Insights into the success and failure of systemic therapy for hepatocellular carcinoma

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Systemic treatment for hepatocellular carcinoma (HCC) has been boosted by the incorporation of new agents after many negative phase III trials in the decade since the approval of sorafenib. Sorafenib introduced the concept that targeting specific hallmarks of hepatocarcinogenesis could modify the dismal prognosis of this disease, with the drug remaining a cornerstone in the upfront therapy for advanced HCC. The design of clinical trials in this malignancy is complicated by important obstacles related to patient selection, prognostic assessment and the need for endpoints that correlate with improvement in survival outcomes. In addition, the currently used criteria to determine treatment response or progression might prevent physicians from making appropriate clinical judgements and interpreting evidence arising from trials. In this Review, we discuss the advances in systemic therapy for HCC and critically review trial designs in HCC. Although novel therapies, such as new targeted agents and immunotherapies, are being rapidly incorporated, it is paramount to design future clinical trials based on the lessons learned from past failures and successes.

Key points

  • The changing landscape of hepatocellular carcinoma treatment demands a critical interpretation of how therapies have evolved and what future challenges lie ahead.

  • Improving overall survival is the main objective in advanced hepatocellular carcinoma, and the use of surrogate endpoints, such as response rate, time to progression or progression-free survival, lacks scientific evidence.

  • Criteria for response to treatment should evolve so that validated signals of activity prime transition into phase III trials.

  • Trial design and analysis should include novel clinical characteristics such as pattern of progression and pattern of adverse events with prior therapy.

  • Phase III trials in ill-defined target populations with limited clinical characterization might provide unreliable (positive or negative) results.

  • Molecular stratification is hampered by tumour heterogeneity and lacks prognostic power and linkage to treatment.

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Fig. 1: Tumour burden and survival.
Fig. 2: Refining concepts of response.
Fig. 3: Magnitude and duration of response.
Fig. 4: Prognostic value of progression patterns.
Fig. 5: Clinical decision-making upon detection of progression at imaging according to common criteria such as RECIST 1.1.
Fig. 6: Clinical trials performed in first-line therapies for hepatocellular carcinoma.
Fig. 7: Patients with tumours at high risk of recurrence because of conventional pathology features are followed at shorter intervals than patients at low risk of recurrence, aiming to detect and treat recurrence earlier.
Fig. 8: The Barcelona Clinic Liver Cancer stage and treatment system establishes prognosis and treatment recommendations with impact on survival for each of the five stages.
Fig. 9: Systemic treatment sequence for advanced hepatocellular carcinoma based on prospective trials.


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M.R. received grant support from Instituto de Salud Carlos III (PI15/00145). J.B. received grant support from Instituto de Salud Carlos III (PI18/00768), AECC (PI044031), Secretaria d’Universitats i Recerca del Departament d’Economia i Coneixement (2014 SGR 605) and WCR (AICR) 16–0026. CIBERehd is funded by the Instituto de Salud Carlos III.

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J.B. mentored the ideas and concepts of the manuscript. All authors contributed to all aspects of the preparation of the manuscript, including writing, editing and discussion the content of the manuscript.

Correspondence to Jordi Bruix.

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J.B. has consulted for Arqule, Bayer-Shering Pharma, Novartis, BMS, BTG-Biocompatibles, Eisai, Kowa, Terumo, Gilead, Bio-Alliance, Roche, AbbVie, Merck, Roche, Sirtex, Ipsen, Astra-Medimmune, Incyte, Quirem, Adaptimmune, Lilly, Basilea and Nerviano; and has received research and educational grants from Bayer and BTG. L.d.F. has received travel grants from Bayer and speaker fees from Bayer-Shering Pharma, BTG-Biocompatibles, Eisai, Terumo, Sirtex and Ipsen. M.R. has received speaker fees from Gilead, BMS, BTG, Lilly and Bayer, and consultancy fees for Bayer, BMS and AstraZeneca.

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