Liver cancer experts at the Johns Hopkins Kimmel Cancer Center and 16 other cancer centers have compiled new guidance on the best treatments for hepatocellular carcinoma (HCC) in North America. The resource, called BEACON-HCC, was published Aug. 7 in the journal Hepatology by HCC-LIVE , a consortium of North American experts in HCC.
BEACON-HCC spells out treatment recommendations, supported by data from the medical literature, for each stage of HCC. It incorporates the degree of tumor burden, invasion into the vascular system, tumor biology and more to align treatment allocation with the practices of HCC experts in North America. BEACON-HCC incorporates emerging modalities such as external beam radiation therapy, a treatment that uses high energy beams of radiation to shrink or destroy cancer cells; transarterial radioembolization, a minimally invasive therapy that delivers radioactive beads directly into the blood vessels feeding a tumor; and novel combination therapies that work throughout the body and specifically target the tumors.
For nearly 30 years, clinicians around the world have relied on the Barcelona Clinic Liver Cancer (BCLC) staging and treatment allocation system, says BEACON-HCC co-author Mark Yarchoan, M.D. , an associate professor of oncology at the Johns Hopkins University School of Medicine. However, the treatment landscape for HCC has changed dramatically, necessitating new systems, he says: "The BCLC does not elevate all of the treatment paradigms that we have available to us, and promotes treatment decisions that are somewhat different from how we have practiced at our institution."
"HCC management is a complex multidisciplinary effort due to disease biology and the variety of treatment options," adds co-author Jeffrey Meyer, M.D. , an associate professor of radiation oncology and molecular radiation sciences at the Johns Hopkins University School of Medicine. "We wanted to lay out these issues and marshal together different approaches for each stage of the disease, reflecting our practices at Johns Hopkins and other centers."
The idea for BEACON-HCC arose as Yarchoan, Meyer and colleagues at Johns Hopkins recognized that their management of patients with HCC was increasingly diverging from the BCLC recommendations. "For example, BCLC classifies tumors that invade the blood vessels as advanced disease and recommends systemic therapy alone," Yarchoan says. "But in the modern treatment era, vascular invasion does not necessarily mean that remission is out of reach. In a prospective clinical trial at Johns Hopkins, we showed that selected patients with vascular invasion could still undergo potentially curative resection."
Meyer points to radiation as another example. Earlier versions of the BCLC did not recognize radiation as a major treatment option, but high-level clinical trial data now show that it can play "a very meaningful role" in HCC management, he says, either as the primary treatment or in combination with other therapies.
The team began reaching out to other experts in the U.S. who were making similar observations and decided to write its own guidance, a process that took nearly two years.
The 20 co-authors validated BEACON-HCC in two ways. First, they pulled 29 de-identified patient cases from their institutions. Each submission included brief clinical information and tumor imaging. All co-authors independently reviewed each case and selected their recommended initial treatment approach from options such as surgical resection, liver transplantation and other therapies. They also shared the same cases with 18 North American HCC clinical experts who were not involved in the development of BEACON-HCC to get their feedback on the best course of treatment. Then, they compared the percentage of agreement of both groups with BEACON-HCC recommendations and BCLC 2025 treatment recommendations. The experts' treatment decisions were 96.6% in alignment with the BEACON-HCC recommendations but only 72.4% in agreement with the BCLC recommendations.
"Our hope was to explain to the broader community how we currently manage HCC in our own multidisciplinary clinic," Yarchoan says. "Hopefully, it can influence the way that people think about this cancer."
HCC is the third-leading cause of cancer-related death worldwide and the leading cause of cancer-related death in patients with cirrhosis. The five-year survival for HCC remains below 25% despite improvements in screening and treatment.
BEACON-HCC provides a framework to consider each patient at their stage and appreciate all of the different treatment options that are available, says Meyer. "It summarizes what we have available but also recognizes some of the outstanding questions for patients," he says. "I think it will help provide a good framework for tumor board and multidisciplinary clinic discussions."
"As systemic and locoregional therapies continue to evolve, BEACON-HCC provides a dynamic, adaptable framework that can grow alongside our expanding therapeutic armamentarium for HCC," says Marina Baretti, M.D. , an assistant professor of oncology and the Jiasheng Chair in Hepato-Biliary Cancer Research at the Johns Hopkins University School of Medicine. Baretti, co-director of the Liver and Biliary Cancer Multidisciplinary Clinic at the Kimmel Cancer Center, was one of the experts who helped validate the tool. "What excites me most about BEACON-HCC is that it reflects the reality of multidisciplinary HCC care: No single factor determines treatment, and a classification system should reflect that complexity, while remaining practical and clinically actionable."
Study co-authors were from UT Southwestern Medical Center in Dallas; UCLA in Los Angeles; University of Toronto in Canada; USC in Los Angeles; NYU Langone Health in New York City; Mayo Clinic in Rochester, Minnesota; University of California, San Francisco; University of Michigan in Ann Arbor; University of Chicago; Northwestern University in Chicago; Hospital Universitario Vall d'Hebron in Barcelona, Spain; University Health Network in Toronto, Canada; and Mount Sinai Medical Center in New York City.
Meyer has sponsored research support from Razyebio to the institution and royalties from UpToDate and Springer. Yarchoan receives grants and/or research support to Johns Hopkins from Bristol Myers Squibb, Genentech and Incyte. He is a consultant for AstraZeneca, Genentech, Incyte, Boehringer Ingelheim, Boston Scientific and Bristol Myers Squibb. Yarchoan also is a co-inventor on multiple filed and licensed patents related to cancer vaccines (assigned to and managed by Johns Hopkins) and is a co-founder of and holds ownership interest in Adventris Pharmaceuticals, a private biopharma company focused on therapeutic cancer vaccines. These relationships are managed by The Johns Hopkins University in accordance with its conflict-of-interest policies.
