Hepatocellulair carcinoom

Initiatief: NVMDL Aantal modules: 23

Welke palliatieve systeemtherapie wordt geadviseerd bij patiënten met een (niet lokaal behandelbaar)-HCC?

Uitgangsvraag

Welke palliatieve systeemtherapie wordt geadviseerd bij patiënten met een (niet lokaal behandelbaar)-HCC?

Aanbeveling

Maak samen met de patiënt een afweging om wel of geen palliatieve systeemtherapie te starten. Bespreek de wensen en verwachtingen van de patiënt.

 

Bepaal voorafgaand aan de behandeling de leverfunctie. Een voldoende behouden leverfunctie is een voorwaarde om te starten met systeemtherapie (waarbij terughoudendheid bij een hoog geconjugeerd bilirubine wordt geadviseerd). Hierbij is een Child Pugh C niet goed genoeg voor systeemtherapie; bij A en B zal in het levercentrum de leverfunctie beoordeeld worden.

 

Geef bij patiënten met een behouden leverfunctie, die met eerstelijns palliatieve systeemtherapie behandeld willen worden, atezolizumab plus bevacizumab. Verifieer voor start dat er een gastroscopie is die niet ouder is dan 6 maanden met behandelde varices alvorens de behandeling te starten.

 

Geef sorafenib of lenvatinib bij patiënten die met palliatieve systeemtherapie behandeld willen worden die een behouden leverfunctie hebben, maar een contra-indicatie voor atezolizumab en bevacizumab. Hierbij heeft sorafenib de voorkeur gezien uitgebreidere ervaring en kosten, en kan er een voorkeur zijn voor lenvatinib gezien het hogere responspercentage.

 

Overweeg sorafenib in tweedelijn bij progressie op atezolizumab plus bevacizumab.

 

Overweeg regorafenib in de volgende lijn bij progressie op sorafenib.

Overwegingen

Voor- en nadelen van de interventie en de kwaliteit van het bewijs

Er is literatuuronderzoek verricht naar de verschillen in klinische uitkomsten tussen de verschillende (eerste, tweede en derdelijns) behandelingen die in Nederland aangeboden worden. Tot en met 15 april 2022 werden er vier gerandomiseerde gecontroleerde studies (RCTs) gevonden in de eerstelijnsbehandeling en één studie in de tweedelijnsbehandeling. Er zijn geen studies gevonden naar een derdelijns behandeling bij gevorderd of gemetastaseerd hepatocellulair carcinoom. Na de zoekdatum is er een update beschikbaar gekomen van één van de geïncludeerde RCTs. Deze is ook meegenomen in de literatuuranalyse (Cheng, 2022).

 

Binnen de eerstelijnsbehandeling werden vier RCTs gevonden, waarbij sorafenib vergeleken werd met placebo (Llovet, 2008; Cheng, 2009), lenvatinib met sorafenib (Kudo, 2018) en atezolizumab + bevacizumab met sorafenib (Finn, 2020; Cheng, 2022). De systematische literatuuranalyse laat zien dat de behandeling met sorafenib vergeleken met placebo een positief effect zou kunnen hebben op de algemene overleving, evenals de behandeling van atezolizumab + bevacizumab vergeleken met sorafenib. Lenvantib is non inferieur aan sorafenib. De overall bewijskracht van de literatuur binnen de eerstelijnsbehandelingen werd gegradeerd als laag en zeer laag. Dit heeft te maken met de imprecisie van de bevindingen (kleine aantal studies) en beperkingen in studie opzet (risk of bias).

 

Voor de tweedelijns behandeling werd één RCT gevonden, waarbij regorafenib vergeleken werd met placebo (Bruix, 2017). De systematische literatuuranalyse laat zien dat de behandeling met regorafenib positieve effecten zou kunnen hebben op de totale en ziektevrije overleving. Voor de uitkomstmaten tumor respons, complicaties en kwaliteit van leven waren er geen positieve klinische effecten te zien. De overall bewijskracht van de literatuur binnen de tweedelijnsbehandelingen werd gegradeerd als laag. Dit heeft te maken met imprecisie van de bevindingen doordat de bevindingen gebaseerd zijn op één studie. De Celestial studie is niet geselecteerd omdat patiënten met tweedelijns en derdelijns palliatieve systeemtherapie geïncludeerd werden, zonder dat hiervoor gestratificeerd werd. De overlevingswinst van deze groepen samen waren wel statistisch significant maar voldeden niet  aan de oude PASKWIL criteria (OS van 10,2 versus 8,0 maanden; Δ 2,2 maanden, HR: 0,76; 95%-BI: 0,63- tot 0,92; P = 0,005).

 

Al de geïncludeerde fase III studies bevatten patiënten met Child-Pugh A (behalve Cheng, 2009) waardoor er geen uitspraak te doen is over patiënten met een Child-Pugh B leverrcirose. Op basis van retrospectieve data is terughoudendheid geboden voor behandeling met palliatieve systeemtherapie bij de groep met Child–Pugh B (Labeur, 2018) omdat deze data tonen dat de effectiviteit van de systeemtherapie minder is dan in de originele studie gezien werd. Tevens geldt dat terughoudendheid in acht moet worden genomen bij een geconjugeerd bilirubine van 3 keer ULN omdat dat in de meeste studies een exclusiecriterium was

 

Overige overwegingen

Waarden en voorkeuren van patiënten (en eventuele hun verzorgers)

Indien er een mogelijkheid is voor palliatieve systeemtherapie, is het wenselijk om de beslissing samen met de patiënt te nemen. Doel van palliatieve systeemtherapie is verlenging van overleving en vergroting van kwaliteit van leven. Persoonlijke voorkeuren van de patiënt zijn van grote invloed op deze keuze om wel of niet palliatieve systeemtherapie te starten.

 

In geval van wens voor palliatieve systeemtherapie heeft in eerstelijn atezolizumab met bevacizumab een grotere winst op OS (19.2 maanden versus 13.4 maanden, HR 0.66) en op kwaliteit van leven in vergelijking met sorafenib. De mediane tijd tot verslechtering van kwaliteit van leven was 11.2 maanden met atezolizumab plus bevacizumab versus 3.6 maanden met sorafenib (HR 0.73 95% CI 0.46 tot 0.85). Behandelgerelateerde bijwerkingen graad 3/4 waren gelijk namelijk 43 % in de groep met atezolizumab en bevacizumab versus 46% met sorafenib. Aspecten die gecontroleerd dienen te worden zijn of er contra-indicaties zijn voor immuuntherapie en of er therapeutische antistolling gebruikt wordt. Daar moet rekening mee gehouden worden in de behandeling met atezoluzimab plus bevacizumab. Daarnaast moet de leverfunctie voldoende zijn en dienen oesophagusvarices behandeld te zijn, indien geïndiceerd.

 

Indien er een contra-indicatie voor atezolizumab en/of bevacizumab is, heeft de behandelend arts in samenspraak met de patiënt de keuze om te starten met sorafenib of lenvatinib. Vanwege de langere ervaring met sorafenib versus lenvantinib en de lagere kosten heeft sorafenib de voorkeur boven lenvatinib. Echter, indien een snelle respons gewenst is, is lenvatinib te prefereren boven sorafenib (ORR lenvantinib 40.6% vergeleken met 12.4% met sorafenib). Behandelgerelateerde graad 3-4 bijwerkingen van sorafenib versus lenvatinib waren vergelijkbaar, maar het bijwerkingen patroon was verschillend. Dus bij toxiciteit van sorafenib kan een switch gemaakt worden naar lenvantinib.

 

De tweedelijns studie met regorafenib versus placebo toont een bescheiden overlevingswinst en geen verschil in kwaliteit van leven in vergelijking met placebo. Overweeg deze behandeling alleen bij fitte patiënten die progressief zijn onder behandeling met sorafenib en een goede leverfunctie hebben, en sorafenib goed hebben verdragen.

 

Er is nog geen wetenschappelijk bewijs voor tweedelijns behandeling na atezolizumab en bevacizumab. In dit geval zal op basis van klinische expertise, bijwerkingen profiel een afweging voor sorafenib conform de add-on gemaakt worden.

 

Op basis van exploratieve analyses zijn in zijn algemeenheid enkele prognostisch slechte factoren te duiden, te weten aanwezigheid van macrovasculaire invasie en een hoog alpha FP.

 

Bij patiënten met een fibrolamellair HCC zal casus per casus overwogen moet worden welke behandeling het best toepasbaar is, omdat deze patiënten bij elke interventiestudie met HCC geëxcludeerd werden.

Kosten (middelenbeslag)

Er zijn geen studies verricht naar kosteneffectiviteit van atezolizumab en bevacizumab versus sorafenib. De kosten van atezolizumab zijn substantieel hoger dan die van sorafenib. Echter, omdat de effectiviteit van atezolizumab en bevacizumab zo duidelijk groter is, spelen de kosten een ondergeschikte rol bij de afweging.

 

Aanvaardbaarheid, haalbaarheid en implementatie

Bij voorkeur behandelen in gespecialiseerd centrum waar multidisciplinaire kennis is van het HCC conform SONCOS-normeringen.

 

Rationale van de aanbeveling: weging van argumenten voor en tegen de interventies

Persoonlijke voorkeuren van de patiënt zijn van grote invloed op deze keuze om wel of niet palliatieve systeemtherapie te starten, zeker gezien de verwachte winst in overleving versus de kwaliteit van leven. Daarom is de aanbeveling zo geformuleerd dat altijd in overleg met de patiënt wordt besloten of er wel of niet met palliatieve systeemtherapie wordt gestart.

Alhoewel in studies een CP score aangehouden wordt is het advies naast de getalsmatige criteria ook klinische parameters een grote impact te geven. Daarom is gekozen voor de term behouden leverfunctie, die ook in de internationale richtlijnen toegepast wordt. In geval van twijfel overleg met een expertisecentrum.

Onderbouwing

In de vorige richtlijnen was sorafenib de enig geregistreerde palliatieve behandeling voor het HCC. Nadien zijn er meerdere middelen in eerste en tweede lijn onderzocht en geregistreerd. Het doel van de module is de plaatsbepaling van deze middelen in de Nederlandse situatie te beschrijven.

First-line treatment

Conclusions

Overall survival (crucial)

Sorafenib versus placebo

Low

GRADE

Treatment with sorafenib may result in a higher overall survival when compared with placebo in patients with hepatocellular carcinoma.

 

Sources: (Llovet, 2008; Cheng, 2009)

 

Atezolizumab + Bevacizumab versus Sorafenib

Low

GRADE

Treatment with atezolizumab + bevacizumab may result in a higher overall survival when compared with sorafenib in patients with hepatocellular carcinoma.

 

Sources: (Cheng, 2022)

 

Lenvatinib versus Sorafenib

Low

GRADE

Treatment with lenvatinib may result in little to no difference in overall survival when compared with sorafenib in patients with hepatocellular carcinoma.

 

Sources: (Kudo, 2018)

 

Progression-free survival (crucial)

Sorafenib versus placebo

Very low GRADE

The evidence is very uncertain about the effect of sorafenib on progression-free survival when compared with placebo in patients with hepatocellular carcinoma.

 

Sources: (Llovet, 2008; Cheng, 2009)

Atezolizumab + Bevacizumab versus Sorafenib

Low

GRADE

Treatment with atezolizumab + bevacizumab may result in higher progression-free survival when compared with sorafenib in patients with hepatocellular carcinoma.

 

Sourcse: (Cheng, 2022)

 

Lenvatinib versus Sorafenib

Low

GRADE

Treatment with lenvatinib may result in a higher progression-free survival when compared with sorafenib in patients with hepatocellular carcinoma.

 

Sources: (Kudo, 2018)

 

Tumour response rate (important)

Sorafenib versus placebo

Very Low GRADE

The evidence is very uncertain about the effect of sorafenib on tumour response rate when compared to placebo in patients with hepatocellular carcinoma.

 

Sources: (Llovet, 2008; Cheng, 2009)

 

Atezolizumab + Bevacizumab versus Sorafenib

Low

GRADE

Treatment with atezolizumab + bevacizumab may result in a higher tumour response rate when compared with sorafenib in patients with hepatocellular carcinoma.

 

Sources: (Cheng, 2022)

 

Lenvatinib versus Sorafenib

Low

GRADE

Treatment with lenvatinib may result in a higher tumour response rate when compared with sorafenib in patients with hepatocellular carcinoma.

 

Sources: (Kudo, 2018)

 

Serious adverse events (important)

Sorafenib versus placebo

Very Low GRADE

The evidence is very uncertain about the effect of sorafenib on serious adverse events when compared to placebo in patients with hepatocellular carcinoma.

 

Sources: (Llovet, 2008; Cheng, 2009)

 

Atezolizumab + Bevacizumab versus Sorafenib

Low

GRADE

Treatment with atezolizumab + bevacizumab may result in little to no difference in serious adverse events when compared with sorafenib in patients with hepatocellular carcinoma.

 

Sources: (Cheng, 2022)

 

Lenvatinib versus Sorafenib

Low

GRADE

Treatment with lenvatinib may result in little to no difference in serious adverse events when compared with sorafenib in patients with hepatocellular carcinoma.

 

Sources: (Kudo, 2018)

 

Quality of life (important)

Sorafenib versus placebo

-

grade

No evidence was found regarding the effect of sorafenib on the quality of life when compared with placebo in in patients with hepatocellular carcinoma.

 

Atezolizumab + Bevacizumab versus Sorafenib

Low

GRADE

Treatment with atezolizumab + bevacizumab may result in a higher quality of life when compared with sorafenib in patients with hepatocellular carcinoma.

 

Sources: (Finn, 2020)

 

Lenvatinib versus Sorafenib

Low

GRADE

Treatment with lenvatinib may result in little to no difference in quality of life when compared with sorafenib in patients with hepatocellular carcinoma.

 

Sources: (Kudo, 2018)

 

Second-line treatment

Conclusions

Overall survival (crucial)

Regorafenib versus placebo

Low

GRADE

Treatment with regorafenib may result in a higher overall survival when compared with placebo in patients with hepatocellular carcinoma.

 

Sources: (Bruix, 2017)

 

Progression-free survival (crucial)

Regorafenib versus placebo

Low

GRADE

Treatment with regorafenib may result in a higher progression-free survival when compared with placebo in patients with hepatocellular carcinoma.

