Advances in the Multidisciplinary
Management of Hepatocellular
Carcinoma: Strategies for
Incorporating Emerging
Immunotherapy Treatment Options
Interim Outcomes ReportMerck & Co., Inc.Grant ID: AAN-170919-044712
Activity Description: Expert faculty Richard Finn, MD, discusses treatment options and strategies in acase-based approach for two patients who have failed conventional therapies and may be candidates for immunotherapy. The activity features an online virtual patient platform that affords clinicians an opportunity to absorb relevant clinical and evidence-based information.
Launch Date: March 30, 2018Expiration Date: March 30, 2019
Credit: 0.50 AMA PRA Category 1 CreditsTM
Sponsored by: The Academy for Continued Healthcare Learning (ACHL)Supported by: An educational grant from Merck & Co., Inc.
Intended Audience: This activity is intended for physicians (oncologists, interventional radiologists,hepatologists) and other clinicians who care for patients with hepatocellular carcinoma (HCC).
Activity link-ACHL Site: http://www.achlcme.org/hccActivity link-myCME Site: http://www.mycme.com/advances-in-the-multidisciplinary-management-of-hepatocellular-carcinoma-hcc-strategies-for-incorporating-emerging-immunotherapy-treatment-options/activity/5347/
Outcomes Methodology: Activity-related changes in clinician knowledge, competence, and practiceswere evaluated by using Level 5 outcomes to determine whether the educational objectives of the activitywere achieved.
Overview
Participation
539 Participants; 142 Certificates (1000-1500 participant guarantee), data as of 8/7/18
Practicing Type
50% Physicians/PA’s; 35% RNs/NPs; 15% Other
Participant Satisfaction
Objectivity and balance rated as good/excellent by 96% of learners
Learning Objectives
98% of learners strongly agree or agree that all learning objectives were met, with an average rating of 3.44/4.0
Faculty
Dr. Finn was highly rated by learners at 3.46/4.0
Executive Summary: Levels 1-2
Executive Summary: Levels 3-4
53% indicated participation in the activity will impact their patient outcomes
63% of learners indicated that their competence increased after participation in this activity
Changes made from this activity will impact 577 to more than 1,464 patients each month
Cost, lack of opportunity (patients), and lack of experience were reported as the most common barriers to implementing changes in practice
Following the activity, learners demonstrated increased knowledge and competence about the use of tyrosine kinase inhibitors as well as immunotherapy treatment options in the management of HCC
Level 1: Participation
20%
30%
13%
22%
15%
Participation by Clinician Type
Physician Assistant
Physician
Nurse Practitioner
Nurse
Other
Participants Certificates
539 142
17%
11%
12%
11%4%
5%
6%
4%
30%
Participation by Specialty
Family Medicine/General Practice
Hematology/Oncology
Internal Medicine
Oncology
Surgery
Cardiology
Gastroenterology/Proctology
Emergency Medicine
Other
Level 2: Learning Objectives
98% of learners strongly agree or agree that all learning objectives were met, with an average rating of 3.44.
Please rate the following objectives to indicate if you are better able to: Analysis of RespondentsRating scale:
4=Strongly Agree;
1=Strongly Disagree
Differentiate the mechanisms of action and scientific rationale of currently available
systemic therapies with the use of immunotherapy approaches in advanced HCC3.52
Discuss the role of new and emerging immunotherapies in current treatment
paradigms for advanced HCC3.42
Review the efficacy, safety and tolerability of emerging agents for advanced HCC
and the management of immune-related adverse events3.42
Evaluate the evolving immunotherapeutic research landscape, including ongoing
studies in earlier stages of disease as well as personalized and locoregional
therapies
3.42
N=133
Level 2: Satisfaction
All aspects of the activity were highly rated with an average of 3.36/4.0.
Overall Evaluation Analysis of Respondents
Rating scale: 4=Excellent; 1=Poor
Scientific rigor 3.42
Effectiveness of teaching method used 3.33
Appropriateness and effectiveness of active learning strategies 3.31
Time allotted for presentation of information 3.36
N=133
99% of learners would recommend this activity to a colleague.
Level 2: Faculty Evaluation
The faculty was rated good or excellent across all areas by 90% of learners, with an average rating of 3.46/4.0
Please rate the faculty on the
criteria listed
Rating scale: 4=Excellent; 1=Poor
Ability to effectively
convey the subject matter
Ability to present
scientifically rigorous
information
Expertise on
subject matter
Richard Finn, MD 3.47 3.43 3.48
N=133
Objectivity & Balance
Activity was perceived as objective, balanced and non-biased.
