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Modified Charlson Comorbidity Index to Improve Management of Patients with Hepatocellular Carcinoma: A Step Towards
Eleonora Alimenti1, Massimo Iavarone1,2, Elia Fracas3
1Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy.
Insights
A modified Charlson Comorbidity Index (mCCI) better stratifies hepatocellular carcinoma (HCC) patients by risk, improving treatment allocation and predicting survival. This refined comorbidity assessment aids in personalized HCC therapeutic strategies.
Area of Science:
- Hepatology and Oncology
- Clinical Epidemiology
- Biostatistics
Background:
- Hepatocellular carcinoma (HCC) patients often have comorbidities complicating treatment and increasing mortality.
- The standard Charlson Comorbidity Index (CCI) may not accurately reflect comorbidity burden in HCC.
- A modified CCI (mCCI) excluding HCC-specific factors was developed to improve risk stratification.
Purpose of the Study:
- To evaluate the performance of the CCI and mCCI in stratifying HCC patients.
- To assess the ability of mCCI to predict treatment allocation and overall survival (OS).
- To identify predictors of mortality in HCC patients using mCCI.
Main Methods:
- Retrospective analysis of 401 de novo HCC patients.
- Calculation of CCI and mCCI at diagnosis.
- Kaplan-Meier analysis for OS and Cox models for mortality prediction; association between mCCI and treatment allocation analyzed.
Main Results:
- mCCI provided better risk stratification than CCI, categorizing patients into high-risk (21%), intermediate-risk (48%), and low-risk (31%).
- High-risk mCCI was associated with reduced access to curative treatment in BCLC B patients (14% vs. 47%).
- mCCI demonstrated a strong correlation with survival, with significantly shorter OS in high/intermediate-risk groups (36-49 months) vs. low-risk (74 months).
- mCCI classes, alpha-fetoprotein, CPT, and BCLC stage were independent predictors of mortality. Age and cardiovascular diseases were significant mCCI components impacting mortality.
Conclusions:
- The mCCI offers a more accurate comorbidity assessment for HCC patients compared to the standard CCI.
- mCCI is significantly associated with overall survival in HCC.
- mCCI can aid in developing personalized therapeutic strategies for HCC patients.
Abstract:
Background and aims: Hepatocellular carcinoma (HCC) patients frequently present with comorbidities that limit therapeutic options and increase mortality. This study evaluated the performance of the Charlson Comorbidity Index (CCI) and a modified CCI (mCCI) in stratifying patients with HCC to predict treatment allocation and survival. Methods: A retrospective single-center cohort study analyzed 401 patients with de novo HCC (74% male, median age 68 years, 80% Child-Pugh-Turcotte (CPT) A, 65% viral etiology, 70% Barcelona Clinic Liver Cancer stage (BCLC) 0/A). CCI and mCCI (with points related to HCC and chronic liver disease excluded), were calculated at diagnosis for each patient. The primary endpoint was overall survival (OS) estimated by Kaplan-Meier method and compared across mCCI classes; Cox uni/multivariable models were applied to identify predictors of mortality. The secondary aim was evaluating the association between mCCI and treatment allocation. Results: While CCI classified 94% of patients as "high-risk", mCCI reclassified patients into "high-risk" (21%), "intermediate-risk" (48%), and "low-risk" (31%), demonstrating better stratification whilst maintaining a strong correlation with CCI (Kendall's tau-b = 0.57, p < 0.001). BCLC B patients with "high-risk" mCCI exhibited significantly lower access to first-line curative treatment (14% vs. 47%, p = 0.03). Moreover, "high" or "intermediate-risk" patients according to mCCI experienced significantly shorter OS compared to "low-risk" (median OS 36 vs. 49 vs. 74 months, p < 0.001). "High-risk" and "intermediate-risk" mCCI classes were independent predictors of mortality, alongside alpha-fetoprotein, CPT and BCLC stage. Considering the items composing mCCI, age and cardiovascular diseases were independent predictors of mortality. Conclusions: mCCI provides a more accurate assessment of comorbidities than the standard CCI and is associated with survival, hence it can contribute to designing patient-tailored therapeutic strategies.
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