In recent years, with the continuous deepening of research on molecular signaling pathways and tumor microenvironments of liver cancer, targeted therapy has shown obvious advantages and occupied an important position in the treatment of advanced liver cancer. In this context, as a supplement to the "Guidelines for the Diagnosis and Treatment of Primary Liver Cancer (2022 Edition)", the "Expert Consensus on Targeted Therapy for Liver Cancer" (hereinafter referred to as the "Consensus"), led by Professor Cai Jianqiang of the Cancer Hospital of the Chinese Academy of Medical Sciences, came into being, and has been published in the authoritative journal In the field of liver cancer, Liv Cancer (impact factor 11.74), which has been internationally recognized. Based on this, with the strong support of the Cancer Hospital of the Chinese Academy of Medical Sciences, on February 13, the China Medical Tribune held the "Expert Consensus on Targeted Therapy for Liver Cancer" press conference, with Professor Cai Jianqiang as the chairman of the conference, Professor Bi Xinyu of the Cancer Hospital of the Chinese Academy of Medical Sciences as the special guest host, dozens of experts in the field of liver cancer to participate in the meeting, and invited nearly 20 media to participate in the publicity and promotion. The on-site academic atmosphere is strong, and the media and the consensus expert group interact in depth to help promote the "consensus".
China's first targeted therapy for liver cancer consensus, the three characteristics of the consensus advantages
At the beginning of the press conference, Professor Cai Jianqiang said in his opening speech: "Primary liver cancer, as the fourth common malignant tumor and the second most common tumor cause of death in mainland China, the burden of liver cancer diagnosis and treatment is huge for both patients and the medical system. At present, targeted therapy has shown obvious advantages and occupies an important position in the treatment of advanced liver cancer. In order to better assist doctors, patients, medical service providers and health security policy makers in making decisions on targeted therapy and comprehensive treatment of liver cancer, the Multidisciplinary Collaboration Group of Gastrointestinal Tumors of Cancer Hospital of the Chinese Academy of Medical Sciences and Peking Union Medical College elaborated on the consensus reached on the use of targeted therapy for liver cancer in mainland China. I hope that the release of the "consensus" is a new beginning, and then we can implement the "consensus" content in clinical treatment with the joint efforts of all medical colleagues, achieve the goal of "increasing the 5-year survival rate of liver cancer patients in mainland China by 15%" as soon as possible, and achieve the requirements for clinicians in the "Healthy China 2030" Planning Outline as soon as possible. ”
Subsequently, Professor Zou Yinghua of Peking University First Hospital, Professor Liang Jun of Peking University International Hospital, Professor Lu Shichun of PLA General Hospital, Professor Zhou Aiping and Professor Zhao Hong of Cancer Hospital of Chinese Academy of Medical Sciences also delivered speeches as invited experts. Experts unanimously recognized the role of the "consensus" in promoting the clinical diagnosis and treatment of liver cancer. This "consensus", combined with global high-quality evidence, comprehensive collection of liver cancer targeted therapy essence, based on the characteristics of Chinese groups, to create a consensus with Chinese characteristics, MDT multidisciplinary participation, the formulation of optimal treatment strategies three characteristics as outstanding advantages, for the rational use of new molecular targeted drugs, including dosage, joint strategy, in different stages of liver cancer and multidisciplinary means of combination, adverse reaction management, efficacy evaluation and prediction of advanced HCC treatment, etc., to help guide clinicians in making decisions on liver cancer targeted treatment, Lay a high starting point for targeted treatment of liver cancer in China.
Explain the core of consensus from multiple angles, and show the strength of consensus in all dimensions
The high incidence and mortality of liver cancer in mainland China are the second leading causes of tumor death. Professor Zhou stressed that targeted therapy is still the basic strategy for advanced HCC system therapy. At present, a total of 7 targeted drugs for liver cancer have been approved internationally, and 5 have been approved in China, of which 2 are locally developed drugs. This "consensus" also focuses on targeted monotherapy for advanced liver cancer, targeted combination with other drugs, targeted drug dose selection, efficacy evaluation/prediction, and adverse reaction treatment. At present, first-line targeted monotherapy is still dominated by sorafenib, lunvatinib, and donatin, with a recommended level and a level of evidence of 1 (expert consensus 1). Recommendations for second-line therapy after sorafenib failure include rigofenib and apatinib, both at a level of evidence level 1 (expert consensus 2). The best second-line targeting strategy has not been established after the failure of renvatinib. In the era of immunotherapy, targeted drugs combined with immunization have become the preferred choice of first-line therapy, and bevacizumab plus atezizumab or bevacizumab (analogue) combined with sindilimab (PD-1) is recommended as a level I recommendation (expert consensus 3, evidence level 1). The expert consensus also mentions that the results of other strategies including rigofenib, lunvatinib, apatinib and other targeted drugs combined with PD-1 monoclonal antibody have also achieved similar efficacy.
