Expert Discusses What Advances to Expect in Liver Cancer

In order to advance the field of liver cancer treatment, it is crucial to understand personalized medicine and navigate the controversies around neoadjuvant treatment, says Michael Choti, M.D.

In an interview with CURE, Choti, professor and chair of surgery, UT Southwestern Medical Center, discusses the importance of biomarkers when it comes to choosing treatments, which treatments to choose for certain patients with GI cancer, and the improvement of systemic therapy.

Can you share some key points on liver-directed therapy?

This is a focus that is part of the School of GI Oncology to really emphasize the fact that cancer of liver, often metastatic to the liver, is a common pattern. Often it's an area that is probably associated with a complex management that involves medical oncologists, radiation oncologists, imaging, gastroenterology and even interventional radiology. The reason we have this as a particular focus of this course is that management of patients with liver metastases is often complex and often very multidisciplinary.

Are there any advances in managing liver cancer on the horizon?

There are significant advances that are happening. First, globally, just understanding personalized medicine and understanding better biomarkers to identify which patients may be better candidates for therapy directed to whatever specific organ, like the liver.

If we can understand, for example, prognostic biomarkers that can define which patients can derive benefit for surgical therapy from liver metastases, then that would be very advantageous. We're clearly making advances in that area. Similarly, we may identify better with predictive biomarkers for which patients may do better or worse with liver-directed therapies.

What is the potential for PD-1 inhibitors in liver cancer?

PD-1 inhibitors are a class of immunotherapy. I think that certainly that new class of agents offers a new ability ­ — the ability to treat patients who in the past have not been candidates for systemic therapy.

What do you think we can expect within the next few years, as far as advances in treating liver cancer?

Significant changes are happening in how we treat patients with liver cancer. As a surgical oncologist, we're certainly increasing therapies, techniques, minimally invasive surgery, for example, and other approaches to treat patients more safely, and more aggressively in some cases, for liver cancer and liver metastatic disease. We're also having advances in the area of imaging, in the areas of other liver-directed therapies in terms of arterial approaches, ablation, and other ways.

Of course, systemic therapies are improving, and not only offer better, long-term outcomes for patients, but they may actually increase the opportunity with responses, for example, to immunotherapy or systemic therapies. We may actually be asked to have an increasingly aggressive approach of residual disease in the liver, for example.

In GI cancers in general, how do you decide which patient can receive one therapy and not the other?

The biology of GI cancers can vary, not just by the site of origin, but based on molecular genetics and other patterns based on how patients will do. How we decide on which patients receive which therapy is often multifactorial. It's based on team decisions, multidisciplinary tumor boards, and looking at the biology of the pattern. Not only the choice of which chemotherapy a patient may be offered, but also whether to be offered local therapy or surgical therapy for metastatic disease. Certainly in patients with localized GI cancer, surgical therapy is still the mainstay of curative therapy for patients with gastrointestinal malignancies.

Even with the advances of new agents and new therapies, these are still largely used in patients with incurable forms of cancer. So the ability to offer surgical therapy in patients with localized disease is still there, first and foremost, but there may be increasingly opportunities to offer local or surgical therapies, even in patients with more advanced disease as we're getting better with new systemic therapies.

What is the role of neoadjuvant treatment in liver cancer?

This has been, in the past, very controversial, as to whether to give treatment prior to surgical removal of a patient with cancer of the pancreas. Now that we have more effective systemic chemotherapy in patients with advanced pancreatic cancer, these are being introduced into patients who are operable. There's a clear enthusiasm in recommending pre-operative therapy in patients with operable pancreatic cancer. Clearly, as we're getting better with systemic chemotherapy, it may or may not be a pattern in whether or not we will integrate radiation, if at all, in patients with operable pancreatic cancer.