve, where we can learn from other colleagues.

At the same time, also, how can we pass the great information that we are learning together about the new advance of the different checkpoint inhibitor doublets, like for example, durvalumab plus tremelimumab, and others to our colleagues.

Well, this has been a brief, but great discussion. I hope we gave you something to think about and thanks for tuning in.

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