Systemic Therapy for Advanced Hepatocellular Carcinoma

Patient Guideline

Publication Date: March 18, 2024
Last Updated: May 14, 2024

 

 

This patient guideline summarizes key takeaways from the American Society of Clinical Oncology (ASCO) guidelines for Systemic Therapy for Advanced Hepatocellular Carcinoma (HCC). The purpose of this guidance is to provide new evidence-based recommendations to support clinical decision-making for patients with advanced HCC.

Background and Definitions

Background and Definitions

  • Hepatocellular carcinoma (HCC) is the most common type of liver cancer.

  • This summary focuses on HCC that is “advanced” – which means the cancer has spread to other parts of the body and is less likely to be controlled with certain treatments.

  • This summary also focuses on “systemic therapy” – which includes:
    • Targeted therapy – A treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells. It also limits damage to healthy cells.
    • Immunotherapy – Immunotherapy uses the body's natural defenses to fight cancer by improving your immune system’s ability to attack cancer cells.

  • Throughout this summary we will refer to “lines” of therapy.
    • “First Line” means initial treatment.
    • “Second Line” means second treatment after initial or first-line treatment.
    • “Third Line” means treatment that happens after first-line and second-line treatments.

Treatment Overview

Treatment Overview

  • The current recommendations for HCC treatment depend on several factors, including:
    • How much the cancer has affected the liver
    • 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 health

  • Clinicians use a “Child-Pugh” score to help determine how your liver is working.
    • Class A means the liver is working normally; you have good liver function.
    • Class B means mild to moderate liver damage.
    • Class C means there is severe liver damage.

  • Performance Status is another rating system clinicians use to help determine the treatment options for HCC.
    • PS 0 means you are active and generally have no issues with your day-to-day activities.
    • PS 1 means you can’t perform heavy or physical work but can mostly do anything else.
    • PS 2 means you are up and about more than half the day and that you can look after yourself but can’t work.
    • PS 3 means you are in bed or a chair for more than half the day, and you need help to look after yourself.
    • PS 4 means you are in bed or a chair all the time and need help or care at all times.

  • Following the first treatment, subsequent courses of treatment depend upon the response to previous therapy. These treatment plans represent multiple trials conducted under strict rules in major healthcare facilities. Such trials are the foundation of progress in cancer treatment.

Patient-Clinician Communication

Patient-Clinician Communication

  • 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 with your care provider, consider the following:
    • Disease activity
    • Your personal medical history and current health
    • Treatment benefits vs. side effects
    • Your personal goals and preferences
    • Quality of life
    • Current insurance coverage
    • Cost of treatment and availability of lower cost alternatives
    • Ability to travel to and from treatments and other care visits
    • Friends, family and your current support network

Tables and Figures

Tables and Figures

Systemic Therapy Options for Advanced Hepatocellular Carcinoma. 

Having trouble viewing table?
Name Type Taken As Treatment sequencea
atezolizumab & bevacizumab Immunotherapy & Targeted Therapy IV 1st preferred OR 2nd
durvalumab & tremelimumab Immunotherapy IV 1st preferred OR 2nd
sorafenib Targeted Therapy (TKI) Oral 1st alternate OR 2nd
lenvatinib Targeted Therapy (TKI) Oral 1st alternate OR 2nd
durvalumab Immunotherapy IV 1st alternate OR 2nd
nivolumab & ipilimumab Immunotherapy IV 2nd
nivolumab Immunotherapy IV 2nd
pembrolizumab Immunotherapy IV 2nd
ramucirumab Targeted Therapy (patients with AFP ≥400 ng/mL) IV 2nd
cabozantinib Targeted Therapy (TKI) Oral 2nd
regorafenib Targeted Therapy (TKI) Oral 2nd
a For patients who have good liver function, and the ability to do daily activities, third-line treatment with any of the medications listed in this table may be recommended, as long as these medications work differently from any other medications that have already been tried.

Abbreviations: IV, intravenous; TKI, tyrosine kinase inhibitor.

Summary of Treatment Pathway for HCC


Additional Resources

Additional Resources

Source Citation

John D. Gordan, MD, PhD; Erin B. Kennedy, MHSc; Ghassan K. Abou-Alfa, MD, MBA, et al. Systemic Therapy for Advanced Hepatocellular Carcinoma: ASCO Guideline. J Clin Oncol. 2024 March 19. doi: JCO.23.02745