Systemic Treatment of Advanced Unresectable Hepatocellular Carcinoma After First-Line Therapy: Expert Recommendations from Hong Kong, Singapore and Taiwan

Abstract

Background: Asia has a high burden of hepatocellular carcinoma (HCC) due to the high rates of chronic hepatitis B infection, and accounts for 70% of HCC cases globally. In the past 20 years, the systemic treatment landscape of advanced HCC has evolved substantially – from tyrosine kinase inhibitors to immune-oncology agents plus anti-vascular endothelial growth factor agents. The appropriate sequence of therapies has become critical in optimizing patient outcomes given the increase in systemic therapeutic options. This article evaluates the evidence and provides expert recommendations for the use of systemic therapies after first-line treatment in patients with advanced HCC. Summary: Based on three virtual meetings held in early 2021, a team of 17 experts comprising oncologists, a hepatologist and a hepatobiliary surgeon from Hong Kong, Singapore and Taiwan reviewed available data about systemic treatments for HCC after first line and formulated 28 statements. These statements aimed to provide expert guidance on the selecting first- and subsequent lines of therapies as well as recommend therapies in special circumstances, such as poor liver function, post-transplantation, recent gastrointestinal bleeding or autoimmune diseases. Data supporting the statements were drawn from clinical trials and real-world studies. The 28 statements were then voted anonymously using a 5-point Likert scale, and 24 reached consensus, pre-defined as achieving 75% agreement. Statements generated covered the selection of first-line systemic therapy, considerations and goals of second-line systemic therapies, treatment selection following first-line therapy, and treatment recommendations following first-line tyrosine kinase inhibitors, immune-oncology monotherapy or immune-oncology combination therapy. The authors also shared expert opinion on the use of second-line systemic therapy in patients with liver dysfunction, liver transplantation, recent gastrointestinal or autoimmune disease. Key messages: These expert statements summarize the latest data and expert opinion on selecting systemic treatment following first-line therapy in patients with unresectable advanced or metastatic HCC.