Hepatocellular Carcinoma: A Rapidly Evolving Treatment Landscape - Episode 3

The BCLC Staging System

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Richard S. Finn, MD: Can you give us a brief overview of the BCLC [Barcelona Clinic Liver Cancer] staging system? There’s early stage, which is 0; there is A, B, C, and then there’s D stage, which is advanced and generally involves supportive care unless the patient could have a transplant.

Pierre Gholam, MD: The Barcelona Clinic Liver Cancer staging system incorporates 3 important components of care in patients who have advanced liver disease and HCC [hepatocellular carcinoma]. There is the staging system, which factors in the extent of disease, the number of lesions, macrovascular invasion, and extrahepatic spread. Those intuitively make sense when you’re treating cancer. There is an ECOG performance status component, which we all know across different tumor types. It’s an important factor in the patient’s ability to be treated, and it carries prognostic value. There is also the Child-Pugh score, which as we’ve just outlined, is critical in determining the patient’s ability to survive based on the presence of liver disease alone as well as their potential ability to tolerate and receive treatment.

Once you factor all those together, you come up with the 0-to-D system. A patient in stage D is someone who has a very poor performance status or very advanced liver disease; therefore, best supportive care is agreed upon to be the best intervention for these patients. A patient in stage 0 is someone who has a very localized lesion for whom in-home therapy could include ablation or surgery. A patient in stage C, which is the domain of systemic therapy historically, is someone who typically has macrovascular invasion or extrahepatic spread but does not have very advanced liver disease and still has an ECOG performance status of 0 or 1. Therefore, this patient could potentially benefit from treatments that might enable them to improve quality of life, and one might argue that it could certainly extend life based on a number of studies in first- and second-line settings.

A patient with BCLC stage B is someone who may have fairly significant liver disease, but it is mostly confined to the liver. There are those we now call the patients with good stage B and bad stage B. Patients with good stage B may have sizable tumors, but they are localized such that that local-regional therapy with TACE [transarterial chemoembolization] and TARE [transarterial radioembolization] or other interventions might be of benefit. The patients with bad stage B are people who have the disease localized to the liver, but it is fairly widespread throughout the liver such that realistically, one would not be able to be expected to apply local regional-therapy for those patients.

Of course, stage A is the domain of definitive therapy in the proper context and someone who might be able to be a candidate for liver transplantation. That’s a very broad and lengthy discussion of what BCLC tells us.

Transcript edited for clarity.