Context:

Recently, two independent phase III clinical trials published in The Lancet show that immunotherapy can slow the growth of liver cancer in those patients who can’t be treated with surgery. 

Key Highlights of the Study

The EMERALD-1 trial (Phase III) assessed the combination of durvalumab (immunotherapy) and bevacizumab (blood vessel growth blocker) with TACE in 616 global patients.

• Patients received either durvalumab + bevacizumab, durvalumab alone, or a placebo.

Results:

• Durvalumab + bevacizumab delayed liver cancer progression by 6.8 months compared to placebo.
• Durvalumab alone delayed progression by 1.8 months.
• This suggests that combination therapy is more effective. 

The LEAP-012 trial (Phase III) evaluated pembrolizumab (immunotherapy) and lenvatinib (cancer growth blocker) with TACE in 480 global patients.

Results:

• Lenvatinib + pembrolizumab delayed liver cancer progression by 4.6 months compared to placebo.
• This study is the first to show a significant improvement in progression-free survival when combining TACE with systemic therapies.
• It paves the way for a potential new standard of care for liver cancer treatment. 

Significance 

These two trials are significant because they are the first to suggest a potential change in the standard care for liver cancer patients in the last 20 years.

Hepatocellular carcinoma or HCC (a type of cancer where malignant cells grow in the liver’s main cells, called hepatocytes) accounts for the vast majority of liver cancer cases and is one of the leading causes of cancer deaths globally. 

• According to available data, the incidence rate of HCC in India for men “ranges from 0.7 to 7.5 and for women 0.2 to 2.2 per 100,000 population per year.” 

Current Treatment Regimen 

As of now, hepatocellular carcinoma (HCC) is treated by transarterial chemo-embolization (TACE). 

This is a minimally invasive procedure that involves injecting chemotherapy drugs and particles that block blood supply to the tumour through a catheter. 

• Once the particles block blood to the tumour, starving it of oxygen and nutrients, chemotherapy drugs reach it in higher concentrations for a longer period of time, which can kill more cancer cells.

Six immunotherapy options for liver cancer have been approved by the US FDA.

• Immunotherapy can boost the immune system to fight cancer, but it may not work well for patients with a history of hepatitis infection. 

Immunotherapy

• A type of therapy that uses substances to stimulate or suppress the immune system to help the body fight cancer, infection, and other diseases. 
• Some types of immunotherapies only target certain cells of the immune system, others affect the immune system in a general way. 
• Types of immunotherapy include cytokines, vaccines, bacillus Calmette-Guerin (BCG), and some monoclonal antibodies.

Liver Cancer

Primary liver cancer is a disease in which malignant (cancer) cells form in the tissues of the liver itself. Secondary liver cancer starts outside the liver.

The main types of adult primary liver cancer are 

• Hepatocellular carcinoma (HCC): This type of liver cancer is the third leading cause of cancer-related deaths worldwide.
• Bile duct cancer (cholangiocarcinoma): It occurs when malignant cells develop in the bile ducts.