Management of patients with unresectable HCC: A simulation-based assessment of medical oncologists’ practice choices

Abstract

Introduction: For the first time in a decade the hepatocellular carcinoma (HCC) treatment algorithm is undergoing significant change, challenging oncologists to assimilate evidence into practice. Methods: A CME certified virtual patient simulation (VPS) was made available via a website dedicated to professional development. The VPS consisted of 2 cases presented in a platform that allows oncologists to assess the patients and choose from an extensive database of diagnostic and treatment possibilities matching the scope and depth of actual practice. Clinical decisions were analyzed using a sophisticated decision engine, and instantaneous clinical guidance (CG) employing evidence-base and faculty recommendations was provided after each decision. Oncologists were allowed to revise each decision point post-CG, if desired. Rationales for clinical decisions were also collected in real time. Data were collected between 11/27/2017 and 2/21/2018. Results: At the time of initial assessment, 76 oncologists, 76% of whom practiced in the community setting, fulfilled the participation criteria for completing the simulation. Assessment of their practice choices revealed: In a patient with newly diagnosed unresectable HCC, only 52% ordered an appropriate regimen. CG led to a 26% increase in evidence-based treatment orders (P=0.004). Sorafenib remained the systemic treatment of choice, with only 10% choosing a different regimen. In a patient whose disease has progressed on sorafenib after 6 months of therapy, only 36% of oncologists prescribed an appropriate regimen. CG resulted in a 36% improvement in evidence-based treatment orders (P<0.001). The primary rationale for the selected treatment differed based on the chosen regimen, disease characteristics (22%) with use of nivolumab to better efficacy for this patient profile (33%) for regorafenib. Less than 50% of oncologists initially ordered side effect counseling in each case. CG resulted in a 14% (P=0.091) and 25% (P=0.013) improvement in case 1 and case 2, respectively. Conclusion: This study, using an immersive VPS, provides access to unique insights into oncologists' real world clinical practices in an evolving HCC treatment landscape and identifies a lack of clarity about identification of the most appropriate regimen for these patients. Our findings demonstrate a continued need to educate oncologists about how to select and prescribe the most appropriate regimen for a patient with HCC.