Personalised management of patients with hepatocellular carcinoma: a multiparametric therapeutic hierarchy concept.

Advances in the surgical and systemic therapeutic landscape of hepatocellular carcinoma have increased the complexity of patient management. A dynamic adaptation of the available staging-based algorithms is required to allow flexible therapeutic allocation. In particular, real-world hepatocellular carcinoma management increasingly relies on factors independent of oncological staging, including patients' frailty, comorbid burden, critical tumour location, multiple liver functional parameters, and specific technical contraindications impacting the delivery of treatment and resource availability. In this Policy Review we critically appraise how treatment allocation strictly based on pretreatment staging features has shifted towards a more personalised treatment approach, in which expert tumour boards assume a central role. We propose an evidence-based framework for hepatocellular carcinoma treatment based on the novel concept of multiparametric therapeutic hierarchy, in which different therapeutic options are ordered according to their survival benefit (ie, from surgery to systemic therapy). Moreover, we introduce the concept of converse therapeutic hierarchy, in which therapies are ordered according to their conversion abilities or adjuvant abilities (ie, from systemic therapy to surgery).

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Declaration of interests GC declares consulting fees from Bayer, Roche, Ipsen, Merck Sharp & Dohme, Eisai, and AstraZeneca. MI declares consulting fees and honoraria for lectures from Bayer, Bristol Myers Squibb, Gilead Sciences, Roche, Ipsen, Merck Sharp & Dohme, and Eisai. DJP declares grants from Bristol Myers Squibb, Merck Sharp & Dohme, and GlaxoSmithKline; consulting fees from Mina Therapeutics, Eisai, Roche, Avamune, DaVolterra, Mursla, H3B, Ipsen, Exact Sciences, and AstraZeneca; payment for lectures from Roche, Bristol Myers Squibb, and Eisai; participation on advisory boards from Mina Therapeutics, Eisai, Roche, Avamune, DaVolterra, Mursla, H3B, Ipsen, LIfT Biosciences, Exact Sciences, and AstraZeneca. CC declares advisory board and speaker fees from Eisai, Merck Sharp & Dohme, and Ipsen. GG declares honoraria from Roche and Eisai. LC declares consulting fees from AstraZeneca, Biomedical, GEM, and Terumo; and payment for lectures from Angiodynamics, AstraZeneca, Boston, Cascination, Terumo, Varian, and Esaote. EGG declares honoraria for lectures from Eisai, Merck Sharp & Dohme, Roche, and AstraZeneca. FF declares honoraria from Roche and Eisai. FT declares research funding from Roche, AbbVie, Merck Sharp & Dohme, and Bayer; consulting fees and advisory boards from Roche, AstraZeneca, Eisai, and Bayer. All other authors declare no competing interests.