BCLC strategy for prognosis prediction and treatment recommendations: The 2026 update

Area of Science:

• Hepatobiliary Surgery
• Medical Oncology
• Clinical Decision-Making

Background:

• The Barcelona Clinic Liver Cancer (BCLC) staging system is a globally recognized standard for hepatocellular carcinoma (HCC) prognostication and treatment allocation.
• Existing guidelines require structured methodologies to manage the clinical complexity inherent in HCC patient care.
• Integrating recent scientific advances into clinical practice necessitates a framework that balances evidence-based recommendations with individual patient needs.

Purpose of the Study:

• To present the 2025 update of the BCLC staging system for hepatocellular carcinoma.
• To introduce the Complexity, Uncertainty, Subjectivity, and Emotion (CUSE) framework into clinical decision-making for HCC.
• To provide a cohesive, evidence-based approach for prognostication and treatment allocation in HCC, emphasizing patient-centered care.

Main Methods:

• The 2025 BCLC update maintains its stage-linked, evidence-based treatment approach.
• Incorporation of the CUSE framework to guide multidisciplinary tumor boards in decision-making.
• The CUSE framework facilitates a structured, iterative process for defining therapeutic goals, grading options, and aligning choices with patient values and context.

Main Results:

• The updated BCLC algorithm provides a clear link between HCC stage and evidence-based first-line treatments.
• The CUSE framework offers a systematic method to address complexity, uncertainty, and patient-specific factors in treatment planning.
• The integration of CUSE promotes shared decision-making, aligning treatment with patient goals, comorbidities, and feasibility.

Conclusions:

• The 2025 BCLC update refines HCC management by incorporating recent advances within a simple, evidence-based framework.
• The CUSE framework enhances the BCLC approach by embedding patient-centeredness and structured handling of uncertainty into clinical decision-making.
• These updates provide crucial guidance for clinicians, tumor boards, and guideline developers, improving the management of complex HCC cases and fostering iterative treatment planning.