Prognosis of advanced hepatocellular carcinoma: comparison of three staging systems in two French clinical trials

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Abstract
Objective: The objective of this study was to assess the performance of three staging systems [Okuda, Cancer of the Liver Italian Program (CLIP) and Barcelona Clinic Liver Cancer group (BCLC)], for predicting survival in patients with hepatocellular carcinoma (HCC) and to explore how to improve prognostic classification among French patients with HCC whose main etiology is alcoholic cirrhosis. Methods: We have pooled two randomized clinical trials in palliative condition from the Fédération Francophone de Cancerologie Digestive. They had included 416 and 122 patients. Performances of Okuda, CLIP and BCLC scores have been compared using Akaike information criterion, discriminatory ability (Harrell's C and the Royston's D statistics), monotonicity of gradients and predictive accuracy (Schemper statistics Vs). To explore how to improve classifications, univariate and multivariate Cox model analyses were carried out. Results: The pooled database included 538 patients. The median survival was 5.3 months (95% confidence interval 4.6–6.2). For all statistics CLIP staging system had a better prognostic ability. Performances of all staging systems were rather disappointing. World Health Organization performance status (WHO PS) for CLIP or α-fetoprotein for BCLC allowed a significant improvement of prognostic information. Conclusion: Our results indicate that CLIP staging seems to be most adapted to palliative setting and that it could be better by associating WHO PS.