Appointment sheet
Advanced hepatocellular carcinoma (BCLC C)
Prepared with OnCo (onco.cc/prep/hcc-advanced/). Orientation, not medical advice; your team knows your case.
My details
Name
Date of appointment
Hospital and clinician
Who is coming with me
What I know, what is unclear, changes to discuss
Saved in this browserWhat I know so far
What is unclear to me
Changes since last time
My questions
20 on the sheetNewly diagnosed
- 1.What is my exact diagnosis, stage, and grade, and which tests established them?
- 2.Which biomarkers have been tested on my tumour (for example Child-Pugh A and ALBI grade, Alpha-fetoprotein 400 or above, Portal vein tumour thrombus extent, Varices on endoscopy before bevacizumab, Hepatitis B DNA and antiviral cover), and what were the results?
- 3.Which subtype is my cancer, and does that change the recommended treatment?
- 4.Is germline (inherited) genetic testing recommended for me or my family?
First line
- 5.For my situation (first line), which of the standard options do you recommend and why?
- 6.Am I a candidate for Atezolizumab, Bevacizumab, Durvalumab or related drugs, and what side effects should I expect?
- 7.How do the results of IMbrave150 and HIMALAYA apply to someone like me?
First line when immunotherapy is unsuitable
- 8.For my situation (first line when immunotherapy is unsuitable), which of the standard options do you recommend and why?
- 9.Am I a candidate for Lenvatinib, Sorafenib, and what side effects should I expect?
- 10.How do the results of REFLECT and SHARP apply to someone like me?
Second line and beyond
- 11.For my situation (second line and beyond), which of the standard options do you recommend and why?
- 12.Am I a candidate for Regorafenib, Cabozantinib, Ramucirumab or related drugs, and what side effects should I expect?
- 13.How do the results of RESORCE and CELESTIAL apply to someone like me?
Portal vein tumour thrombus
- 14.For my situation (portal vein tumour thrombus), which of the standard options do you recommend and why?
Liver disease during treatment
- 15.For my situation (liver disease during treatment), which of the standard options do you recommend and why?
Any stage
- 16.Are there clinical trials I could join, for example of CheckMate 9DW, Camrelizumab + rivoceranib, Ivonescimab, Livmoniplimab?
- 17.Would a second opinion at a high-volume centre change anything, and can you help arrange it?
- 18.What supportive care (symptom control, nutrition, exercise, mental health, financial help) is available from the start?
- 19.I read that “No trial has defined the best drug after progression on immunotherapy”. How does that affect my plan?
- 20.I read that “Patients with Child-Pugh B liver function are excluded from trials yet make up a large share of the clinic”. How does that affect my plan?
The words I may hear
- Child-Pugh score: A score of how well a damaged liver is still working, from five simple measures (bilirubin, albumin, clotting, fluid in the abdomen, confusion).
- Hepatitis B and C as cancer causes: Two viruses cause most liver cancer worldwide.
- Portal vein tumour thrombus (macrovascular invasion): Liver cancer growing into the main vein that brings blood from the gut to the liver.
- Alpha-fetoprotein (AFP): Alpha-fetoprotein is a protein made by the fetal liver that a substantial share of hepatocellular carcinomas switch back on.
Tests and results to bring
Biomarker results to ask for: Child-Pugh A and ALBI grade (eligibility for all trials), Alpha-fetoprotein 400 or above (ramucirumab), Portal vein tumour thrombus extent, Varices on endoscopy before bevacizumab, Hepatitis B DNA and antiviral cover, Aetiology (viral versus non-viral) as a possible modifier of immunotherapy benefit.
Scans and tests linked to this cancer: MRD / molecular residual disease testing.
Bring copies of scan reports, pathology and blood results, and a list of every medicine and supplement.
The treatments I may be offered
- First line: Atezolizumab with bevacizumab (IMbrave150) after endoscopic assessment of varices, or durvalumab with a single dose of tremelimumab (HIMALAYA); nivolumab with ipilimumab (CheckMate 9DW) where approved. (IMbrave150, HIMALAYA, CheckMate 9DW, Atezolizumab, Bevacizumab, Durvalumab, Tremelimumab, Nivolumab, Ipilimumab, Child-Pugh score)
- First line when immunotherapy is unsuitable: Lenvatinib (REFLECT) or sorafenib (SHARP), for example after liver transplantation or with active autoimmune disease. (REFLECT, SHARP, Lenvatinib, Sorafenib)
- Portal vein tumour thrombus: Radiotherapy or radioembolisation to the thrombus alongside systemic therapy; hepatic artery infusion chemotherapy in Asian centres. (Portal vein tumour thrombus (macrovascular invasion), SBRT / SABR (stereotactic radiotherapy), Radioembolisation (TARE / SIRT, yttrium-90))
- Liver disease during treatment: Antiviral therapy for hepatitis B, variceal management and monitoring of liver function, which decides whether further lines are possible. (Hepatitis B and C as cancer causes, Child-Pugh score)
- Second line and beyond: Lenvatinib or sorafenib after immunotherapy; regorafenib (RESORCE), cabozantinib (CELESTIAL) or ramucirumab when alpha-fetoprotein is 400 or above, all proven after sorafenib. (RESORCE, CELESTIAL, Regorafenib, Cabozantinib, Ramucirumab, Lenvatinib, Sorafenib, Alpha-fetoprotein (AFP))
From the standard of care recorded for this cancer; which apply depends on your stage and biomarkers. Ask which the team recommends and why.
Answers and next steps
Saved in this browserWhat I was told
Agreed next steps, dates and who to call