 

Sources: (Bruix, 2017)

 

Tumour response rate (important)

Regorafenib versus placebo

Low

GRADE

Treatment with regorafenib may result in little to no difference in tumour response rate when compared with placebo in patients with hepatocellular carcinoma.

 

Sources: (Bruix, 2017)

 

Serious adverse events (important)

Regorafenib versus placebo

Low

GRADE

Treatment with regorafenib may result in little to no difference in serious adverse events when compared with placebo in patients with hepatocellular carcinoma.

 

Sources: (Bruix, 2017)

 

Quality of life (important)

Regorafenib versus placebo

Low

GRADE

Treatment with regorafenib may result in little to no difference in quality of life when compared with placebo in patients with hepatocellular carcinoma.

 

Sources: (Bruix, 2017)

 

Third-line treatment

Conclusions

Overall survival (crucial), progression-free survival (crucial), tumour response rate (important), serious adverse events (important), quality of life (important)

-

GRADE

No evidence was found in the third-line treatment setting for patients with hepatocellular carcinoma.

Park (2021) performed a systematic review and network meta-analyses (NMA) to evaluate the efficacy and safety of various systemic therapies in advanced hepatocellular carcinoma (HCC) in the first line and second line setting. Inclusion criteria were RCTs with head-to-head comparisons of at least two arms; systemic therapy in the first line or second line or later setting for advanced or metastatic HCC; and had at least one of the following clinical outcomes: objective response rate (ORR), progression-free survival (PSF) or time to progression if PFS was not reported. Three databases (PubMed, Embase, Cochrane) were searched up to April 2020. 13 first-line and 11 second-line trials were included in the final quantitative and qualitative synthesis.

 

Oranratnachai (2021) performed a systematic review and network meta-analyses (NMA) to evaluate the efficacy and safety of various systemic therapies in advanced hepatocellular carcinoma (HCC) in the first-line setting. Inclusion criteria were RCTs who included adults with advanced HCC who were treatment-naïve; comparing any pair of chemotherapy agents, MKIs, or placebo; and had at least one of the following clinical outcomes: OS, PFS, ORR and AE. Two databases (PubMed and SCOPUS) were searched up to November 30, 2019. 20 first-line studies were included in the final quantitative and qualitative synthesis.

 

Solimando (2022) performed a systematic review and network meta-analyses (NMA) to evaluate the efficacy and safety of various systemic therapies in advanced hepatocellular carcinoma (HCC) in the first-line setting. Inclusion criteria were RCTs who included adults with advanced HCC who were already treated with sorafenib; receiving a second-line systemic treatment in a phase II or phase III RCT; and had at least one of the following clinical outcomes: OS, PFS and drug withdrawal due to adverse events. Four (PubMed, SCOPUS, Web of Science, and ClincialTrials.gov) were searched up to December 31, 2020. 14 second- line studies were included in the final quantitative and qualitative synthesis.

 

Table 6.1 Overview and characteristics of the included studies evaluating the first-line treatments in the selected systematic reviews

RCT

Year

Trial/Phase

Intervention

Comparison

N

Park
(2021)

Oranratnachai

(2021)

Llovet

2008

SHARP/III

Sorafenib

Placebo

602

X

X

Cheng

2009

NCT00492752/III

Sorafenib

Placebo

226

X

X

Cheng

2013

SUN1170/III

Sunitinib

Sorafenib

1074

X

X

Johnson

2013

BRISK-FL/III

Brivanib

Sorafenib

1155

X

X

Zhu

2015

SEARCH/III

Erlotinib + Sorafenib

Sorafenib

720

X

X

Cainap

2015

NCT01009593/III

Linifanib

Sorafenib

1035

X

X

Cheng

2015

NCT01033240/II

Tigatuzumab + Sorafenib

Sorafenib

162

X

X

Kudo

2017

NCT02400788/II

Resminostat + Sorafenib

Sorafenib

-

X

 

Kudo

2018

REFLECT/III

Lenvatinib

Sorafenib

954

X

X

Yau

2019

CheckMate 459/III

Nivolumab

Sorafenib

743

X

 

Abou-Alfa

2019

CALGB80802/III

Sorafenib + Doxorubicin

Sorafenib

356

X

X

Finn

2020

IMbrave150/III

Atezolizumab + Bevacizumab

Sorafenib

485

X

 

Bi and Qin

2020

NCT02645981/II-III

Donafenib

Sorafenib

659

X

 

Lai

1988

-/III

Doxorubicin

No treatment

106

 

X

Mok

1999

-/II

Nolatrexed

Doxorubicin

54

 

X

Yeo

2005

-/III

PIAF

Doxorubicin

188

 

X

Gish

2007

-/III

Nolatrexed

Doxorubicin

445

 

X

Qin

2013

NCT00471965 /III

FOLFOX4

Doxorubicin

371

 

X

Ji*

2013

-/III

Sorafenib

No treatment

189

 

X

Palmer

2018

NCT01004003 /II

Nintedanib

Sorafenib

93

 

X

Thomas

2018

NCT00881751/II

Bevacizumab + Erlotinib

Sorafenib

90

 

X

Yen

2018

NCT00987935 /II

Nintedanib

Sorafenib

95

 

X

Assenat

2019

PRODIGE 10/II

Sorafenib + GEMOX

Sorafenib

95

 

X

Koeberle

2016

SAKK77/08 and SASL 29/II

Sorafenib + Everolimus

Sorafenib

105

 

X

In bold the selected RCTs which are based on available therapies in the Netherlands

*Child-Pugh Class B population

 

Table 6.2 Overview and characteristics of the included studies evaluating the second-line treatments in the selected systematic reviews

RCT

Year

Trial/Phase

Intervention

Comparison

N

Park
(2021)

Solimando

(2021)

Bruix

2017

RESORCE/III

Regorafenib

Placebo

573

X

X

Abou-Alfa

2018

CELESTIAL/III

Cabozantinib

Placebo

707

X

X

Zhu

2015

REACH/III

Ramucirumab

Placebo

644

X

X

Zhu

2019

REACH-2/III

Ramucirumab

Placebo

292

X

X

Li (Qin)

2020

NCT02329860/III

Apatinib

Placebo

393

X

 

Finn

2019

KEYNOTE-240/III

Pembrolizumab

Placebo

413

X

X

Llovet

2013

BRISK-PS/III

Brivanib

Placebo

395

X

X

Santoro

2013

NCT00988741/II

Tivantinib

Placebo

107

X

X

Zhu

2014

EVOLVE-1/III

Everolimus

Placebo

546

X

X

Kang

2015

NCT01210495/II

Axitinib

Placebo

202

X

X

Rimassa

2018

RESORCE/III

Tivantinib

Placebo

340

x

 

Abou-Aifa

2016

NCT01507168/III

Codrituzumab

Placebo

185

 

X

Kudo

2017

S/CUBE/III

S-1

Placebo

333

 

X

Abou-Aifa

2018

ADIPEG20/III

ADIPEG240

Placebo

635

 

X

Rimassa

2018

METIV-HCC/III

Tivantinib

Placebo

340

 

X

Kudo

2020

JET-HCC/III

Tivantinib

Placebo

195

 

X

In bold the selected RCT which is based on available therapies in the Netherlands

 

First-line treatment

Four RCTs were selected that assessed the systemic therapy in the first-line setting.

 

Sorafenib versus placebo was studied in two RCTS (Llovet, 2008; Cheng, 2009). Lenvatinib versus sorafenib was studied in one RCT (Kudo, 2018). Atezolizumab + bevacizumab versus sorafenib was studied in 1 RCT (Finn, 2020) (see table 6.1).

 

Second-line treatment

1 RCT was selected that assessed the systemic therapy within the second-line setting.

 

This study assessed the efficacy and safety of regorafenib in patients with HCC who have progressed during sorafenib treatment (Bruix, 2017) (see table 6.2).

 

Third-line treatment

No studies reporting efficacy and safety of third-line treatment in patients with (unresectable) HCC were included in this literature review.

 

Description of studies

Subquestion 1 – Which first line systemic therapy is the most effective and safe for use in patients with (unresectable) HCC?

Sorafenib versus placebo

Llovet (2008) - SHARP described a phase III, double-bind, placebo-controlled trial, which was conducted in 21 countries (121 sites) in Europe, North America, South America, and Australasia. They evaluated the efficacy and safety of sorafenib in patients with advanced hepatocellular carcinoma who had not received previous systemic therapy. A total of 602 patients were randomized to receive sorafenib (n=299) at a dose of 400 mg twice daily or placebo (n=303). The mean (SD) age was 64.9 (11.2) years in the intervention group, compared with 66.3 (10.2) years in the control group. In the intervention group 260/299 (87%) were males, compared with 264/303 (87%) in the control group. All patients had a Child-Pugh class A score. The following relevant outcome measures were included: overall survival, time to symptomatic progression, objective response (partial/complete), adverse events. This RCT was included in the systematic review by Park (2021) and Oranratnachai (2021).

 

Cheng (2009) - described a phase III, double-bind, placebo-controlled trial, which was conducted in 23 sites within the Asia-Pacific region, in China, Taiwan, and South-Korea. They evaluated the efficacy and safety of sorafenib in patients with advanced hepatocellular carcinoma who had not received previous systemic therapy. A total of 226 patients were randomized to receive sorafenib (n=150) at a dose of 400 mg twice daily or placebo (n=76). The median (range) age was 51 (23-86) years in the intervention group, compared with 52 (25-79) years in the control group. In the intervention group 127/150 (84.7%) were males, compared with 66/76 (86.8%) in the control group. All patients had a Child-Pugh class A score. The following relevant outcome measures were included: overall survival, time to progression, objective response (partial/complete), adverse events, quality of life. This RCT was included in the systematic review by Park (2021) and Oranratnachai (2021).

 

Atezolizumab + Bevacizumab versus Sorafenib

Finn (2020) – IMbrave150 described a phase III, global, open-label randomized controlled trial, which was conducted at 111 sites in 17 countries. They evaluated the efficacy and safety of atezolizumab plus bevacizumab compared to sorafenib in patients with advanced hepatocellular carcinoma who had not received previous systemic therapy. A total of 573 patients were randomized to receive atezolizumab (IV, 1200 mg on day 1 of each 21-day cycle) plus bevacizumab (IV, 15 mg/kg on day 1 of each 21 day cycle (n=336), compared with sorafenib (orally administered 400 mg twice per day on days 1-21 of each 21-day cycle) (n=165). In the intervention group 277/336 (82%) were males, compared with 137/165 (83%) in the control group. All patients had a Child-Pugh class A score. The following relevant outcome measures were included: overall survival, progression-free survival, objective response (partial/complete), adverse events, quality of life.  This RCT was included in the systematic review by Park (2021) and Oranratnachai (2021). After the search date, a recent update became available which present updated data after 12 months of additional follow-up (Cheng, 2022). This study is added to the evidence table and data-synthesis.   

 

Lenvatinib versus Sorafenib

Kudo (2018) – REFLECT described a phase III, open-label, randomized controlled non-inferiority trial which was conducted at 154 sites in 20 countries throughout the Asia-Pacific, European, and North American region. They compared the overall survival in patients treated with lenvatinib versus sorafenib in patients with advanced hepatocellular carcinoma who had not received previous systemic therapy. A total of 954 patients were randomized to receive lenvatinib (12 mg/day for bodyweight ≥60 kg or 8 mg/day for bodyweight) (n=478) or sorafenib 400 mg twice-daily in 28-day cycles (n-476). In the intervention group 405/478 (85%) were males, compared with 401/476 (84%) in the control group. All patients had a Child-Pugh Class A score. The following relevant outcome measures were included: overall survival, progression-free survival, objective response (partial/complete), adverse events, quality of life.

 

Subquestion 2 – Which second line systemic therapy is the most effective and safe for use in patients with (unresectable) HCC?

Regorafenib versus placebo

Bruix (2017) - RESORCE described a phase III, double-bind, placebo controlled trial, which was conducted in 21 countries (152 sites) in North America, South America, Europe, Asia, and Australia. They evaluated the efficacy and safety of regorafenib in patients with advanced hepatocellular carcinoma who tolerated sorafenib (≥400 mg/day for ≥20 of last 28 days of treatment) and progressed on sorafenib. A total of 573 patients were randomized to receive regorafenib at a dose of 160 mg every day for 3 weeks of every 4-week cycle plus best supportive care (n=379) or placebo + best supportive care (n=194). The median (range) age was 64 (54-71) years in the intervention group, compared with 62 (55-68) years in the control group. In the intervention group 333/379 (88%) were males, compared with 171/194 (88%) in the control group. All patients had a Child-Pugh class A score. The following relevant outcome measures were included: overall survival, progression-fee survival, objective response (partial/complete), adverse events. This RCT was included in the systematic review by Park (2021) and Solimando (2022).

 

Subquestion 3 – Which third line systemic therapy is the most effective and safe for use in patients with (unresectable) HCC?

No studies reporting efficacy and safety of third-line treatment in patients with (unresectable) HCC were included in this literature review.

 

The Celestial study was not included as patients with both second- and third-line treatment were permitted without preplanned subpopulations efficacies.

First-line treatment

Overall survival (OS) (crucial)

Sorafenib versus placebo

Two studies (Llovet, 2008; Cheng, 2009) reported the median overall survival.

 

Llovet (2008) reported OS, which was measured from the date of randomization until the date of death from any cause. The median OS was 10.7 months in the intervention group, compared with 7.9 in de control group. This resulted in a HR of 0.69 (95% CI 0.55 to 0.87). This difference is considered clinically relevant.

 

Cheng (2009) reported OS, which measured from the date of randomization until the date of death from any cause. The median OS was 6.5 in the intervention group, compared with 4.2 in the control group. This resulted in a HR of 0.65 (95% CI 0.53 to 0.81). This difference is considered clinically relevant.

 

Level of evidence of the literature

The level of evidence started as high, because the studies were RCTS. The level of evidence was downgraded by 2 levels, because of study limitations (risk of bias, -1 (see RoB assessment)) and because the optimal information was criteria is not met (imprecision, -1). Therefore, the level of evidence for the outcome ‘overall survival’ is considered low.

 

Atezolizumab + Bevacizumab versus Sorafenib

Cheng (2022) reported OS, which measured from the date of randomization until the date of death from any cause. The median OS was 19.2 in the intervention group, compared with 13.4 in the control group. This resulted in a HR of 0.66 (95% CI 0.53 to 0.81). This difference is considered clinically relevant.