4%
96%
Did you perceive any bias?
Yes No
47%50%
3%0%
0%
10%
20%
30%
40%
50%
60%
Excellent Good Fair Poor
Rating of objectivity & balance
N=133
Levels 3-4: Pretest vs. Posttest
Physician participants demonstrated improved knowledge and competence in both topics, while performance for immunotherapy use did not improve for other healthcare providers. Additional expanded education for use of
both tyrosine kinase inhibitors and immunotherapy agents in a first- and secondline setting foradvanced HCC would be beneficial to improve more dramatic clinical knowledge and awareness,
particularly for non-physician health care providers.
Topic% Change
Physicians
% Change
NPs/PAs
% Change
Other
REFLECT Study:
TKI Use in Advanced HCC8% 11% -64%
KEYNOTE 224 Study:
Immunotherapy Use in
Advanced HCC
28% 0% -49%
Overview of Correct Responses*
*first attempt responses
Pre=54
Post=44Pre=96
Post=79
Pre=25
Post=14
22%19%
48%
11%18%
23%
52%
7%
0%
20%
40%
60%
80%
100%
A B C D
Physicians Pre=54
Post=44
22% 24%
35%
19%20%27%
39%
14%
0%
20%
40%
60%
80%
100%
A B C D
NPs/PAs Pre=96
Post=79
36%
12%
40%
12%
50%
29%
14%7%
0%
20%
40%
60%
80%
100%
A B C D
Other Pre=25
Post=14
NPs/PAs demonstrated the greatest knowledge improvement on this clinical subtopic, increasing knowledge performance by 11% versus pre-test.As anticipated, physicians demonstrated a relatively high pre-test knowledge; after the educational activity, they exhibited a 8% increased performance.
A. The multi-kinase inhibitor lenvatinib is inferior to sorafenib in both overall survival and progression-free survival.
B. The overall reported adverse events of both lenvatinib and sorafenib are equivalent
C. The multi-kinase inhibitor lenvatinib is not inferior to sorafenib in overall survival but is superior in progression-free survival and objective response rate
D. Sorafenib showed a greater maximum change in tumor size than lenvatinib
For a patient with advanced, unresectable HCC with no prior history of systematic therapy, which of the following statements regarding the use of a multi-kinase inhibitor in a frontline setting is correct based on results of the REFLECT trial?
Levels 3-4: Pretest vs. PosttestREFLECT Study: TKI Use in Advanced HCC
35% 39%
22%
4%
32%
50%
18%
0%0%
20%
40%
60%
80%
100%
A B C D
Physicians Pre=54
Post=44
35%43%
12% 10%
30%
43%
19%
8%
0%
20%
40%
60%
80%
100%
A B C D
NPs/PAs Pre=96
Post=79
24%
56%
16%
4%
36%29% 29%
7%
0%
20%
40%
60%
80%
100%
A B C D
Other Pre=25
Post=14
Physicians showed the greatest knowledge improvement on this topic, increasing knowledge performance by 28% versus pre-test. NPs/PAs stilldemonstrated relatively high pretest performance levels that remained unchanged. Given the new and novel use of immunotherapy agents within this disease
state, it is evident that further education can help to increase awareness and knowledge of these emerging agents as part of newtreatment paradigms that in turn can translate to better clinical understanding and utilization for appropriate patients.
When used as second-line immunotherapy treatment option, which of the following checkpoint inhibitors has been shown in the KEYNOTE 224 study to demonstrate a significant change in tumor lesion size in both HBV and HVC patients with advanced HCC?
A. Nivolumab
B. Pembrolizumab
C. Durvalumab
D. Avelumab
Levels 3-4: Pretest vs. PosttestKEYNOTE 224 Study: Immunotherapy Use in Advanced HCC
Level 4: Practice Change
56% of learners will change their practice!
44%
10%
37%
26%
0% 10% 20% 30% 40% 50%
This activity validated my currentpractice; no changes will be made
Other changes
Change the management and/ortreatment of my patients
Create/revise treatment protocols,policies, and/or procedures
N=133; multiple responses allowed; other changes found in appendix
Polling Question – Patient Case 1
If or when approved, how confident are you in using immunotherapies in clinical practice for advanced HCC patients in a frontline setting?
63% of learners indicated low confidence in immunotherapy agents while 48% indicated low likelihood of use in a firstline setting.Given the practice-changing impact that immunotherapy will likely yield in the treatment of advanced HCC disease, it is imperative to
increase depth and breadth of education across clinician types to ensure better patient outcomes through immunotherapiesand to promote greater confidence and likeliness of use in the clinic among all health care providers.
