Systemic Therapy for Liver Cancer

Publication Date: February 21, 2022
Last Updated: April 8, 2024

Objective

Objective

  • This patient guideline summarizes key takeaways from American Gastroenterological Association (AGA) guidelines for Systemic Therapy for Hepatocellular Carcinoma (HCC). The purpose of this guidance is to provide guidance on the use of systemic therapy in the treatment of HCC in adults.

Treatment Overview

Treatment Overview

  • Hepatocellular Carcinoma is the most common type of liver cancer. We will use the abbreviation “HCC” throughout this summary to refer to hepatocellular carcinoma.
  • Throughout this summary we will refer to “lines” of therapy. Brief descriptions of each are below:
    • “First Line” – Initial treatment
    • “Second Line” – Second treatment after initial, or first-line treatment
    • “Adjuvant” – Treatment to reduce the risk of cancer returning
  • This summary focuses on the following treatment approaches:
    • Systemic Therapy - a type of cancer treatment that uses medications to destroy cancer cells throughout the entire body
    • Surgery – also called a resection, is a procedure to remove part of the liver to completely remove (resect) a tumor
    • Locoregional therapies (or LRT for short)
      • Transcatheter liver-directed intra-arterial therapies (TACE) - outpatient treatment that involves injecting medications directly into your blood vessel
      • Ablation – treatment that uses heat, cold, or radio waves to destroy tumors without removing them
      • Radiation - treatment that uses high-energy particles or rays to kill cancer cells
  • Surgery and locoregional therapies are the preferred treatment approaches, but not all patients are candidates due to one or more reasons, including
    • How much of the liver is affected by the cancer
    • The damage to the remaining cancer-free area of the liver
    • Whether the damage is causing issues with day to day activities
    • If the cancer has spread
    • Individual patient preferences and overall health
  • Systemic therapy for advanced HCC usually includes one or more of the following medications.
    • atezolizumab + bevacizumab
    • sorafenib
    • lenvatinib
    • cabozantinib
    • pembrolizumab
    • ramucirumab
    • regorafenib
  • The best treatment approach should be individualized, and is based on multiple factors. The choice of therapy should be a shared-decision between you and your care team, and based on factors such as: disease activity, medical history, potential treatment side effects, cost of treatment, potential risks vs. rewards, and your personal goals and preferences.

First Line Therapy

First Line Therapy

  • In patients with a healthy liver, who are not eligible for LRTs or surgery, or for patients whose cancer has spread to other parts of the body, the following medications are recommended for first-line therapy:
    • atezolizumab + bevacizumab*
In patients who are not candidates for treatment with atezolizumab + bevacizumab, the following medications are recommended:
  • lenvatinib
  • sorafenib
Bevacizumab can cause bleeding in the digestive tract, so checking for and treating any varices (enlarged veins) in the esophagus before treatment is important.
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Second Line Therapy

Second Line Therapy

  • In patients with a healthy liver, but are not eligible for LRTs or surgery, or for patients who not achieve treatment goals with sorafenib, the following mediations are recommended for second-line therapy:
    • cabozantinib
    • pembrolizumab
    • regorafenib
    • ramucirumab
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Additional Treatment Considerations

Additional Treatment Considerations

  • In patients whose liver is not working properly, or whose cancer has spread to other parts of the body, the use of sorafenib is not recommended.
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  • In patients who are currently being treated with LRTs or surgery, the use of sorafenib is not recommended.
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  • For patients undergoing a specific LRT procedure called transcatheter arterial chemoembolization (TACE), the use of both sorafenib and bevacizumab is not recommended.
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Shared Decision Making

Shared Decision Making

  • Shared decision making between you and your care provider is very important. The more knowledgeable you can become about your treatment choices, and the potential risks and benefits, the more likely it is that you and your care provider will make the best possible choice for your situation.
  • When choosing a treatment choice, consider the following:
    • Current insurance coverage
    • Cost of treatment and availability of lower cost alternatives
    • Survival benefits vs. side effects and quality of life
    • The stage and progression of the cancer
    • Ability to travel to and from treatments and other care visits
    • Friends, family and your current support network
    • And more

Source Citation

Grace L. Su, Osama Altayar, Robert O’Shea, Raj Shah, Bassam Estfan, Candice Wenzell, Shahnaz Sultan, Yngve Falck-Ytter, AGA Clinical Practice Guideline on Systemic Therapy for Hepatocellular Carcinoma, Gastroenterology, Volume 162, Issue 3, 2022, Pages 920-934, ISSN 0016-5085, https://doi.org/10.1053/j.gastro.2021.12.276.

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.