 

Level of evidence of the literature

The level of evidence started as high, because the study was an RCT. The level of evidence was downgraded by 2 levels, because the optimal information size criteria is not met (imprecision, -2). Therefore, the level of evidence for the outcome ‘overall survival’ is considered low.

 

Lenvatinib versus Sorafenib

Kudo (2018) reported OS, which measured from the date of randomization until the date of death from any cause. The median OS was 13.6 in the intervention group, compared with 12.3 in the control group. This resulted in a HR of 0.92 (95% CI 0.79 to 1.06). This difference is not considered clinically relevant.

 

Level of evidence of the literature

The level of evidence started as high, because the study was an RCT. The level of evidence was downgraded by 2 levels, because the optimal information size criteria is not met (imprecision, -2). Therefore, the level of evidence for the outcome ‘overall survival’ is considered low.

 

Progression-free survival (PFS) (crucial)

Sorafenib versus placebo

Cheng (2009) reported the time to progression. The median time to progression was 2.8 months in the intervention group, compared with 1.4 months in the control group. This resulted in a HR of 0.57 (95% CI 0.42 to 0.79). This difference is considered clinically relevant.

 

Llovet (2008) reported the time to symptomatic progression. The median time to symptomatic progression was 4.1 months in the intervention group, compared with 4.9 in the control group. This resulted in a HR of 0.58 (95% CI 0.45 to 0.74). This difference is considered clinically relevant.

 

Level of evidence of the literature

The level of evidence started as high, because the studies were RCTS. The level of evidence was downgraded by 3 levels, because of study limitations (risk of bias, -1 (see RoB assessment)) and low number of patients (imprecision, -1), differences in outcome measures (indirectness, -1). Therefore, the level of evidence for the outcome ‘progression-free survival’ is considered very low.

 

Atezolizumab + Bevacizumab versus Sorafenib

Cheng (2022) reported PFS. The median PFS was 6.9 in the intervention group, compared with 4.3 in the control group. This resulted in a HR of 0.65 (95% CI 0.53 to 0.81). This difference is considered clinically relevant.

 

Level of evidence of the literature

The level of evidence started as high, because the study was an RCT. The level of evidence was downgraded by 2 levels, because the optimal information size criteria is not met (imprecision, -2). Therefore, the level of evidence for the outcome ‘progression-free survival’ is considered low.

 

Lenvatinib versus Sorafenib

Kudo (2018) reported PFS. The median PFS was 7.3 in the intervention group, compared with 3.6 in the control group. This resulted in a HR of 0.64 (95% CI 0.55 to 0.75. This difference is considered clinically relevant.

 

Level of evidence of the literature

The level of evidence started as high, because the study was an RCT. The level of evidence was downgraded by 2 levels, because the optimal information size criteria is not met (imprecision, -2). Therefore, the level of evidence for the outcome ‘progression-free survival’ is considered low.

 

Tumour response rate (important)

Sorafenib versus placebo

Two studies (Llovet, 2008; Cheng, 2009) reported the response rate.

 

Llovet (2008) reported the tumour response rate, defined as the proportion of patients with a best response of complete response or partial response according to RECIST. There were no complete responses in either group. In the intervention group 7/299 (2.3%) achieved a partial response, compared with 2/303 (0.7%) in the control group. The RD was 1.7% (95% CI -0.26 to 3.6). This difference is not considered clinically relevant.

 

Cheng (2009) reported the tumour response, defined as the proportion of patients with a best response of complete response or partial response according to RECIST. There were no complete responses in either group. In the intervention group 5/150 (3.3%) achieved a partial response, compared with 1/76 (1.3%) in the control group. The RD was 2% (95% CI -1.8 to 5.9). This difference is not considered clinically relevant.

 

Level of evidence of the literature

The level of evidence started as high, because the studies were RCTS. The level of evidence was downgraded by 3 levels, because of study limitations (risk of bias, -1 (see RoB assessment)) and low number of events (imprecision, -2). Therefore, the level of evidence for the outcome ‘tumour response rate’ is considered very low.

 

Atezolizumab + Bevacizumab versus Sorafenib

Cheng (2022) reported the tumour response, defined as the proportion of patients with a best response of complete response or partial response according to RECIST 1.1. In the intervention group, 25/326 (7.7%) patients achieved a complete response and 72/326 (22.1%) a partial response. In the control group 1/159 (0.6%) patients achieved a complete response and 17/159 (10.7%) a partial response. The overall response rate was 97/326 (29.8%) in the intervention group compared to 18/159 (11.3%) in the control group. The RD was 18.4% (95% CI 11.4 to 25.4). This difference is not considered clinically relevant.

 

Level of evidence of the literature

The level of evidence started as high, because the study was an RCT. The level of evidence was downgraded by 2 levels, because the optimal information size criteria is not met (imprecision, -2). Therefore, the level of evidence for the outcome ‘tumour response rate’ is considered low.

Lenvatinib versus Sorafenib

Kudo (2018) reported the tumour response, defined as the proportion of patients with a best response of complete response or partial response according to a masked independent imaging review with a modified RECIST (mRECIST). In the intervention group, 10/478 (2.1%) patients achieved a complete response and 184/478 (38.5%) a partial response. In the control group 4/476 (0.8%) patients achieved a complete response and 55/476 (11.6%) a partial response. The overall response rate was 194/478 (40.6%) in the intervention group, compared to 59/476 (12.4%) in the control group. The RD was 28.2% (95% CI 22.9 to 33.5). This difference is considered clinically relevant.

 

Level of evidence of the literature

The level of evidence started as high, because the study was an RCT. The level of evidence was downgraded by 2 levels, because the optimal information size criteria is not met (imprecision, -2). Therefore, the level of evidence for the outcome ‘tumour response rate’ is considered low.

 

Serious adverse events (important)

Sorafenib versus placebo

Two studies (Llovet, 2008; Cheng, 2009) reported the incidence of serious treatment-emergent adverse events.

 

Llovet (2008) reported the incidence of serious treatment-emergent adverse events.

 

In the intervention group was 52/297 (17.5%) patients experienced a treatment-emergent adverse event, compared with 54/302 (17.9%) in the control group. Diarrhea, weight loss, hand–foot skin reaction, and hypophosphatemia were more frequent in the sorafenib group (intervention). The RD was -0.4% (95% CI -6.5 to 5.8). This difference is not considered clinically relevant.

 

Cheng (2008) reported the incidence of serious treatment-emergent adverse events. In the intervention group, 71/149 (47.7%) patients experienced a treatment-emergent adverse event, compared with 34/75 (45.3%) in the control group. Hand-foot skin reactions, diarrhoea and fatigue were more frequent in the sorafenib group (intervention). The RD was 2.3% (95% CI -11.5 to 16.1). This difference is not considered clinically relevant.

 

Level of evidence of the literature

The level of evidence started as high, because the studies were RCTS. The level of evidence was downgraded by 3 levels, because of study limitations (risk of bias, -1 (see RoB assessment)) and low number of events (imprecision, -2). Therefore, the level of evidence for the outcome ‘serious adverse events’ is considered very low.

 

Atezolizumab + Bevacizumab versus Sorafenib

Cheng (2022) reported the incidence of serious adverse events and the incidence of serious treatment-emergent adverse events. In the intervention group, 76/329 (23.1%) patients experienced a treatment-emergent adverse event, compared with 25/156 (16.0%) in the control group. Proteinuria, hypertension and fatigue was most comment with atezolizumab plus bevacizumab (intervention), whereas palmar-plantar, erythrodysesthesia syndrome and diarrhea was most common in the sorafenib arm (control). The RD was 7.1% (95% CI -0.27 to 14.4). This difference is not considered clinically relevant.

 

Level of evidence of the literature

The level of evidence started as high, because the study was an RCT. The level of evidence was downgraded by 2 levels, because the optimal information size criteria is not met (imprecision, -2). Therefore, the level of evidence for the outcome ‘serious adverse events’ is considered low.

 

Lenvatinib versus Sorafenib

Kudo (2018) reported the incidence of serious treatment-emergent adverse events. In the intervention group, 205/476 (43.1%) patients experienced a treatment-emergent adverse event, compared with 144/475 (30.3%) in the control group. Hypertension, diarrhea, decreased appetite, and decreased weight was most common in the lenvatinib arm (intervention), whereas palmar-plantar erythrodysaesthesia, diarrhoea, hypertension, and decreased appetite was most common in the sorafenib arm (control). The RD was 12.8% (95% CI 6.7 to 18.8). This difference is not considered clinically relevant.

 

Level of evidence of the literature

The level of evidence started as high, because the study was an RCT. The level of evidence was downgraded by 2 levels, because the optimal information size criteria is not met (imprecision, -2). Therefore, the level of evidence for the outcome ‘serious adverse events’ is considered low.

 

Quality of life (important)

Sorafenib versus placebo

Quality of life was not reported.

 

Level of evidence of the literature

The level of evidence was not graded because no study reported quality of life.

 

Atezolizumab + Bevacizumab versus Sorafenib

Finn (2020) reported on the patient-reported outcomes, which were evaluated with the use of the European Organization for Research and Treatment of Cancer (EORTC) quality-of-life questionnaire for cancer (EORTC QLQ–C30). Finn (2020) reported the time to deterioration of quality of life, which was defined as decrease from baseline of 10 or more point on the EORTC QLQ–C30 maintained for two consecutive assessments or a decrease of 10 points or more in one assessment followed by death from any cause within 3 weeks. The median time to deterioration of patient-reported quality of life in the intervention group was 11.2 months (95% CI, 6.0 to not estimable), compared to 3.6 months (95% CI, 3.0 to 7.0) (HR 0.73, 95% CI 0.46 to 0.85) (favours atezolizumab + bevacizumab). This difference is considered clinically relevant.

 

Level of evidence of the literature

The level of evidence started as high, because the study was an RCT. The level of evidence was downgraded by 2 levels, because the optimal information size criteria is not met (imprecision, -2). Therefore, the level of evidence for the outcome ‘quality of life’ is considered low.

 

Lenvatinib versus Sorafenib

Kudo (2018) reported the quality of life, which was assessed with the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ-C30)23,24 and the hepatocellular carcinoma-specific EORTC QLQ-HCC1825 health questionnaires. For between-group comparison, the summary score was not significantly different between the treatment arms (HR 0.87, 95% CI 0.75 to 1.01)(QLQ-C30 questionnaire). HCC18 questionnaire domains ranges between 0.79 (body image, favours lenvatinib) and 1.14 (pain, favours sorafenib). This difference is not considered clinically relevant.

 

Level of evidence of the literature

The level of evidence started as high, because the study was an RCT. The level of evidence was downgraded by 2 levels, because the optimal information size criteria is not met (imprecision, -2). Therefore, the level of evidence for the outcome ‘quality of life’ is considered low.

 

Second-line treatment

Overall survival (OS) (crucial)

Regorafenib versus placebo

Bruix (2017) reported the median OS, which was measured from the date of randomization until the date of death from any cause. The median OS was 10.6 months in the intervention group, compared with 7.6 in de control group. This resulted in a HR of 0.63 (95% CI 0.50 to 0.79). This difference is considered clinically relevant.

 

Level of evidence of the literature

The level of evidence started as high, because the study was an RCT. The level of evidence was downgraded by 2 levels, because the optimal information size criteria is not met (imprecision, -2). Therefore, the level of evidence for the outcome ‘overall survival’ is considered low.

 

Progression-free survival (PFS) (crucial)

Regorafenib versus placebo

Bruix (2017) reported the median PFS. The median PFS was 3.4 months in the intervention group, compared with 1.5 in de control group. This resulted in a HR of 0.43 (95% CI 0.35 to 0.52). This difference is considered clinically relevant.

 

Level of evidence of the literature

The level of evidence started as high, because the study was an RCT. The level of evidence was downgraded by 2 levels, because the optimal information size criteria is not met (imprecision, -2). Therefore, the level of evidence for the outcome ‘progression-free survival’ is considered low.

 

Tumour response rate (important)

Regorafenib versus placebo

Bruix (2017) reported the objective response rate. In the intervention group, 2/379 (0.5%) patients achieved a complete response and 38/379 (10.0%) a partial response. In the control group 0/194 (0%) patients achieved a complete response and 8/194 (4.1%) a partial response. The overall response rate was 40/379 (10.6%) in the intervention group, compared to 8/194 (4.1%) in the control group. The RD was 6.4% (95% CI 2.3 to 10.6). This difference is not considered clinically relevant.

 

Level of evidence of the literature

The level of evidence started as high, because the study was an RCT. The level of evidence was downgraded by 2 levels, because the optimal information size criteria is not met (imprecision, -2). Therefore, the level of evidence for the outcome ‘tumour response rate’ is considered low.

 

Serious adverse events (important)

Regorafenib versus placebo

Bruix (2017) reported the incidence of serious adverse events.

 

In the intervention group was 166/397 (41.8%) patients experienced a serious adverse event, compared with 90/194 (46.3%) in the control group. Diarrhea, weight loss, hand–foot skin reaction, and hypophosphatemia were more frequent in the sorafenib group (intervention). Hypertension, hand-foot skin reaction, fatigue, and diarrhea were more frequent in the regorafenib group (intervention). The RD was -2.6% (95% CI -11.2 to 6.0). This difference is not considered clinically relevant.

 

Level of evidence of the literature

The level of evidence started as high, because the study was an RCT. The level of evidence was downgraded by 2 levels, because the optimal information size criteria is not met (imprecision, -2). Therefore, the level of evidence for the outcome ‘serious adverse events’ is considered low.

 

Quality of life

Regorafenib versus placebo

Quality of life was assessed with the Functional Assessment of Cancer Therapy (FACT-G), FACT-Hepatobiliary (FACT-Hep), EQ-5D and EQ-VAS. No clinically meaningful differences were noted between the regorafenib and placebo groups in HRQoL.

 

Level of evidence of the literature

The level of evidence started as high, because the study was an RCT. The level of evidence was downgraded by 2 levels, because the optimal information size criteria is not met (imprecision, -2). Therefore, the level of evidence for the outcome ‘quality of life’ is considered low.

A systematic review of the literature was performed to answer the following question:

Which treatment is to be advised for patients with (unresectable) HCC?

 

PICO

P: Non-locally-treatable patients with a diagnosis of hepatocellular carcinoma;

I: Systemic therapy;

C: Other systemic therapy or placebo;

O: Overall survival, progression-free survival, response rate, adverse events, quality of life.