N=54
41%
22%
26%
11%
0% 10% 20% 30% 40% 50% 60%
Not at all confident
Somewhat confident
Moderately confident
Very confident
Looking beyond current frontline treatments for advanced HCC, and given acceptable efficacy, safety and tolerability, how likely are you to employ immunotherapies for HCC treatment if or when approved?
23%
15%
27%
35%
0% 10% 20% 30% 40% 50% 60%
Not at all likely
Somewhat likely
Moderately likely
Very likely N=26
Polling Question – Patient Case 2
How suitable do you consider this patient to treat with an immunotherapy such as a checkpoint inhibitor assecond-line treatment?
While 63% of learners consider an advanced HCC patient suitable for treatment with a checkpoint inhibitor in a secondline setting,55% indicated likeliness to utilize it for treatment. Additional education emphasizing the safety and tolerability of these agents is
imperative to ensure routine and robust clinical utilization for appropriate patients.
N=52
4%
33%
40%
23%
0% 10% 20% 30% 40% 50% 60%
Not at all suitable
Somewhat suitable
Moderately suitable
Very suitable
In considering both efficacy and safety, how likely are you to use an approved immunotherapy such as a checkpoint inhibitor as second-line treatment on this patient?
15%
30%
25%
30%
0% 10% 20% 30% 40% 50% 60%
Not at all likelySomewhat likelyModerately likely
Very likely N=20
8%
8%
53%
31%
Not at all
Often
Very Often
Always
0% 10% 20% 30% 40% 50% 60%
Follow-up Survey
Since completing the activity, how often have you utilized checkpoint inhibitors for second-line treatment of a patient with advanced HCC who has progressed post-sorafenib?
84% of learners have always, or very often, utilized checkpoint inhibitors for second-line treatmentof a patient with advanced HCC who has progressed post-sorafenib.
N=13
0%
0%
46%
38%
16%
Not confident at all
Not very confident
Somewhat confident
Very confident
Extremely confident
0% 10% 20% 30% 40% 50% 60%
Follow-up Survey
Since completing the activity, how confident are you in selecting immunotherapy for your patients with HCC in the second-line setting and if/when approved in the first-line setting?
After participating in this activity, 54% of learners indicate that they are extremely or very confidentin selecting immunotherapy for their patients with HCC in the second-line setting and if/when approved
in the first-line setting. Additional education elaborating on the most recent data released from clinical trialscan help to bolster and enthuse greater confidence for immunotherapy agents.
N=13
8%
46%
31%
15%
Cluster of differentiation 152 (CD152)
Cytotoxic T-lymphocyte associated antigent4 (CTLA-4)
Programmed cell death-ligand 1 (PD-L1)
Programmed cell death protein 1 (PD-1)
0% 10% 20% 30% 40% 50% 60%
Follow-up Survey
Pembrolizumab, an immunotherapy under investigation for HCC in the first-line setting and approved for use in the second-line setting, is an antibody against:
Although survey responses were small, greater awareness of pembrolizumab as a PD-1 blocker is needed, particularly as it offers the prospect to transform treatment of advanced disease in both treatment setting.
N=13
Follow-up Survey
In the time since your participation in this activity, where do you feel immunotherapy will have a compelling clinical impact in the treatment of advanced HCC?
55% of learners indicated that they feel immunotherapy will have a compelling clinical impact inboth first and second-line therapy. Further education can help shift such perspective to even more positive levels in
line with expectations arising from promising clinical trial data.
N=13
15%
15%
15%
55%
0% 10% 20% 30% 40% 50% 60%
I haven't implemented immunotherapy into my practices
As a second-line therapy
As a first-line therapy
In both first- and second- line therapy
0%
0%
50%
50%
Not at all
Often
Very often
Always
0% 10% 20% 30% 40% 50% 60%
Follow-up Survey
In the REFLECT clinical trial, the multi-kinase inhibitor lenvatinib showed superiority in progression-free survival and objective response rate over sorafenib in patients with advanced, unresectable HCC with no prior history of systematic therapy. How likely are you to use lenvatinib in a frontline setting for such patients?
N=4
Following this educational activity, 100% of respondents are willing to usethe TKI lenvatinib in a frontline setting for advanced HCC patients.
Level 5: Follow-up Survey
N=4
Please list 1-2 ways you have changed your practice as a result of attending this activity:
• Discussing immunotherapy options with my colleagues and patients
• Feeling better informed about this medication, thank you!
