Systemic Therapy for Advanced Hepatocellular Carcinoma
Guideline Status: Current
Published Online: March 19, 2024
Last Updated: August 8, 2024
Published ahead of print March 19, 2024, DOI: 10.1200/JCO.23.02745
John D. Gordan, Erin B. Kennedy, Ghassan K. Abou-Alfa, Eliza Beal, Richard S. Finn, Terence P. Gade, Laura Goff, Shilpi Gupta, Jennifer Guy, Hang T. Hoang, Renuka Iyer, Ishmael Jaiyesimi, Minaxi Jhawer, Asha Karippot, Ahmed O. Kaseb, R. Kate Kelley, Jeremy Kortmansky, Andrea Leaf, William M. Remak, Davendra P.S. Sohal, Tamar H. Taddei, Andrea Wilson Woods, Mark Yarchoan, and Michal G. Rose
Purpose
To update an evidence-based guideline to assist in clinical decision-making for patients with advanced hepatocellular carcinoma (HCC)
Methods
ASCO convened an Expert Panel to update the 2020 guideline on systemic therapy for HCC. The panel updated the systematic review to include randomized controlled trials (RCTs) published through October 2023 and updated recommendations.
Results
Ten new RCTs met the inclusion criteria and were added to the evidence base.
Updated Recommendations
Atezolizumab 1 bevacizumab (atezo 1 bev) or durvalumab 1 tremelimumab (durva 1 treme) may be offered first-line for patients with advanced HCC, Child-Pugh class A liver disease, and Eastern Cooperative Oncology Group performance status 0-1. Where there are contraindications to these therapies, sorafenib, lenvatinib, or durvalumab may be offered first-line. Following first-line treatment with atezo 1 bev, second-line therapy with a tyrosine kinase inhibitor (TKI), ramucirumab (for patients with alpha-fetoprotein [AFP] ≥400 ng/mL), durva 1 treme, or nivolumab 1 ipilimumab (nivo 1 ipi) may be recommended for appropriate candidates. Following first-line therapy with durva 1 treme, second-line therapy with a TKI is recommended. Following first-line treatment with sorafenib or lenvatinib, second-line therapy options include cabozantinib, regorafenib for patients who previously tolerated sorafenib, ramucirumab (AFP ≥400 ng/mL), nivo 1 ipi, or durvalumab; atezo 1 bev or durva 1 treme may be considered for patients who did not have access to these therapies in the first-line setting, and do not have contraindications. Pembrolizumab or nivolumab are also options for appropriate patients following sorafenib or lenvatinib. Third-line therapy may be considered in Child-Pugh class A patients with good PS, using one of the agents listed previously that has a nonidentical mechanism of action with previously received therapy. A cautious approach to systemic therapy is recommended for patients with Child-Pugh class B advanced HCC. Further guidance on choosing between options is included within the guideline.
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