 

Relevant outcome measures

The guideline development group considered overall survival and progression-free survival as a crucial outcome measure for decision making; and response rate, complications/adverse events and quality of life as important outcome measures for decision making.

 

The guideline development group defined the outcome measures as follows:

Overall survival (OS)

Time from randomisation to death from any cause, with a minimum follow-up of 1 years

Progression-free survival (PFS)

Time from randomisation or initiation of treatment to the occurrence of disease progression or death, with a minimum follow-up of 1 year

Tumour response rate (TRR)

Tumour response rate, with a minimum follow-up of 1 year

Adverse events (AE)

Grade ≥ 3

Quality of life (QoL)

Overall QoL, measured with a validated and reliable instrument

 

Clinically relevant difference

The guideline development group defined a minimal clinically relevant difference at a minimum ofsof:

  • Overall survival: >12 weeks or HR <0.7.
  • Progression-free survival: >12 weeks or HR <0.7.

And, in case of absence of a clinically relevant difference in overall survival or progression-free survival:

  • Response rate: >20% difference.
  • Quality of life: A minimal clinically important difference of 10 points on the quality of life instrument EORTC QLQ-C30 or a difference of a similar magnitude on other quality of life instruments.
  • Adverse events: <25% difference.

Data-synthesis

Results from RCTs studies were described and synthesized (preferably by meta-analysis) separately.

 

Search and select (Methods)

The databases Medline (via OVID) and Embase (via Embase.com) were searched with relevant search terms until April 15th, 2022. The detailed search strategy is depicted under the tab Methods.

The systematic literature search resulted in 1115 hits. Studies were selected based on the following criteria:

  • included patients HCC, ineligible for surgical intervention;
  • compared systemic therapy;
  • reported at least one of the outcomes of interest;
  • the study design is a systematic review (SR) (preferably of randomized controlled trials; RCTs), or RCT;
  • written in English language.

Based on title and abstract screening, 14 studies were initially selected. After reading the full text and thorough assessment of the studies, 11 studies were excluded (see table with reasons for exclusion under the tab Methods), and 3 systematic reviews were included.

 

Results

A total of three studies were included in the analysis of the literature. The important study characteristics and results are summarized in the evidence tables. The assessment of the risk of bias is summarized in the risk of bias tables.

 

Not all systemic therapies are included in the literature summary. The Committee BOM (cieBOM) makes recommendations about the procedure on the basis of the evidence relating to its efficacy and safety. Therefore, we will answer the question which of the available therapies in the Netherlands is the most effective and safe in patients with (unresectable) HCC in the first-line, second-line and third-line. An overview of all the included RCTs in the systematic reviews and the selected RCTs can be found in table 6.1 and table 6. 2.

 

The first line available treatments in the Netherlands are:

  • Sorafenib.
  • Atezolizumab + Bevacizumab.
  • Lenvatinib.

The second- and further line available treatments in the Netherlands are:

  • Sorafenib (add-on).
  • Regorafenib.

Currently, no drugs of proven efficacy in the third-line settings are available in the Netherlands.

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  18. Koeberle D, Dufour JF, Demeter G, Li Q, Ribi K, Samaras P, Saletti P, Roth AD, Horber D, Buehlmann M, Wagner AD, Montemurro M, Lakatos G, Feilchenfeldt J, Peck-Radosavljevic M, Rauch D, Tschanz B, Bodoky G; Swiss Group for Clinical Cancer Research (SAKK). Sorafenib with or without everolimus in patients with advanced hepatocellular carcinoma (HCC): a randomized multicenter, multinational phase II trial (SAKK 77/08 and SASL 29). Ann Oncol. 2016 May;27(5):856-61. doi: 10.1093/annonc/mdw054. Epub 2016 Feb 15. PMID: 26884590.
  19. Kudo M, Finn RS, Qin S, Han KH, Ikeda K, Piscaglia F, Baron A, Park JW, Han G, Jassem J, Blanc JF, Vogel A, Komov D, Evans TRJ, Lopez C, Dutcus C, Guo M, Saito K, Kraljevic S, Tamai T, Ren M, Cheng AL. Lenvatinib versus sorafenib in first-line treatment of patients with unresectable hepatocellular carcinoma: a randomised phase 3 non-inferiority trial. Lancet. 2018 Mar 24;391(10126):1163-1173. doi: 10.1016/S0140-6736(18)30207-1. PMID: 29433850.
  20. Kudo M, Moriguchi M, Numata K, Hidaka H, Tanaka H, Ikeda M, Kawazoe S, Ohkawa S, Sato Y, Kaneko S, Furuse J, Takeuchi M, Fang X, Date Y, Takeuchi M, Okusaka T. S-1 versus placebo in patients with sorafenib-refractory advanced hepatocellular carcinoma (S-CUBE): a randomised, double-blind, multicentre, phase 3 trial. Lancet Gastroenterol Hepatol. 2017 Jun;2(6):407-417. doi: 10.1016/S2468-1253(17)30072-9. Epub 2017 Apr 6. PMID: 28497756.
  21. Kudo M, Morimoto M, Moriguchi M, Izumi N, Takayama T, Yoshiji H, Hino K, Oikawa T, Chiba T, Motomura K, Kato J, Yasuchika K, Ido A, Sato T, Nakashima D, Ueshima K, Ikeda M, Okusaka T, Tamura K, Furuse J. A randomized, double-blind, placebo-controlled, phase 3 study of tivantinib in Japanese patients with MET-high hepatocellular carcinoma. Cancer Sci. 2020 Oct;111(10):3759-3769. doi: 10.1111/cas.14582. Epub 2020 Aug 26. PMID: 32716114; PMCID: PMC7541009.
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  29. Oranratnachai S, Rattanasiri S, Pooprasert A, Tansawet A, Reungwetwattana T, Attia J, Thakkinstian A. Efficacy of First Line Systemic Chemotherapy and Multikinase Inhibitors in Advanced Hepatocellular Carcinoma: A Systematic Review and Network Meta-Analysis. Front Oncol. 2021 Mar 31;11:654020. doi: 10.3389/fonc.2021.654020. PMID: 33869060; PMCID: PMC8044881.
  30. Palmer DH, Ma YT, Peck-Radosavljevic M, Ross P, Graham J, Fartoux L, Deptala A, Studeny M, Schnell D, Hocke J, Loembé AB, Meyer T. A multicentre, open-label, phase-I/randomised phase-II study to evaluate safety, pharmacokinetics, and efficacy of nintedanib versus. sorafenib in European patients with advanced hepatocellular carcinoma. Br J Cancer. 2018 May;118(9):1162-1168. doi: 10.1038/s41416-018-0051-8. Epub 2018 Mar 22. PMID: 29563636; PMCID: PMC5943284.
  31. Park R, Lopes da Silva L, Nissaisorakarn V, Riano I, Williamson S, Sun W, Saeed A. Comparison of Efficacy of Systemic Therapies in Advanced Hepatocellular Carcinoma: Updated Systematic Review and Frequentist Network Meta-Analysis of Randomized Controlled Trials. J Hepatocell Carcinoma. 2021 Mar 22;8:145-154. doi: 10.2147/JHC.S268305. PMID: 33791250; PMCID: PMC7997949.
  32. Qin S, Bai Y, Lim HY, Thongprasert S, Chao Y, Fan J, Yang TS, Bhudhisawasdi V, Kang WK, Zhou Y, Lee JH, Sun Y. Randomized, multicenter, open-label study of oxaliplatin plus fluorouracil/leucovorin versus doxorubicin as palliative chemotherapy in patients with advanced hepatocellular carcinoma from Asia. J Clin Oncol. 2013 Oct 1;31(28):3501-8. doi: 10.1200/JCO.2012.44.5643. Epub 2013 Aug 26. PMID: 23980077.
  33. Qin S, Li Q, Gu S, Chen X, Lin L, Wang Z, Xu A, Chen X, Zhou C, Ren Z, Yang L, Xu L, Bai Y, Chen L, Li J, Pan H, Cao B, Fang W, Wu W, Wang G, Cheng Y, Yu Z, Zhu X, Jiang D, Lu Y, Wang H, Xu J, Bai L, Liu Y, Lin H, Wu C, Zhang Y, Yan P, Jin C, Zou J. Apatinib as second-line or later therapy in patients with advanced hepatocellular carcinoma (AHELP): a multicentre, double-blind, randomised, placebo-controlled, phase 3 trial. Lancet Gastroenterol Hepatol. 2021 Jul;6(7):559-568. doi: 10.1016/S2468-1253(21)00109-6. Epub 2021 May 8. PMID: 33971141.
  34. Rimassa L, Assenat E, Peck-Radosavljevic M, Pracht M, Zagonel V, Mathurin P, Rota Caremoli E, Porta C, Daniele B, Bolondi L, Mazzaferro V, Harris W, Damjanov N, Pastorelli D, Reig M, Knox J, Negri F, Trojan J, López López C, Personeni N, Decaens T, Dupuy M, Sieghart W, Abbadessa G, Schwartz B, Lamar M, Goldberg T, Shuster D, Santoro A, Bruix J. Tivantinib for second-line treatment of MET-high, advanced hepatocellular carcinoma (METIV-HCC): a final analysis of a phase 3, randomised, placebo-controlled study. Lancet Oncol. 2018 May;19(5):682-693. doi: 10.1016/S1470-2045(18)30146-3. Epub 2018 Apr 3. PMID: 29625879.
  35. Rimassa L, Assenat E, Peck-Radosavljevic M, Pracht M, Zagonel V, Mathurin P, Rota Caremoli E, Porta C, Daniele B, Bolondi L, Mazzaferro V, Harris W, Damjanov N, Pastorelli D, Reig M, Knox J, Negri F, Trojan J, López López C, Personeni N, Decaens T, Dupuy M, Sieghart W, Abbadessa G, Schwartz B, Lamar M, Goldberg T, Shuster D, Santoro A, Bruix J. Tivantinib for second-line treatment of MET-high, advanced hepatocellular carcinoma (METIV-HCC): a final analysis of a phase 3, randomised, placebo-controlled study. Lancet Oncol. 2018 May;19(5):682-693. doi: 10.1016/S1470-2045(18)30146-3. Epub 2018 Apr 3. PMID: 29625879.
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  37. Solimando AG, Susca N, Argentiero A, Brunetti O, Leone P, De Re V, Fasano R, Krebs M, Petracci E, Azzali I, Nanni O, Silvestris N, Vacca A, Racanelli V. Second-line treatments for Advanced Hepatocellular Carcinoma: A Systematic Review and Bayesian Network Meta-analysis. Clin Exp Med. 2022 Feb;22(1):65-74. doi: 10.1007/s10238-021-00727-7. Epub 2021 Jun 19. PMID: 34146196; PMCID: PMC8863772.
  38. Thomas MB, Garrett-Mayer E, Anis M, Anderton K, Bentz T, Edwards A, Brisendine A, Weiss G, Siegel AB, Bendell J, Baron A, Duddalwar V, El-Khoueiry A. A Randomized Phase II Open-Label Multi-Institution Study of the Combination of Bevacizumab and Erlotinib Compared to Sorafenib in the First-Line Treatment of Patients with Advanced Hepatocellular Carcinoma. Oncology. 2018;94(6):329-339. doi: 10.1159/000485384. Epub 2018 May 2. PMID: 29719302; PMCID: PMC7725004.
  39. Yau T, Park JW, Finn RS, Cheng AL, Mathurin P, Edeline J, Kudo M, Han KH, Harding JJ, Merle P, Oorsmorduc O, Wyrwicz L, Schott E, Choo SP, Kelley RK, Begic Dm Chen G, Neely J, Anderson J, Sangro B. CheckMate 459: a randomized, multi-center phase III study of nivolumab (NIVO) versus sorafenib (SOR) as first-line (1L) treatment in patients (pts) with advanced hepatocellular carcinoma (aHCC). Annals of oncology 2019, 30, v874?v875. (abstract)
  40. Yen CJ, Kim TY, Feng YH, Chao Y, Lin DY, Ryoo BY, Huang DC, Schnell D, Hocke J, Loembé AB, Cheng AL. A Phase I/Randomized Phase II Study to Evaluate the Safety, Pharmacokinetics, and Efficacy of Nintedanib versus Sorafenib in Asian Patients with Advanced Hepatocellular Carcinoma. Liver Cancer. 2018 May;7(2):165-178. doi: 10.1159/000486460. Epub 2018 Mar 15. PMID: 29888206; PMCID: PMC5985414.
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Study reference

Study characteristics

Patient characteristics

Intervention (I)

Comparison / control (C)

 

Follow-up

Outcome measures and effect size

Comments

First-line treatments

Atezolizumab + Bevacizumab versus Sorafenib

Finn, 2020

 

(IMbrave150)

 

NCT03434379

Type of study:
Randomized, open-label, phase 3 trial

 

Setting and country:

The study was conducted at 111 sites in 17 countries (Australia, China, Czech Republic, France, Germany, Hong Kong, Italy, Japan, Republic of Korea, Poland, Russia, Singapore, Spain, Taiwan, UK, US)

 

Patients were enrolled between March 13, 2018, and January 30, 2019

 

Funding and conflicts of interest:

F. Hoffmann-La Roche/Genentech

 

Conflicts of interest are disclosed

Patients with unresectable HCC who had not received previous systemic treatment

 

Inclusion criteria:

  • ≤18 years of age
  • Locally advanced metastatic or unresectable HCC (or both)
  • No previous systematic therapy
  • ECOG score 0 or 1
  • Child-Pugh A

 

Exclusion criteria:

  • History of autoimmune disease
  • Coinfection with hepatitis B or C
  • Untreated or incompletely treated esophageal or gastric varices with bleeding or high risk of bleeding.

 

 

N total at baseline:

N = 573

Intervention: N=336

Control: N=165

 

Important prognostic factors:

Age, median (range):

I: 64 (56-74)

C: 66 (59-71)

 

Sex, n/N (%) male:

I: 277/336 (82%)

C: 137/165 (83%)

 

Groups comparable at baseline?

Yes.

