Treatment-stage migration maximizes survival outcomes in patients with hepatocellular carcinoma treated with sorafenib: an observational study

Abstract

Background: Level I evidence supports the use of sorafenib in patients with Barcelona Clinic Liver Cancer (BCLC) stage C hepatocellular carcinoma, where heterogeneity in efficacy exists due to varying clinicopathologic features of the disease. Aim: We evaluated whether prior treatment with curative or locoregional therapies influences sorafenib-specific survival. Methods: From a prospective data set of 785 consecutive patients from international specialist centres, 264 patients (34%) were treatment naïve (TN) and 521 (66%) were pre-treated (PT), most frequently with transarterial chemoembolization (n = 413; 79%). The primary endpoint was overall survival (OS) from sorafenib initiation with prognostic factors tested on uni-and multivariate analyses. Results: Median OS for the entire cohort was 9 months; the median sorafenib duration was 2.8 months, with discontinuation being secondary to progression (n =

Therapeutic hierarchy in hepatocellular carcinoma: A dispute of evidence versus practice

“…One of the key arguments brought in support of a hierarchical treatment allocation is the discrepancy or poor adherence between “real life decisions” and treatment recommendations defined within guidelines. Variation in treatment choices is certainly acknowledged not only in clinical practice but also in treatment guidelines, where concepts like that of “treatment‐stage migration” demonstrate the non‐dogmatic nature of evidence by favouring an expanded use of treatments such as loco‐regional therapies in early‐stage disease or sorafenib in intermediate HCC extrapolating from level I evidence derived in more advanced stages . However, even when recommendations become more fluid, it cannot be forgotten that the mechanism by which each treatment modality has become established in HCC relies strongly on a process of stringent ‘a priori’ categorisation of the disease: an example for all can be found in the Milan criteria, which have made liver transplantation for HCC feasible through restriction of its use in a patient population selected for key pathologic traits …”