Canadian Study Highlights Low Uptake of Systemic Therapy in HCC Despite the Benefits

A real-world study of Canadian patients with advanced unresectable hepatocellular carcinoma (HCC) found that while systemic therapy improved survival compared with patients who did not receive it, uptake was low. The findings were presented at the ASCO Gastrointestinal Cancers Symposium, held Jan. 20-22, 2021, in San Francisco, Calif., and online.

Sorafenib has been the recommended first-line treatment for advanced HCC, but there is an expected shift in treatment with the introduction of several novel systemic therapies. The researchers conducted a retrospective, population-based study of all patients with advanced HCC in Alberta, Canada, from 2008 to 2018 using electronic medical records and administrative claims data. Additional information was captured with a chart review.

A total of 1,297 patients with advanced HCC were included in the review and 42.8% of them were recurrent cases. The median age was 64 years and 82.1% of the patients were men.

“Patients who did not receive systemic therapy were older, had more comorbidities, lower socioeconomic status, live in southern Alberta, and have metastatic disease,” the authors noted.

Less than one-fourth (21.1%) of patients initiated first-line systemic therapy and even fewer (11.7%) initiated it in the second line. Nearly all (97.8%) patients received sorafenib in the first line. In the second line, therapies received were cabozantinib, regorafenib, amcasertib, nivolumab, axitnib, and lenvatinib.

More than half (55.8%) of patients receiving systemic therapy had a dose reduction over the course of treatment, and the median time on systemic therapy was 14.1 weeks in the first line and 11.5 weeks in the second line.

For patients treated with systemic therapy in the first line, the overall survival was a median of 9.40 months, and for patients receiving systemic therapy in the second line it was 8.48 months. Overall, patients receiving systemic therapy has a significantly higher medial survival (12.23 months) compared with patients who did not receive systemic therapy (2.66 months).

Other findings about overall survival for patients who received systemic therapy were:

• Patients with Child-Pugh A had a higher overall survival (median 14.20 months) compared with Child-Pugh B7 (7.81 months) and B8 and B9 (5.28 months)
• Patients without metastatic disease had better overall survival (median 13.71 months) compared with those with metastatic disease (10.72 months)
• Patients with recurrent disease had better overall survival (median 16.50 months) vs de novo disease (9.30 months)

The average time spent in hospital for patients who received first-line systemic therapy was nine days per patient within year one, nine days per patient within year two, and eight days per patient within year three.

The authors noted that the findings of the study highlighted that initiation rates of systemic therapy were low among patients with advanced HCC and dose reductions were common.

“The low uptake of systemic therapy and the modest survival gains highlight the importance of earlier diagnosis and the need for novel and more effective first-line therapies,” they concluded.

Of note is that this study looked at Canadian patients, who have access to a decentralized, universal, publicly funded health system that provides medically necessary hospital and physician services for free. However, outpatient prescriptions are considered excluded services for which some coverage is provided by provinces and territories for targeted groups.

In Alberta, all cancer drugs on the formulary are provided at no charge to eligible residents.