 

Atezolizumab + Bevacizumab

 

Participants received Atezolizumab + Bevacizumab until unacceptable toxicity or loss of clinical benefit as determined by the investigator

 

Drug:

Atezolizumab was administered by IV, 1200 mg on day 1 of each 21 day cycle

 

Drug:

Bevacizumab was administered by IV, 15 mg/kg on day 1 of each 21 day cycle

 

Sorafenib

 

Participants received Sorafenib until unacceptable toxicity or loss of clinical benefit as determined by the investigator

 

 

 

Drug: Sorafenib

Sorafenib was administered by mouth, 400 mg twice per day, on days 1-21 of each 21-day cycle

 

Length of follow-up:

Median follow-up

I: 8.6 months

C: 8.1 months

 

Loss-to-follow-up & incomplete outcome data:

Intervention:

N=7/336 (2.1%) did not receive assigned treatment

 

Control:

N=9/165 (N=5.5%) did not receive assigned treatment

 

 

Intervention:

N=108/336 (32.1%) discontinued the trial

Reasons:

N=95/336 (28.3%) died

N= 1/336 (0.3%) experienced disease progression per RECIST 1.1

N=12/336 (3.6%) withdrew consent

 

Control :

84/165 (50.1%) discontinued the trial

Reasons:

N=65/165 (39.4%) died

N=19/165 (11.5%) withdrew consent

 

 

Overall survival

Median OS (months)

I: Could not be evaluated (NE)

C: 13.2 (10.4 – NE)

 

HR: 0.58 (95% CI, 0.42 to 0.79)

 

Progression-free survival

Median PFS (months)

I: 6.8 (95% CI, 5.7 to 8.3)

C: 4.3 (95% CI 4.0 to 5.6)

 

HR for disease progression or death
HR: 0.59 (95% CI, 0.47 to 0.76)

 

Objective response (RECIST 1.1)

Complete response

I: 18/326 (5.5%)

C: -

 

Partial response

I: 71/326 (21.8%)

C: 19/159 (11.9%)

 

 

Adverse events

From any cause
Grade 3 or 4

I: 186/329 (56.5%)

C: 86/156 (55.1%)

 

Grade 5

I: 15/329 (4.6%)

C: 9/156 (5.8%)

A detailed record of all adverse events is reported in the article.

 

Quality of life

Measured with the EORTC QLQ-C30. Reported as time to deterioration of Quality of Life

Median time to deterioration

I: 11.2 (CI: 6.0-NE)
C: 3.6 (3.0-7.0)

HR: 0.73 (95% CI, 0.46-0.85)

 

  • Child-Pugh class A patient population
  • See Cheng 2022

 

Authors conclusion:

“ In conclusion, treatment with atezolizumab plus bevacizumab was associated with significantly better overall survival and progression-free survival outcomes than sorafenib in patients with advanced unresectable hepatocellular carcinoma not previously treated with systemic therapy. Serious toxic effects were noted in 38% of the patients who received the combination therapy; however, no new or unexpected toxic effects were observed. The combination therapy also resulted in a longer time to deterioration of patient-reported quality of life and functioning than sorafenib.”

Cheng, 2022

 

(IMbrave150)

 

NCT03434379

Updated efficacy and safety data from IMbrave150

 

 

See ‘Finn 2020’

See ‘Finn 2020’

See ‘Finn 2020’

See ‘Finn 2020’

Length of follow-up:

Median (range)

15.6 (0-28.6)

Overall survival

Median OS (months)

I: 19.2 (17.0-23.7)

C: 13.4 (11.4-16.9)

 

HR: 0.66 (95% CI, 0.52 to 0.85)

 

Progression-free survival

Median PFS (months)

I: 6.9 (95% CI, 5.7 to 8.6)

C: 4.3 (95% CI 4.0 to 5.6)


HR: 0.65 (95% CI, 0.53 to 0.81)

 

Objective response (RECIST 1.1)

Complete response

I: 25/326 (7.7%)

C: 1/159 (0.6%)

 

Partial response

I: 72/326 (22.1%)

C: 17/159 (10.7%)

Objective response

I: 97/326 (30%)

C: 18/159 (11%)

 

Adverse events

Treatment-related AE

Grade 3/4

I: 143/329 (43%)

C: 72/156 (46%)

 

Grade 5

I: 6/329 (2%)

C: 1/156 (0.6%)

 

Quality of life

Not reported

Authors conclusion:

“In conclusion, the updated analysis showed that the safety and tolerability profile of atezolizumab plus bevacizumab remained consistent after longer follow-up. After an additional 12 months of follow-up, the clinically meaningful survival and efficacy benefits of atezolizumab plus bevacizumab over sorafenib were maintained and consistent with the primary analysis. This updated analysis demonstrated the longest median OS observed to date in a first-line phase III study in hepatocellular carcinoma, confirming this treatment combination as the standard of care for systemic treatment-naive unresectable hepatocellular carcinoma.”

Sorafenib versus Placebo

Llovet, 2008

 

(SHARP)

 

NCT00105443

Type of study:
Randomized, double-blind, placebo-controlled, phase 3 trial

 

Setting and country:

The study was conducted at 121 sites in 21 countries in Europe, North America, South America, and Australasia

 

Patients were enrolled

between March 10, 2005 and April 11, 2006

 

 

Funding and conflicts of interest:

Bayer HealthCare Pharmaceuticals-Onyx Pharmaceuticals

 

Conflicts of interest are disclosed

Patients with advanced HCC who had not received previous systemic treatment

 

Inclusion criteria:

  • ≤18 years of age
  • No previous systematic therapy
  • Life expectance of at least 12 weeks
  • ECOG score 2 or less
  • Child-Pugh A

 

Exclusion criteria:

  • Previously received molecularly targeted therapies or any other systemic treatment

 

N total at baseline:

N = 602

Intervention: N=299

Control: N=303

 

Important prognostic factors:

Age, mean (SD):

I: 64.9 (11.2)

C: 66.3 (10.2)

 

Sex, n/N (%) male:

I: 260/299 (87%)

C: 264/303 (87%)

 

Groups comparable at baseline?

Yes.

 

Sorafenib

 

Sorafenib 400 mg was administered orally at a dose of 400 mg (2 x 200 mg tablets) twice daily; 2 dose reductions to predefined levels of 400 mg once daily (OD) and 400 mg every other day were permitted for adverse events related to study treatment.

 

 

 

 

 

Placebo

 

Sorafenib-matching placebo tablets were orally administered twice daily (bid). Follow-up / Open Label phase: Subjects on placebo who chose to switch to sorafenib, received an oral dose of 400 mg (2 x 200 mg tablets) bid; similar to the double-blind study.

 

 

 

 

 

 

 

 

 

 

 

Length of follow-up:

No information

 

Loss-to-follow-up & incomplete outcome data:

Intervention:

N=2/299 (0.7%) did not receive assigned treatment

 

Control:

N=1/303 (N=0.3%) did not receive assigned treatment

 

 

Intervention:

N=226/299 (75.6%) discontinued the trial

Reasons:

N=81/299 (35.3%) had an adverse event

N=61/299 (20.0%) had radiologic and symptomatic progression

N=28/299 (9.4%) withdrew consent

N=3/299 (1%) died

N=1/299 (0.3%) had ECOG score of 4

N=47/299 (15.7%) had other reasons

 

 

Control:

N=242/303 (79.9%) discontinued the trial

Reasons:

N=90/303 (29.7%) had an adverse event

N=62/303 (20.4%) had radiologic and symptomatic progression

N=25/303 (8.3%) withdrew consent

N=7/303 (2.3%) had ECOG score of 4

N=6/303 (2.0%) died

N=52/303 (17.2%) had other reasons

 

 

Overall survival

Median OS (months)

I: 10.7 (9.4-13.2)

C: 7.9 (6.8-9.1)

HR: 0.69 (95% CI, 0.55 to 0.87)

 

Progression-free survival

Not reported

 

Time to symptomatic progression

Median (months)

I: 4.1 (3.5-4.8)

C: 4.9 (4.2-6.3)

HR: 0.58 (0.45 to 0.74)

 

 

Objective response (RECIST)

Complete

I: 0/299 (0%)

C: 0/303 (0%)

 

Partial

I: 7/299 (2.3%)

C: 2/303 (0.7%)

Numbers in tables and text are inconsistent

 

 

Adverse events

Treatment-emergent adverse events

Grade 3:

I: 39/297 (13.1%)

C: 24/302 (7.9%)

 

Grade 4:

I: 6/297 (2.0%)

C: 8/302 (2.6%)

 

Serious treatment-emergent adverse events

I: 52/297 (17.5%)

C: 54/302 (17.9%)

 

Data was provided in percentages per adverse event. A detailed record of all adverse events is reported in the article.

 

Quality of life

Not reported

  • Child-Pugh class A patient population

 

Authors conclusion:

  • “In patients with advanced hepatocellular carcinoma, median survival and the time to radiologic progression were nearly 3 months longer for patients treated with sorafenib than for those given placebo.”

Cheng, 2009

 

NCT00492752

Type of study:
Randomized, double-blind, placebo-controlled, phase 3 trial

 

Setting and country:

The study was conducted at 23 sites in China, South Korea and Taiwan

 

Patients were enrolled

between September 20, 2005 and January 31, 2007

 

 

Funding and conflicts of interest:

Bayer HealthCare Pharmaceuticals-Onyx Pharmaceuticals

 

Conflicts of interest are disclosed

Patients with advanced HCC who had not received previous systemic treatment

 

Inclusion criteria:

  • ≤18 years of age
  • No previous systematic therapy
  • Life expectance of at least 12 weeks
  • ECOG score 2 or less
  • Child-Pugh A

 

Exclusion criteria:

  • Previously received molecularly targeted therapies or any other systemic treatment

 

N total at baseline:

N = 226

Intervention: N=150

Control: N=76

 

Important prognostic factors:

Age, median (range):

I: 51 (23-86)

C: 52 (25-79)

 

Sex, n/N (%) male:

I: 127/150 (84.7%)

C: 66/76 (86.8%)

 

Groups comparable at baseline?

Yes.

 

Sorafenib

 

Sorafenib 400 mg was administered orally at a dose of 400 mg (2 x 200 mg tablets) twice daily; 2 dose reductions to predefined levels of 400 mg once daily (OD) and 400 mg every other day were permitted for adverse events related to study treatment

 

 

 

 

 

Placebo

 

Placebo tablets matching in appearance were orally administered bid (twice daily)

 

 

 

 

 

 

 

 

 

 

Length of follow-up:

No information

 

Loss-to-follow-up & incomplete outcome data:

Intervention:

N=129/150 (86%) discontinued treatment

 

Control:

N=72/75 (N=96%) discontinued treatment

 

Intervention:

Reasons:

N=69/150 (46%) had disease progression

N=22/150 (14.7%) adverse events

N=23/150 (15.3%) withdrew consent

N=12/150 (8%) died

N=2/150 (1.3%) lost to follow-up

N=1/150 (0.7%) non-compliant to treatment

 

 

Control

Reasons:

N=48/76 (63.2%) had disease progression

N=7/76 (9.2%) adverse events

N=11/76 (14.5%) withdrew consent

N=2/76 (2.6%) died

N=3/76 (3.9%) lost to follow-up

N=1/76 (1.3%) protocol violation

 

Overall survival

Median OS (months)

I: 6.5 (5.56-7.56)

C: 4.2 (3.75-5.46)

HR: 0.68 (95% CI, 0.50 to 0.93)

 

Progression-free survival

Not reported

 

Median time to progression (months)

I: 2.8 (2.63-3.58)

C: 1.4 (1.35-1.55)

HR: 0.57 (0.42 to 0.79)

 

 

Objective response (RECIST)

Complete

I: 0/150 (0%)

C: 0/150 (0%)

 

Partial

I: 5/150 (3.3%)

C: 1/76 (1.3%)

 

Adverse events

Treatment-emergent serious adverse event

I: 71/149 (47.7%)

C: 34/75 (45.3%)

 

Drug-related serious adverse events of any grade

I: 122/149 (81.9%)

C: 29/75 (38.7%)

 

Data was provided in percentages per adverse event. A detailed record of all adverse events is reported in the article.

 

Quality of life

Not reported

  • Child-Pugh class A patient population

 

Authors conclusion:

  • “Our study shows that sorafenib is a well-tolerated treatment option with an acceptable safety profile for patients with advanced hepatocellular carcinoma from the Asia-Pacific region. The efficacy results of our study were consistent with those of the SHARP trial, despite the patients randomised in our study having more advanced disease and being more likely to have different disease aetiologies (eg, HBV infection) than the patients randomised in the SHARP trial. Furthermore, the primary findings and subanalyses of our study suggest that sorafenib could be used to treat patients with hepatocellular carcinoma with different prognostic factors.”

Levatinib versus Sorafenib

Kudo, 2018

 

NCT01761266

Type of study:
Randomized, double-blind, placebo-controlled, phase 3 trial

 

Setting and country:

The study was conducted at 23 sites in China, South Korea and Taiwan

 

Patients were enrolled

between September 20, 2005 and January 31, 2007

 

 

Funding and conflicts of interest:

Eisai Inc

 

Conflicts of interest are disclosed

Patients with unresectable HCC

 

Inclusion criteria:

  • ≤18 years of age
  • No previous systematic therapy
  • Child-Pugh A
  • Life expectance of at least 12 weeks

 

Exclusion criteria:

  • 50% or higher liver occupation, obvious invasion of the bile duct, or invasion at the main portal vein
  • Received previous systemic therapy for HCC

 

N total at baseline:

N = 954

Intervention: N=478

Control: N=476

 

Important prognostic factors:

Age, median (range):

I: 63.0 (20-88)

C: 62.0 (22-88)

 

Sex, n/N (%) male:

I: 405/478 (85%)

C: 401/476 (84%)

 

Groups comparable at baseline?

Yes.

 

Lenvatinib

 

Participants received lenvatinib capsules 12 milligram (mg) based on the participant's body weight greater than or equal to (>=) 60 kilogram (kg) or 8 mg based on the participant's body weight less than (<) 60 kg at baseline, orally, once daily (QD) in continuous 28-day treatment cycles up to documented disease progression, development of unacceptable toxicity, participant request, or withdrawal of consent.

 

 

 

Sorafenib

 

Participants received sorafenib 400 mg tablets, orally, twice daily (BID) in continuous 28-day treatment cycles up to documented disease progression, development of unacceptable toxicity, participant request, or withdrawal of consent.

