Real-world BCLC adherence and survival in hepatocellular carcinoma: first prospective study from Central America

Hepatocellular carcinoma (HCC) is a major global health concern. The Barcelona Clinic Liver Cancer (BCLC) staging system provides evidence-based therapeutic guidance, yet real-world adherence remains suboptimal, particularly in underrepresented regions. This study aimed to evaluate adherence to 2022 BCLC first-line treatment recommendations and associated survival outcomes in a prospective cohort from Costa Rica, the first such study in Central America.

A total of 260 patients diagnosed with HCC between September 2018, and June 2024 were prospectively enrolled at a national liver transplant center. Clinical, tumor, and treatment characteristics were recorded. Adherence was defined as concordance with BCLC stage-specific first-line recommendations. Survival and predictors of adherence were analyzed using Kaplan-Meier curves and multivariate logistic regression.

Overall adherence to BCLC first-line recommendations was 47.8 %, varying by stage: 44.9 % (BCLC 0/A), 53.7 % (B), 23.1 % (C), and 93.5 % (D) (p < 0.001). Adherent patients had significantly longer median survival (722 vs. 535 days; p = 0.001). Adherence conferred survival benefit in BCLC 0/A (1404 vs. 807 days; p = 0.005) and C (492 vs. 168 days; p = 0.029). Child-Pugh B/C (aOR: 3.82; p < 0.001) and ECOG > 0 (aOR: 5.04; p = 0.022) were associated with adherence, while stages B, C, and D were inversely associated.

Adherence to BCLC guidelines significantly improves survival in HCC, especially in early and advanced stages. Functional status and liver disease severity were key adherence predictors. Targeted strategies are needed to improve guideline implementation in Central America and other resource-limited settings.