An evaluation of hepatocellular carcinoma practice guidelines from a radiation oncology perspective

External beam radiotherapy (EBRT) is actively used for hepatocellular carcinoma (HCC) treatment in clinical practice but has not got attention in several guidelines owing to the lack of high-level evidences. We evaluated HCC treatment guidelines from the radiation oncology perspective using the Appraisal of Guidelines for Research and Evaluation (AGREE II) model, to provide information to choose suitable guidelines and for future guidelines developments.

Guidelines and consensuses for HCC management involving EBRT that have been published until May 2019 were included. Seven appraisers from 6 countries participated; all were radiation oncologists specialized in HCC. Guidelines were assessed using the AGREE II (December 2017 update), and we added an additional domain, "Radiotherapy Content," to evaluate the fidelity of evidence and participation of relevant specialists. Inconsistency among appraisers was evaluated, and standard deviations (SD) among the average scores of each domain were calculated.

Eighteen guidelines or consensuses were included; 4 of them (NCCN, EASL, AASLD, and KLCSG)* were considered applicable without modification. Overall scores were evenly and significantly affected by all domain scores, with "Rigour of Development" showing the most significant correlation. The median scores were the highest for "Scope and Purpose" (63.9%) and "Clarity of Presentation" (65.7%) and the lowest for "Applicability" (36.1%). Inconsistency among appraisers was higher in "Editorial Independence" (median SD: 1.96) than in other domains.

Although the median overall score was moderate (64.3%), further efforts are necessary as all domains had scores <50% except "Scope and Purpose" and "Clarity of Presentation". Future guidelines need to consider more on "Applicability" because modern HCC treatment requires multidisciplinary approaches involving up-to-date techniques and systemic agents. The independency of development and role of funders should be comprehensively described in future guidelines. *National Cancer Comprehensive Network, European Association for the Study of the Liver, American Association for the Study of the Liver Disease, Korean Liver Cancer Study Group.