 

 

 

 

 

 

 

 

 

Length of follow-up:

Median (months)

I: 27.4 (95% CI, 26.4-29.3)

C: 27.1 (95% CI, 25.9-27.7)

 

Loss-to-follow-up & incomplete outcome data:

Intervention:

N=476/478 (99.6%) received assigned treatment

N-475/476 (99.8%) received assigned treatment

 

Intervention:

449/478 (93.9%) discontinued treatment

Reasons:

N=311/478 (65.1%) radiological progression

N=65/478 (13.2%) adverse events

N=32/478 (6.7%) clinical progression

N=28/478 (5.9%) patient’s choice

N=3/478 (0.6%) lost to follow-up

N=9/478 (1.9%) withdrew consent

N=3/478 (0.6%) other

 

Control:

450/476 (94.5%) discontinued treatment

Reasons:

N=347/476 (72.9%) radiological progression

N=43/476 (9.1%) adverse events

N=33/476 (7.0%) clinical progression

N=14/476 (2.9%) patient’s choice

N=1/476 (0.2%) lost to follow-up

N=5/476 (1.1%) withdrew consent

N=7/476 (1.5%) other

 

Overall survival

Median OS (months)

I: 13.6 (12.1-14.9)

C: 12.3 (10.4-13.9)

HR: 0.92 (95% CI, 0.79 to 1.06)

 

Progression-free survival

Masked independent imaging review according to mRECIST

I: 7.3 (5.6-7.5)

C: 3.6 (3.6-3.7)

HR: 0.64 (95% CI, 0.55-0.75)

 

Objective response (RECIST 1.1)

Complete

I: 10/478 (2.1%)

C: 4/476 (0.8%)

 

Partial

I: 184/478 (38.5%)

C: 55/476 (11.6%)

 

Adverse events

Treatment-related treatment-emergent adverse event of grade ≥3

I: 270/476 (57%)

C: 231/475 (49%)

A detailed record of all adverse events is reported in the article.

 

Quality of life

For between-group comparison, the summary score was not significantly different between the treatment arms (HR 0.87, 95% CI 0.754–1.013, appendix).

(QLQ-C30 questionnaire)

 

HCC18 questionnaire domains ranges between 0.79 (body image, favours Lenvatinib) and 1.14 (pain, favours Sorafenib)

 

 

  • Child-Pugh class A patient population

 

Authors conclusion:

  • “In conclusion, this study showed non-inferiority of lenvatinib versus sorafenib in terms of overall survival, as well as statistically significant and clinically meaningful improvement in progression-free survival, time to progression, and objective response rate. The safety profiles of lenvatinib and sorafenib in our study appear consistent with the known safety profiles of these drugs in hepatocellular carcinoma, and no new safety signals were identified. Based on our results, lenvatinib might be a potential new treatment option for advanced hepatocellular carcinoma.”

Second-line treatment

Regorafenib versus placebo

Study reference

Study characteristics

Patient characteristics

Intervention (I)

Comparison / control (C)

 

Follow-up

Outcome measures and effect size

Comments

Bruix, 2017

 

(RESORCE)

 

NCT01774344

Type of study:
Randomized double-blind, placebo-controlled, phase 3  trial

 

Setting and country:

The study was conducted at 152 sites 21 countries in Asia.

 

Funding and conflicts of interest:

Bayer

 

Conflicts of interest are disclosed

Patients with HCC who have progressed during sorafenib treatment

 

Inclusion criteria:

  • Confirmed HCC
  • Failure to prior treatment with sorafenib
  • BCLC stage B or C
  • No benefit from resection, local ablation, or chemoembolization
  • Child-Pugh A

 

Exclusion criteria:

  • Received any other previous treatment for HCC or if they discontinued sorafenib for toxicity

 

 

N total at baseline:

N = 573

Intervention: N=379

Control: N=194

 

Important prognostic factors:

Age, median (range):

I: 64 (54-71)

C: 62 (55-68)

 

Sex, n/N (%) male:

I: 333/379 (88%)

C: 171/194 (88%)

 

Groups comparable at baseline?

Yes.

 

Regorafenib

 

160 mg orally (p.o.) every day (qd) for 3 weeks of every 4 week cycle (i.e. 3 weeks on, 1 week off)

 

+

 

best supportive care

 

 

 

Drug: Regorafenib (Stivarga, BAY73-4506)

Regorafenib, 40 mg tablets

 

Placebo

 

4 matching placebo tablets for 3 weeks of every 4 week cycle (i.e. 3 weeks on, 1 week off)

 

+

 

best supportive care

Length of follow-up:

Not specified

 

Loss-to-follow-up & incomplete outcome data:

Intervention:

N=5/379 (1.3%) did not receive regorafenib

 

Control:

N=1/194 (0.5%) did not receive placebo

 

Intervention:

309/374 (82.6%) discontinued treatment 

 

Primary reason:

N= 149/374 (39.8%) progressive disease, radiological progression

N=21/374 (5.6%)

Progressive disease, clinical progression

N=56/374 (14.9%) adverse event associated with disease progression

N=46/374 (12.6%) adverse event not associated with disease progression

N=1/374 (0.3%) adverse event

N=5/374 (1.3%) death

N=25/374 (6.7%) withdrawal by patient

N=2/374 (0.5%) non-compliance with study drug

N=1/374 (0.3%) physician decision

N=1/374 (0.3%) protocol violation

 

Control:

183/193 (94.8%) discontinued treatment

 

Primary reason:

N= 119/193 (61.7%) progressive disease, radiological progression

N=14/193 (7.3%)

Progressive disease, clinical progression

N=1/193 (0.5%)

Progressive disease

N=28/193 (14.5%) adverse event associated with disease progression

N=12/193 (6.2%) adverse event not associated with disease progression

N=3/193 (1.6%) protocol violation

N=5/193 (2.6%) withdrawal by patient

N=1/193 (0.5%) other

 

Overall survival

(ITT cohort)

Median OS (months)

I: 10.6 (95% CI 9.1 to 12.1)

C: 7.8 (95% CI 6.3 to 8.8)

HR 0.63 (95% CI 0.5 to 0.79)

P<0.001

 

Progression-free survival

Median PFS (months) (RECIST 1.1)

I: 3.4 (95% CI 2.9 to 4.2)

C: 1.5 (95% CI 1.4 to 1.5)

HR 0.43 (95% CI 0.35 to 0.52)

P<0.001

*numbers are retrieved from the supplementary file and slightly differ from the numbers presented in the article

 

Objective response

I: 40/374 (11%)

C: 8/193 (4%)

P=0.0047

 

Adverse events

Treatment-emergent

Grade 3

I: 208/374 (56%)

C: 61/193 (32%)

 

Grade 4

I: 40/374 (11%)

C: 14/193 (7%)

 

Treatment-emergent drug-related

Grade 3

I: 173/374 (46%)

C: 31/193 (16%)

 

Grade 4

I: 14/374 (4%)

C: 1/193 (1%)

 

A detailed record of all adverse events is reported in the article.

 

Quality of life

EQ-5D index

I: 0.76

C: 0.77

Difference = -0.01 (95% CI; -0.03 to 0.02)

 

EQ-5D VAS

I: 71.68

C: 73.45

Difference = -1.77 (95% CI; -3.58 to 0.04)

 

FACT-General

I: 75.14

C: 76.55

Difference = -1.41 (95% CI; -2.93 to 0.11)

 

FACT-Hep

I: 129.31

C: 133.17

Difference = -3.85 (95% CI; -6.06 to -1.65)

 

  • HRQoL was assessed with the Functional Assessment of Cancer Therapy (FACT)–General (FACT-G), FACT–Hepatobiliary (FACT-Hep), EQ-5D, and EQ-VAS questionnaires

 

 

Authors conclusion:

  • “The results of RESORCE show that treatment with regorafenib resulted in a significant improvement in overall survival compared with placebo in patients with disease progression on sorafenib. Significant improvement over placebo was also shown for the secondary endpoints of progression-free survival, time to progression, disease control, and overall tumour response.”

 

Risk of bias table

Study reference

 

(first author, publication year)

Was the allocation sequence adequately generated?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Definitely yes

Probably yes

Probably no

Definitely no

Was the allocation adequately concealed?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Definitely yes

Probably yes

Probably no

Definitely no

Blinding: Was knowledge of the allocated

interventions adequately prevented?

 

Were patients blinded?

 

Were healthcare providers blinded?

 

Were data collectors blinded?

 

Were outcome assessors blinded?

 

Were data analysts blinded?

 

Definitely yes

Probably yes

Probably no

Definitely no

Was loss to follow-up (missing outcome data) infrequent?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Definitely yes

Probably yes

Probably no

Definitely no

Are reports of the study free of selective outcome reporting?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Definitely yes

Probably yes

Probably no

Definitely no

Was the study apparently free of other problems that could put it at a risk of bias?

 

 

 

 

 

 

 

 

 

 

 

 

 

Definitely yes

Probably yes

Probably no

Definitely no

Overall risk of bias

If applicable/necessary, per outcome measure

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LOW

Some concerns

HIGH

 

First-line treatments

Finn, 2020

Definitely yes;

 

Reason: Randomization was performed through an interactive voice-response or Web-response system in stratified permuted blocks

Definitely yes;

 

Reason: Central allocation

Probably no;

 

Reason: Open-label trial.

A blinded independent review of imaging for progression-free survival was selected for the coprimary end point.

 

 

Probably yes;

Numbers and reasons for loss to follow-up are not infrequent. Reasons for missing outcome data unlikely to be related to outcome

Definitely yes;

 

Reason: All outcome measures described in the trial protocol are reported in the results

Probably yes;

 

Reason: No information

LOW

Llovet, 2008

Definitely yes;

 

Reason: Randomization was performed by computer to achieve a balance between the two groups, with stratification before randomization

Definitely yes;

 

Reason: Central allocation

Probably yes;

 

Reason: Participants, care providers were blinded. Not clear whether the outcome assessors were blinded

Probably yes;

Numbers and reasons for loss to follow-up are not infrequent. Reasons for missing outcome data unlikely to be related to outcome

Definitely yes;

 

Reason: All outcome measures described in the trial protocol are reported in the results

Probably yes;

 

Reason: No information

LOW

Cheng, 2009

Definitely yes;

 

Reason: Randomization was performed by an interactive voice-response system.

Definitely yes;

 

Reason: Central allocation

Probably no;

 

Reason: Patients were blinded. Authors stated that investigators were unblinded to treatment assignment, but it is unclear from the text who was also blinded in this double-blind study

Probably yes;

Numbers and reasons for loss to follow-up are not infrequent. Reasons for missing outcome data unlikely to be related to outcome

Probably no;

 

Reason: All outcome measures described in the trial protocol are reported in the results. Data was not shown for Quality of Life.

Probably yes;

 

Reason: No information

Some concerns

Kudo, 2018

Definitely yes;

 

Reason: Randomization was performed by an interactive voice-response system

Definitely yes;

 

Reason: Central allocation

Probably no;

 

Reason: Open-label trial. A blinded independent review of imaging for progression-free survival was selected

 

Probably yes;

Numbers and reasons for loss to follow-up are not infrequent.

Definitely yes;

 

Reason: All outcome measures described in the trial protocol are reported in the results

Probably yes;

 

Reason: No information

LOW

Second-line treatment

Bruix, 2017

Definitely yes;

 

Reason: Randomization was centralized and performed with a computer-generated allocation list

Definitely yes;

 

Reason: Central allocation

Definitely yes;

 

Reason: Participants, care providers, investigators and outcome assessors were blinded

Probably yes;

Numbers and reasons for loss to follow-up were slightly different between the groups. Reasons for missing outcome data unlikely to be related to outcome

Definitely yes;

 

Reason: All outcome measures described in the trial protocol are reported in the results

Probably yes;

 

Reason: No information

LOW

 

Table of excluded studies

Author and year

Reason for exclusion

Ahmed 2021

Study by Finn (2020) is already Included in Park (2021). The study from Lee (2020 is a phase 1b study and compares the treatment atezolizumab with or without bevacizumab in unresectable HCC (not of interest).

An 2021

The RCTs that studied the comparisons of interests are already included in the selected SR.

Chen 2021

The RCTs that studied the comparisons of interests are already included in the selected SR.

Facciorusso 2021

The RCTs that studied the comparisons of interests are already included in the selected SR.

Jácome 2021

The RCTs that studied the comparisons of interests are already included in the selected SR.

Kudo 2021

Pooled results from REACH and REACH-2 studies. Comparison not of interest. 

Liu 2021

The RCTs that studied the comparisons of interests are already included in the selected SR.

Rizzo 2022

Background article

Ronnebaum 2022

The RCTs that studied the comparisons of interests are already included in the selected SR.

Vogel 2021

The RCTs that studied the comparisons of interests are already included in the selected SR.

Ziogas 2021

The RCTs that studied the comparisons of interests are already included in the selected SR.

Autorisatiedatum en geldigheid

Laatst beoordeeld  : 01-01-2024

Laatst geautoriseerd  : 01-01-2024

Geplande herbeoordeling  : 01-01-2029

Initiatief en autorisatie

Initiatief:
  • Nederlandse Vereniging van Maag-Darm-Leverartsen
Geautoriseerd door:
  • Nederlandse Internisten Vereniging
  • Nederlandse Vereniging van Maag-Darm-Leverartsen
  • Nederlandse Vereniging voor Heelkunde
  • Nederlandse Vereniging voor Nucleaire geneeskunde
  • Nederlandse Vereniging voor Pathologie
  • Nederlandse Vereniging voor Radiologie
  • Nederlandse Vereniging voor Radiotherapie en Oncologie
  • Nederlandse Leverpatiënten Vereniging

Algemene gegevens

De ontwikkeling/herziening van deze richtlijnmodule werd ondersteund door het Kennisinstituut van de Federatie Medisch Specialisten (www.demedischspecialist.nl/kennisinstituut) en werd gefinancierd uit de Stichting Kwaliteitsgelden Medisch Specialisten (SKMS).

 

De financier heeft geen enkele invloed gehad op de inhoud van de richtlijnmodule.

Samenstelling werkgroep

Voor het ontwikkelen van de richtlijnmodule is in 2021 een multidisciplinaire werkgroep ingesteld, bestaande uit vertegenwoordigers van alle relevante specialismen (zie hiervoor de Samenstelling van de werkgroep) die betrokken zijn bij de zorg voor patiënten met hepatocellulaircarcinoom.