• Discussed more ways to increase patient compliance
Following this educational activity, positive feedback regarding immunotherapy use in HCC was observed.
Activity Impact
This activity was highly effective, with 56% of attendees indicating participationin this activity will improve their performance.
Self-reported activity impact Yes No No change
Increase knowledge 81% 6% 13%
Increase competence 63% 11% 26%
Improve performance 56% 12% 32%
Improve patient outcomes 53% 17% 30%
N=133; see comments in appendix
Patient Care Impact
32%55%
5%
6%
2%
Number of patients affected by these changes each month:
0
1-5
6-10
11-20
>20
Changes will impact 577 to more than 1,464 patients each month.This assumes data in chart above is representative of all healthcare professionals in attendance (539), who
indicated they would change their practice as a result of their participation in this activity (56%).
Barriers to Planned Change
22%
2%
11%
2%
5%
13%
23%
20%
8%
9%
29%
0% 5% 10% 15% 20% 25% 30% 35%
No barriers
Other
Lack of resources (equipment)
Lack of consensus or professional guidelines
Lack of administrative support
Reimbursement/insurance issues
Lack of experience
Lack of opportunity (patients)
Lack of time to assess/counsel patients
Patient compliance issues
Cost
Participants indicated cost (29%) as most common barrier to implementing changes in their practice, followed by
lack of experience (23%) and lack of opportunity (patients) (20%). Of those who identified barriers, 44% will
attempt to address the perceived barrier(s) in order to affect change.
N=133; multiple responses allowed
Topics of Interest
17%
35%
38%
43%
0% 20% 40% 60%
Workshop on developing treatment strategies for patients withadvanced HCC
Review of trial data on the use of immunotherapies in a frontlinesetting
Review of new and emerging treatment options in the treatmentof advanced HCC
Review of treatment-related adverse events of immunotherapiesand strategies for their management
Review of treatment-related adverse events of immunotherapies and strategies for their
management was rated with highest interest for future education.
N=133; multiple responses allowed
Contact Information
Greg Paladino
VP, Education Development
Academy for Continued Healthcare Learning (ACHL)
P: 773-714-0705 ext. 200
C: 908-448-9241
Appendix
Levels 3-4: Activity Impact
Self-reported increase in knowledge
• Better understanding of treatment options for HCC
• Conservative approach still a factor
• Emerging data on check-point inhibitors in the treatment
of HCC
• Have had little previous experience with treatment strategies
• I have gained more knowledge in the realm of hepatocellular
carcinomas
• Identifying benefits of drug in HCC setting
• This exercise has taught how better to take better care of my
Hepatitis C patients along with my Hepatologist Specialists
• Strengthened my knowledge on neoadjuvent treatment
• The emerging role of immunotherapy for HCC
• Valuable assessment
• Good quality
• Introduced trials that I was not familiar with
• Better understanding of the drugs used
• Overall survival rate
• New medication, treatment dimension
• Knowledge regarding advance therapy that is available
• Improved knowledge on OS, PFS, and SE
Self-reported increase in competence
• All news about management of this lethal condition is
of interest
• CME is the teacher
• Data on OS and PFS
• More knowledge of drugs being studied
• First and second-line therapies
• As an older family Dr, I feel more comfortable talking with the
patient and the liver specialist about my patient’s condition!
• I learned about new trial of immunotherapy
• More in the treatment algorithm
• Plan future salvaged treatment options
• Treatment options
• New pharmacy info for me
• Better understanding of drug therapy in HCC
• All news about management of this lethal condition is of
interest
Level 5: Activity Impact
Self-reported increase in performance
• Better understanding of drugs and side effects
• Communication skills
• Consider immunotherapy clinical trial for patients
• Refer for treatment
• Therapeutic advantages
• It helps me to understand the Rxs of my oncology colleagues
in the care of HCC patients
• I am a nurse who covers for five different oncology doctors
with all different specialties. This was a good lesson to learn
the multiple medications for alternate diagnoses
• Early therapy
• I will be able to discuss treatment options.
• l will be better able to understand the hepatologist treatment
and better able to counsel my patient!
Self-reported increase in patient outcomes
• Increase outcomes for patients
• More in the treatment armamentarium
• Increase OS for HCC patients
• Increased DFS
• I will be better able to interact with the patient and the
hepatologist by understanding the guidelines from the
hepatologist
• Providing better choices in the treatment of HCC
• They will improve and get better
• Treatment options
• It will make me a more effective partner with my oncology
and radiation rx colleages to accomplish best outcomes