Given that multiple studies have shown a correlation between dose and efficacy of targeted drugs, the consensus is that for patients who are suitable for first-line molecularly targeted therapy, the recommended starting dose should be the standard dose (expert consensus 15, level 1 recommendation, evidence level 1). But for Child-Pugh B/C liver function, renal insufficiency, and body weight
Prof. Zhao Hong: Expert Consensus on Joint Surgery
Professor Zhao Hong focused on the application of targeted therapy in the postoperative adjuvant of liver cancer and post-liver transplantation in the "Consensus" sharing session. For patients with low-risk relapse, the "consensus" is not to recommend targeted adjuvant therapy after radical resection (expert consensus 5). In patients at high risk of recurrence, the "consensus" recommends adjuvant therapy with sorafenib or rumpatinib after radical resection (Expert Consensus 6). Multiple studies have confirmed that sorafenib-targeted therapy after radical resection significantly reduces the risk of recurrence and prolongs survival in patients with high-risk relapse [2]. In addition, rigofenib combined with immunotherapy with advanced liver cancer ORR of 31 percent [3-4]. For patients who relapse after liver transplantation, the "consensus" recommends a combination of targeted drugs such as sorafenib and rigofenib, and recommends sirolimus-based regimen as the preferred immunosuppressive regimen (expert consensus 7). Sorafenib has been confirmed to improve survival in patients with recurrent inelectivable HCC liver transplantation [5-6]. Studies have confirmed that in patients who are unresectable after recurrent HCC liver transplantation, there is a survival benefit with rigofenib after treatment failure with sorafenib.
Professor Yang Zhengqiang: Joint local treatment of expert consensus
The "consensus" gives expert opinions on targeted combined local therapy from three aspects, including local ablation combined targeted therapy, external beam radiation therapy combined with targeted therapy, and TACE combined targeted therapy, and guides clinical practice. These include: "consensus" does not recommend assisted molecularly targeted therapy after local ablation (expert consensus 9) for patients with early HCC; for patients with non-surgical B or C stage BCLC without extrahepatic metastases, the "consensus" recommends that post-radiotherapy sequential sorafenib be considered (expert consensus 10); for patients with hepatic cancer oligomethatasis, the "consensus" recommends the addition of SBRT (expert consensus 11); and studies have confirmed that radiotherapy combined with sorafenib improves survival in patients with CLIP 0-1 [8] For patients with good liver function, the consensus recommends TACE combined targeted therapy (expert consensus 13). Large retrospective studies have shown that second-line therapy with TACE plus rigofenib significantly improves patient survival [9-10], and TACE plus sorafenib sequential rigofenib significantly improves os and PFS compared with TACE alone [11]. In advanced patients with hepatic cancer complicated with portal vein carcinoma suppository, hepatic artery continuous perfusion chemotherapy (HAIC) combined with molecularly targeted drugs is superior to molecularly targeted drugs alone. Clinicians need to choose a comprehensive treatment strategy that is appropriate for the patient on the basis of fully evaluating the patient's individualized situation to maximize the efficacy of the targeted drug.
The spark can ignite the plains, and multidisciplinary efforts can work together to draw a new blueprint for targeted treatment of liver cancer
Professor Cai Jianqiang: Under the strong support of the national medical insurance policy, under the active research and development of large pharmaceutical enterprises, and under the continuous exploration of the pathogenesis and targeted pathways of liver cancer by the majority of researchers, we will work together to solve the problem of "card neck" in liver cancer diagnosis and treatment in mainland China.
Professor Zhou Aiping: As oncologists, we pay attention to the safety of drugs in addition to the efficacy of drugs. Only if the patient can tolerate the current treatment regimen can the patient's treatment compliance and quality of life be guaranteed. Playing iron also needs to be hard. On the basis of digging deep into the mechanism of action of drugs and early warning of adverse reactions, we will strengthen the construction of a therapeutic evaluation and adverse reaction prevention and control system for liver cancer targeted therapy to escort liver cancer patients.
Professor Zhao Hong: Under the wave of liver cancer target exemption, how to formulate a precise and individualized solution is particularly critical. In the future, we also need to further explore the more effective targeted combination of the program, timing, population, etc., to give full play to the advantages of targeted drugs.
Professor Yang Zhengqiang: Based on the anti-angiogenesis mechanism, small molecule targeted drugs such as sorafenib and rigofenib have fundamentally curbed the progression of tumors. Similarly, this mechanism also plays an important role in the combination of interventional therapy. All of this makes targeted drugs an important and even dominant role in the whole process of liver cancer management.
Professor Tang Yu: Although clinical practice has shown benefits, high-quality, high-evidence-level research is still urgently needed in the treatment of liver cancer, and clinicians also need more standardized radiation therapy guidance for liver cancer. It is believed that radiotherapy will play a greater role and produce greater value in the comprehensive treatment of liver cancer.
Professor Jiang Liming: Imaging plays an indispensable role in many aspects of the whole process of liver cancer management, including early screening, early diagnosis, efficacy evaluation, follow-up monitoring, etc. Improve the participation of imaging doctors in liver cancer MDT activities, and help improve the level of diagnosis and treatment of liver cancer patients.
Xiong Guan Man Dao is really like iron, and now he steps forward from the beginning. It is the common mission of clinicians to scientifically practice "consensus", attach importance to the whole process of HCC management, strive for the longest survival for patients through the optimization of each line of treatment, and take into account the best quality of life! It is hoped that under the impetus of consensus, Chinese liver cancer patients will usher in a better long life map.