 

Werkgroep

  • Prof. dr. R.A de Man, MDL-arts, Erasmus MC, Rotterdam, NVMDL (voorzitter)
  • Dr. K.J. van Erpecum, MDL-arts, UMC Utrecht, Utrecht, NVMDL
  • Dr. E.T.T.L. Tjwa, MDL-arts, Radboud UMC, Nijmegen, NVMDL
  • Dr. R.B. Takkenberg, MDL-arts, Amsterdam UMC, Amsterdam, NVMDL
  • Dr. F.G.I. van Vilsteren, MDL-arts, UMCG, Groningen, NVMDL
  • Dr. D. Sprengers, MDL-arts, Erasmus MC, Rotterdam, NVMDL
  • Dr. M.J. Coenraad, MDL-arts, LUMC, Leiden, NVMDL
  • Prof. dr. B. van Hoek, MDL-arts, LUMC, Leiden, NVMDL
  • Dr. N. Haj Mohammad, Internist-oncoloog, UMC Utrecht, Utrecht, NIV
  • Dr. J. de Vos-Geelen, Internist-oncoloog, MUMC, Maastricht, NIV
  • Drs. J.A. Willemse, Directeur Nederlandse Leverpatiënten Vereniging
  • Prof. dr. M.G.E. Lam, Nucleair geneeskundige, UMC Utrecht, Utrecht, NVNG
  • Prof. dr. J. Verheij, Patholoog, Amsterdam UMC, Amsterdam, NVvP
  • Dr. M. (Michail) Doukas, Patholoog, Erasmus MC, Rotterdam, NVvP
  • Dr. A.M. Mendez Romero, Radiotherapeut, Erasmus MC, Rotterdam, NVvR
  • Dr. A.E. Braat, Chirurg, LUMC, Leiden, NVvH
  • Dr. M.W. Nijkamp, Chirurg, UMCG, Groningen, NVvH
  • Prof. Dr. J.N.M. Ijzermans, Chirurg, ErasmusMC, Rotterdam, NVvH
  • Drs. J.I. Erdmann, Chirurg, Amsterdam UMC, Amsterdam, NVvH
  • Dr. M.C. Burgmans, Radioloog, LUMC, Leiden, NVvR
  • Drs. F.E.J.A. Willemssen, Radioloog, ErasmusMC, Rotterdam, NVvR
  • Prof. Dr. O.M. (Otto) van Delden, Radioloog, AmsterdamUMC, Amsterdam, NVvR
  • J.I. Franken, Verpleegkundig specialist, ErasmusMC, Rotterdam, V&VN

Met ondersteuning van

  • Dr. C. Gaasterland, Adviseur, Kennisinstituut van de Federatie Medisch Specialisten
  • Dr. D. Nieboer, Adviseur, Kennisinstituut van de Federatie Medisch Specialisten
  • Dr. N. Zielonke, Adviseur, Kennisinstituut van de Federatie Medisch Specialisten
  • Drs. M. Oerbekke, Adviseur, Kennisinstituut van de Federatie Medisch Specialisten
  • Drs. M. te Lintel Hekkert, Junior adviseur, Kennisinstituut van de Federatie Medisch Specialisten
  • Drs. S van Duijn, Junior adviseur, Kennisinstituut van de Federatie Medisch Specialisten
  • Drs. A. van Hoeven, Junior adviseur, Kennisinstituut van de Federatie Medisch Specialisten
  • D.P. Gutierrez, projectsecretaresse, Kennisinstituut van de Federatie Medisch Specialisten

Belangenverklaringen

De Code ter voorkoming van oneigenlijke beïnvloeding door belangenverstrengeling is gevolgd. Alle werkgroepleden hebben schriftelijk verklaard of zij in de laatste drie jaar directe financiële belangen (betrekking bij een commercieel bedrijf, persoonlijke financiële belangen, onderzoeksfinanciering) of indirecte belangen (persoonlijke relaties, reputatiemanagement) hebben gehad. Gedurende de ontwikkeling of herziening van een module worden wijzigingen in belangen aan de voorzitter doorgegeven. De belangenverklaring wordt opnieuw bevestigd tijdens de commentaarfase.

 

Een overzicht van de belangen van werkgroepleden en het oordeel over het omgaan met eventuele belangen vindt u in onderstaande tabel. De ondertekende belangenverklaringen zijn op te vragen bij het secretariaat van het Kennisinstituut van de Federatie Medisch Specialisten.

 

Achternaam werkgroeplid

Hoofdfunctie

Nevenwerkzaamheden

Persoonlijke financiële belangen

Persoonlijke relaties

Extern gefinancierd onderzoek

Intellectuele belangen en reputatie

Overige belangen

De Man (vz.)

Hoogleraar Hepatologie, Erasmus MC Rotterdam

Geen

Geen

Geen

Geen

Geen

Geen

Haj Mohammad

Internist-oncoloog, Universitair Medisch Centrum Utrecht

Penningmeester Dutch Upper GI Cancer (DUCG), onbetaald
Wetenschappelijke raad Dutch Heptocellular and Cholangiocarcinoma group (DHCG), onbetaald
Lid richtlijn galwegcarcinoom, onbetaald. De DHCG is een gemeenschappelijk initiatief van Nederlandse medisch specialisten om de krachten in de strijd tegen lever- en galwegkanker te bundelen

Geen

Geen

Geen

Lid wetenschappelijke raad Dutch Hepato and Cholangio Carcinoma Group(DHCG)

Geen

Burgmans

Sectiehoofd interventie radiologie LUMC

Voorzitter Nederlandse Vereniging Interventieradiologie
Bestuurslid Nederlandse Vereniging voor Hepatologie
Voorzitter Normendocument interventieradiologie
Lid Wetenschappelijke Commissie Interventieradiologie

Allen onbetaald

Geen

Geen

PROMETHEUS studie, subsidie KWF, project leider
HORA EST HCC studie, subsidie ZonMW, MLDS, Health Holland, project leider

Geen

Geen

Lam

Nucleair geneeskundige, UMC Utrecht

Geen

Geen

Geen

Terumo, Quirem Medical en Boston scientific leveren financiële steun aan wetenschappelijke projecten

Geen

Het UMC Utrecht ontvangt royalties en milestone payments van Terumo/Quirem Medical

Franken

Verpleegkundig Specialist Levertumoren
Afdeling HPB - transplantatie chirurgie
Erasmus MC

Geen

Geen

Geen

Geen

Geen

Geen

Verheij

Hoogleraar hepatopancreatobiliaire Pathologie aan de Universiteit van Amsterdam
Klinisch Patholoog Amsterdam UMC, Amsterdam

lid medische adviesraad NLV (onbezoldigd)

Geen

Geen

Geen

Geen

Geen

Sprengers

MDL-arts Erasmus MC

Geen

Geen

Geen

Ik doe translationeel onderzoek met als doel behandeling van patiënten met een HCC te verbeteren. Daarbij wordt soms samengewerkt met famaceutische partijen die producten ontwikkelen die hieraan bij kunnen dragen. Te allen tijde betreft dit objectief wetenschappelijk onderzoek zonder winstoogmerk.

Geen

Geen

Van Vilsteren

MDL-arts UMCG 0,9 fte

Geen

Geen

Geen

Geen

Geen

Geen

Takkenberg

Maag- Darm Leverarts met specifiek aandachtsgebied leverziekten. Sinds 1-4-2015 in deinst van het Amsterdam UMC, locatie AMC.

Geen

Betaald adviesschap:
Swedish Orphan Biovitrum BV/SRL (Sobi)
Norgine bv.

Geen

Ik ben PI van de PEARL studie. Dit is een dubbelblind gerandomiseerde studie bij patiënten die een transjugulaire intrahepatische portosysthemische shunt (TIPS) krijgen. Patiënten worden gerandomiseerd tussen profylactisch lactulose en rifaximin versus lactulose en placebo. Doel is het voorkomen van post-TIPS hepatische encafalopathie (EudraCT-nummer 2018-004323-37). Deze studie wordt gefinancierd door ZonMW en ondersteund door Norgine. Zij leveren de rifaximin en placebo tabletten.

Secretaris Dutch Hepatocellular and cholangiocarcinoma Group (DHCG)
Voorzitter werkgroep portale hypertensie van de Nederlandse Vereniging voor Hepatologie (NVH).
Voorzitter commissie ter organisatie van de Dutch Liver Week.
Bestuurslid NVH.

Geen

Van Erpecum

MDL-arts UMC Utrecht

Associate Editor European Journal of Internal Medicine (onbetaald)
Editorial Board Clinics and Research in Hepatology and Gastroenterology (onbetaald)
Editorial Board Biochimica Biophysica Acta, Molecular and Cell Biology of Lipids (onbetaald)
Lid Medisch Ethische Toetsingscommissie UMC (onbetaald)

Geen

Geen

Geen

Geen

Geen

Willemssen

Abdominaal Radioloog
Erasmus MC Rotterdam

Bestuurslid abdominale sectie NVvR (onbetaald)

Geen

Geen

Geen

Geen

Geen

Méndez Romero

Staflid afdeling radiotherapie in het Erasmus MC

Als staflid in ee adademisch ziekenhuis ben ik in loondienst van het ErasmusMC

Geen

Geen

Geen

Geen

Geen

Tjwa

MDL arts / hepatoloog

Geen

Geen

Geen

Geen

Geen

Geen

Braat

chirurg
LUMC

Geen

Geen

Geen

Geen

Geen

Geen

Nijkamp

Chirurg Universitair Medisch Centrum Groningen

Geen

Geen

Geen

Geen

Geen

Geen

Willemse

Directeur Nederlandse Leverpatiënten Vereniging

* Bestuurslid Liver Patients International (onbetaald)
* Bestuurslid ERN Rare Liver (onbetaald)

Geen

Geen

Geen

Geen

Geen

IJzermans

Hoofd HPB & Transplantatiechirurgie Erasmus MC

-

Niet van toepassing

Nee

Niet van toepassing

Niet van toepassing

Nee

Vos, de - Geelen

* Internist - Medisch Oncoloog Maastricht UMC+
* Secretaris DHCG - Landelijke werkgroep HCC en BTC

Has served as a constultant for Amgen, AstraZeneca, MSD, Pierre Fabre and Servier and has received institutional research funding from Servier

Has served as a constultant for Amgen, AstraZeneca, MSD, Pierre Fabre and Servier and has received institutional research funding from Servier. Geen directe financiële belangen in een farmaceutisch bedrijf

Geen

* Servier: Microbioomonderzoek - Projectleider
* MLDS: Keuzehulp alvleesklierkanker - Projectleider

Geen

Geen

Hoek, van

* Hoogleraar Hepatologie, Universiteit Leiden
* MDL-arts, medisch hoofd levertransplantatie en hepatologie, afd MDL, LUMC Leiden
* Lid managementteam transplantatie afdeling LUMC, Leiden

* Norgine Pharma - patient voorlichtingsmateriaal maken, onder andere podcast - betaald
* Norgine Pharma - farmaco-economische analyse - betaald
* Sandoz Pharma - implementatie DBS monitoring immunsuppressie - betaald (lumc)
* Astellas Pharma - optimaliseren levertransplantaties database - betaald (aan lumc)
* Chiesi Pharma & ZonMW - controlled trial auto-immuun hepatitis (betaald aan lumc)

Geen

Nee

* Roche - Piranga Studie (hepatitis B) - Projectleider
* ZonMW -TAILOR studie (auto-immuun hepatitis) - Projectleider
* Takeda (Arrowhead) - AROOAT studie (alfa-1-anti trypsine deficientie) - Projectleider
* Chiesi - MOTTO studie (tacrolimus na levertransplantatie) - Projectleider
* Dicerna - Studie naar alfa-1-anti trypsine deficientie) - Projectleider
* Sandoz - Implementatie DBS voor immunsuppressie monitoring - Projectleider
* Nutricia - voedingsonderzoek bij leverziekte/-transplantatie - Projectleider

Geen

Nee

Delden, van

Radioloog, Amsterdam UMC

Voorzitter DHCG

Geen

Geen

Geen

Geen

Geen

Doukas

Universitair Medisch Specialist, Patholoog, Afdeling Pathologie Erasmus MC, Rotterdam

Geen

Niet van toepassing

Niet van toepassing

Niet van toepassing

Niet van toepassing

Niet van toepassing

Coenraad

Associate professor, MDL arts Leids Universitair Medisch Centrum (1.0 fte)
Visitng professor afd Hepatologie KU Leuven Belgie (onbezoldigd)

Nevenfuncties:
-Bestuursvoorzitter Nederlandse Vereniging voor Hepatologie (onbetaald)
-United European Gastroenterology Summer School Course Director (onbetaald)
-Lid Landelijk Overleg Levertransplantatie (onbetaald)
-Associate Editor van peer-reviewed internationaal tijdschift Liver International (hiervoor ontvang ik jaarlijks plm 2000 Euro onkostenvergoeding)
-Voorzitter van Nederlands richtsnoer Lever Transplantatie voor HCC (onbetaald)
-Bestuurslid Dutch Hepatocellular Carcinoma Group (onbetaald)
-2019-2022 2019 UEG National Societies Committee member, UEG education committee member (onbetaald)

Niet van toepassing

Niet van toepassing

* Horizon2020 - EU Project id 945096. Title ‘Novel treatment of acute-on-chronic liver failure using synergistic action of G-CSF and TAK-242 - Geen projectleider
* 2020 MLDS grant - Gepersonaliseerde blended coaching ter bevordering van een gezonde leefstijl bij mensen met (risico op) leververvetting - Geen projectleider
* 2020 Dutch Cancer Society - Prospective multicenter study of the relationship between safety margin and recurrent tumor after thermal ablation in patients with liver cancer - Geen projectleider
*  2019 Johanna Zaaijer Fund - Role of endothelial cells in pathogenesis of acute decompensation, acute on chronic liver failure and in liver regeneration - Projectleider

Niet van toepassing

Niet van toepassing

Erdmann

Chirurg AUMC

geen

geen

geen

AGEM - perfusie onderzoek (50K), rol als projectleider

geen

geen

Inbreng patiëntenperspectief

Er werd aandacht besteed aan het patiëntenperspectief door deelname van de afgevaardigde patiëntenvereniging Nederlandse Leverpatiëntenvereniging in de werkgroep. De afgevaardigde heeft meebeslist bij het opstellen van de uitgangsvragen, de keuze voor de uitkomstmaten en bij het opstellen van de overwegingen. De conceptrichtlijn is tevens voor commentaar voorgelegd aan de Nederlandse Leverpatiëntenvereniging en de eventueel aangeleverde commentaren zijn bekeken en verwerkt.

 

Wkkgz & Kwalitatieve raming van mogelijke substantiële financiële gevolgen

Kwalitatieve raming van mogelijke financiële gevolgen in het kader van de Wkkgz

Bij de richtlijn is conform de Wet kwaliteit, klachten en geschillen zorg (Wkkgz) een kwalitatieve raming uitgevoerd of de aanbevelingen mogelijk leiden tot substantiële financiële gevolgen. Bij het uitvoeren van deze beoordeling zijn richtlijnmodules op verschillende domeinen getoetst (zie het stroomschema op de Richtlijnendatabase).

 

Uit de kwalitatieve raming blijkt dat er geen substantiële financiële gevolgen zijn voor deze richtlijn, gezien het aantal patiënten kleiner is dan 5000.

Werkwijze

AGREE

Deze richtlijnmodule is opgesteld conform de eisen vermeld in het rapport Medisch Specialistische Richtlijnen 2.0 van de adviescommissie Richtlijnen van de Raad Kwaliteit. Dit rapport is gebaseerd op het AGREE II instrument (Appraisal of Guidelines for Research & Evaluation II; Brouwers, 2010).

 

Knelpuntenanalyse en uitgangsvragen

Tijdens de voorbereidende fase inventariseerde de werkgroep de knelpunten in de zorg voor patiënten met Hepatocellulaircarcinoom. De werkgroep beoordeelde de aanbeveling(en) uit de eerdere richtlijn Hepatocellulaircarcinoom op noodzaak tot revisie. Tevens zijn er knelpunten aangedragen door de deelnemende WV-en, de V&VN en de Nederlandse Leverpatiëntenvereniging.

 

Op basis van de uitkomsten van de knelpuntenanalyse zijn door de werkgroep concept-uitgangsvragen opgesteld en definitief vastgesteld.

 

Uitkomstmaten

Na het opstellen van de zoekvraag behorende bij de uitgangsvraag inventariseerde de werkgroep welke uitkomstmaten voor de patiënt relevant zijn, waarbij zowel naar gewenste als ongewenste effecten werd gekeken. Hierbij werd een maximum van acht uitkomstmaten gehanteerd. De werkgroep waardeerde deze uitkomstmaten volgens hun relatieve belang bij de besluitvorming rondom aanbevelingen, als cruciaal (kritiek voor de besluitvorming), belangrijk (maar niet cruciaal) en onbelangrijk. Tevens definieerde de werkgroep tenminste voor de cruciale uitkomstmaten welke verschillen zij klinisch (patiënt) relevant vonden.

 

Methode literatuursamenvatting

Een uitgebreide beschrijving van de strategie voor zoeken en selecteren van literatuur is te vinden onder ‘Zoeken en selecteren’ onder Onderbouwing. Indien mogelijk werd de data uit verschillende studies gepoold in een random-effects model. Review Manager 5.4 werd gebruikt voor de statistische analyses. De beoordeling van de kracht van het wetenschappelijke bewijs wordt hieronder toegelicht.

 

Beoordelen van de kracht van het wetenschappelijke bewijs

De kracht van het wetenschappelijke bewijs werd bepaald volgens de GRADE-methode. GRADE staat voor ‘Grading Recommendations Assessment, Development and Evaluation’ (zie http://www.gradeworkinggroup.org/). De basisprincipes van de GRADE-methodiek zijn: het benoemen en prioriteren van de klinisch (patiënt) relevante uitkomstmaten, een systematische review per uitkomstmaat, en een beoordeling van de bewijskracht per uitkomstmaat op basis van de acht GRADE-domeinen (domeinen voor downgraden: risk of bias, inconsistentie, indirectheid, imprecisie, en publicatiebias; domeinen voor upgraden: dosis-effect relatie, groot effect, en residuele plausibele confounding).

 

GRADE onderscheidt vier gradaties voor de kwaliteit van het wetenschappelijk bewijs: hoog, redelijk, laag en zeer laag. Deze gradaties verwijzen naar de mate van zekerheid die er bestaat over de literatuurconclusie, in het bijzonder de mate van zekerheid dat de literatuurconclusie de aanbeveling adequaat ondersteunt (Schünemann, 2013; Hultcrantz, 2017).

 

GRADE

Definitie

Hoog

  • er is hoge zekerheid dat het ware effect van behandeling dichtbij het geschatte effect van behandeling ligt;
  • het is zeer onwaarschijnlijk dat de literatuurconclusie klinisch relevant verandert wanneer er resultaten van nieuw grootschalig onderzoek aan de literatuuranalyse worden toegevoegd.

Redelijk

  • er is redelijke zekerheid dat het ware effect van behandeling dichtbij het geschatte effect van behandeling ligt;
  • het is mogelijk dat de conclusie klinisch relevant verandert wanneer er resultaten van nieuw grootschalig onderzoek aan de literatuuranalyse worden toegevoegd.

Laag

  • er is lage zekerheid dat het ware effect van behandeling dichtbij het geschatte effect van behandeling ligt;
  • er is een reële kans dat de conclusie klinisch relevant verandert wanneer er resultaten van nieuw grootschalig onderzoek aan de literatuuranalyse worden toegevoegd.

Zeer laag

  • er is zeer lage zekerheid dat het ware effect van behandeling dichtbij het geschatte effect van behandeling ligt;
  • de literatuurconclusie is zeer onzeker.

 

Bij het beoordelen (graderen) van de kracht van het wetenschappelijk bewijs in richtlijnen volgens de GRADE-methodiek spelen grenzen voor klinische besluitvorming een belangrijke rol (Hultcrantz, 2017). Dit zijn de grenzen die bij overschrijding aanleiding zouden geven tot een aanpassing van de aanbeveling. Om de grenzen voor klinische besluitvorming te bepalen moeten alle relevante uitkomstmaten en overwegingen worden meegewogen. De grenzen voor klinische besluitvorming zijn daarmee niet één op één vergelijkbaar met het minimaal klinisch relevant verschil (Minimal Clinically Important Difference, MCID). Met name in situaties waarin een interventie geen belangrijke nadelen heeft en de kosten relatief laag zijn, kan de grens voor klinische besluitvorming met betrekking tot de effectiviteit van de interventie bij een lagere waarde (dichter bij het nuleffect) liggen dan de MCID (Hultcrantz, 2017).

 

Overwegingen (van bewijs naar aanbeveling)

Om te komen tot een aanbeveling zijn naast (de kwaliteit van) het wetenschappelijke bewijs ook andere aspecten belangrijk en worden meegewogen, zoals aanvullende argumenten uit bijvoorbeeld de biomechanica of fysiologie, waarden en voorkeuren van patiënten, kosten (middelenbeslag), aanvaardbaarheid, haalbaarheid en implementatie. Deze aspecten zijn systematisch vermeld en beoordeeld (gewogen) onder het kopje ‘Overwegingen’ en kunnen (mede) gebaseerd zijn op expert opinion. Hierbij is gebruik gemaakt van een gestructureerd format gebaseerd op het evidence-to-decision framework van de internationale GRADE Working Group (Alonso-Coello, 2016a; Alonso-Coello, 2016b). Dit evidence-to-decision framework is een integraal onderdeel van de GRADE methodiek.

 

Formuleren van aanbevelingen

De aanbevelingen geven antwoord op de uitgangsvraag en zijn gebaseerd op het beschikbare wetenschappelijke bewijs en de belangrijkste overwegingen, en een weging van de gunstige en ongunstige effecten van de relevante interventies. De kracht van het wetenschappelijk bewijs en het gewicht dat door de werkgroep wordt toegekend aan de overwegingen, bepalen samen de sterkte van de aanbeveling. Conform de GRADE-methodiek sluit een lage bewijskracht van conclusies in de systematische literatuuranalyse een sterke aanbeveling niet a priori uit, en zijn bij een hoge bewijskracht ook zwakke aanbevelingen mogelijk (Agoritsas, 2017; Neumann, 2016). De sterkte van de aanbeveling wordt altijd bepaald door weging van alle relevante argumenten tezamen. De werkgroep heeft bij elke aanbeveling opgenomen hoe zij tot de richting en sterkte van de aanbeveling zijn gekomen.

 

In de GRADE-methodiek wordt onderscheid gemaakt tussen sterke en zwakke (of conditionele) aanbevelingen. De sterkte van een aanbeveling verwijst naar de mate van zekerheid dat de voordelen van de interventie opwegen tegen de nadelen (of vice versa), gezien over het hele spectrum van patiënten waarvoor de aanbeveling is bedoeld. De sterkte van een aanbeveling heeft duidelijke implicaties voor patiënten, behandelaars en beleidsmakers (zie onderstaande tabel). Een aanbeveling is geen dictaat, zelfs een sterke aanbeveling gebaseerd op bewijs van hoge kwaliteit (GRADE-gradering HOOG) zal niet altijd van toepassing zijn, onder alle mogelijke omstandigheden en voor elke individuele patiënt.

 

Implicaties van sterke en zwakke aanbevelingen voor verschillende richtlijngebruikers

 

Sterke aanbeveling

Zwakke (conditionele) aanbeveling

Voor patiënten

De meeste patiënten zouden de aanbevolen interventie of aanpak kiezen en slechts een klein aantal niet.

Een aanzienlijk deel van de patiënten zouden de aanbevolen interventie of aanpak kiezen, maar veel patiënten ook niet. 

Voor behandelaars

De meeste patiënten zouden de aanbevolen interventie of aanpak moeten ontvangen.

Er zijn meerdere geschikte interventies of aanpakken. De patiënt moet worden ondersteund bij de keuze voor de interventie of aanpak die het beste aansluit bij zijn of haar waarden en voorkeuren.

Voor beleidsmakers

De aanbevolen interventie of aanpak kan worden gezien als standaardbeleid.

Beleidsbepaling vereist uitvoerige discussie met betrokkenheid van veel stakeholders. Er is een grotere kans op lokale beleidsverschillen. 

 

Organisatie van zorg

In de knelpuntenanalyse en bij de ontwikkeling van de richtlijnmodule is expliciet aandacht geweest voor de organisatie van zorg: alle aspecten die randvoorwaardelijk zijn voor het verlenen van zorg (zoals coördinatie, communicatie, (financiële) middelen, mankracht en infrastructuur). Randvoorwaarden die relevant zijn voor het beantwoorden van deze specifieke uitgangsvraag zijn genoemd bij de overwegingen. Meer algemene, overkoepelende, of bijkomende aspecten van de organisatie van zorg worden behandeld in de module Organisatie van zorg.

 

Commentaar- en autorisatiefase

De conceptrichtlijnmodule werd aan de betrokken (wetenschappelijke) verenigingen en (patiënt) organisaties voorgelegd ter commentaar. De commentaren werden verzameld en besproken met de werkgroep. Naar aanleiding van de commentaren werd de conceptrichtlijnmodule aangepast en definitief vastgesteld door de werkgroep. De definitieve richtlijnmodule werd aan de deelnemende (wetenschappelijke) verenigingen en (patiënt) organisaties voorgelegd voor autorisatie en door hen geautoriseerd dan wel geaccordeerd.

 

Literatuur

Agoritsas T, Merglen A, Heen AF, Kristiansen A, Neumann I, Brito JP, Brignardello-Petersen R, Alexander PE, Rind DM, Vandvik PO, Guyatt GH. UpToDate adherence to GRADE criteria for strong recommendations: an analytical survey. BMJ Open. 2017 Nov 16;7(11):e018593. doi: 10.1136/bmjopen-2017-018593. PubMed PMID: 29150475; PubMed Central PMCID: PMC5701989.

 

Alonso-Coello P, Schünemann HJ, Moberg J, Brignardello-Petersen R, Akl EA, Davoli M, Treweek S, Mustafa RA, Rada G, Rosenbaum S, Morelli A, Guyatt GH, Oxman AD; GRADE Working Group. GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices. 1: Introduction. BMJ. 2016 Jun 28;353:i2016. doi: 10.1136/bmj.i2016. PubMed PMID: 27353417.

 

Alonso-Coello P, Oxman AD, Moberg J, Brignardello-Petersen R, Akl EA, Davoli M, Treweek S, Mustafa RA, Vandvik PO, Meerpohl J, Guyatt GH, Schünemann HJ; GRADE Working Group. GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices. 2: Clinical practice guidelines. BMJ. 2016 Jun 30;353:i2089. doi: 10.1136/bmj.i2089. PubMed PMID: 27365494.

 

Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, Fervers B, Graham ID, Grimshaw J, Hanna SE, Littlejohns P, Makarski J, Zitzelsberger L; AGREE Next Steps Consortium. AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ. 2010 Dec 14;182(18):E839-42. doi: 10.1503/cmaj.090449. Epub 2010 Jul 5. Review. PubMed PMID: 20603348; PubMed Central PMCID: PMC3001530.

 

Hultcrantz M, Rind D, Akl EA, Treweek S, Mustafa RA, Iorio A, Alper BS, Meerpohl JJ, Murad MH, Ansari MT, Katikireddi SV, Östlund P, Tranæus S, Christensen R, Gartlehner G, Brozek J, Izcovich A, Schünemann H, Guyatt G. The GRADE Working Group clarifies the construct of certainty of evidence. J Clin Epidemiol. 2017 Jul;87:4-13. doi: 10.1016/j.jclinepi.2017.05.006. Epub 2017 May 18. PubMed PMID: 28529184; PubMed Central PMCID: PMC6542664.

 

Medisch Specialistische Richtlijnen 2.0 (2012). Adviescommissie Richtlijnen van de Raad Kwalitieit. http://richtlijnendatabase.nl/over_deze_site/over_richtlijnontwikkeling.html

 

Neumann I, Santesso N, Akl EA, Rind DM, Vandvik PO, Alonso-Coello P, Agoritsas T, Mustafa RA, Alexander PE, Schünemann H, Guyatt GH. A guide for health professionals to interpret and use recommendations in guidelines developed with the GRADE approach. J Clin Epidemiol. 2016 Apr;72:45-55. doi: 10.1016/j.jclinepi.2015.11.017. Epub 2016 Jan 6. Review. PubMed PMID: 26772609.

 

Schünemann H, Brożek J, Guyatt G, et al. GRADE handbook for grading quality of evidence and strength of recommendations. Updated October 2013. The GRADE Working Group, 2013. Available from http://gdt.guidelinedevelopment.org/central_prod/_design/client/handbook/handbook.html.

Zoekverantwoording

Zoekacties zijn opvraagbaar. Neem hiervoor contact op met de Richtlijnendatabase.

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