Machine learning models for predicting liver cancer: a real-world cohort study in China

Liver cancer has high incidence and mortality worldwide, and timely identification is important for improving prognosis. However, prediction models based on routinely available clinical data remain insufficiently evaluated in hospitalized real-world populations. This study aimed to develop and interpret a machine-learning model for liver cancer prediction using multidimensional clinical and laboratory features.

This retrospective real-world cohort included 9,284 hospitalized patients from Hainan General Hospital between January 2020 and December 2023. Patients were divided into a training set (n = 6,426) and an internal validation set (n = 2,858). Seventy-four demographic, clinical, and laboratory variables were collected. Feature selection was performed using least absolute shrinkage and selection operator regression in the training set. Six models were developed: logistic regression, random forest, support vector machine, k-nearest neighbors, extreme gradient boosting (XGBoost), and Elastic Net. Discrimination was assessed primarily using the area under the receiver operating characteristic curve (AUC). Decision curve analysis evaluated clinical net benefit, and SHapley Additive exPlanations (SHAP) were used for model interpretation.

Liver cancer accounted for 48.7% of the training cohort and 48.8% of the validation cohort. LASSO retained 57 nonzero model terms at the minimum-error penalty. XGBoost achieved the highest AUC among all models, with an AUC of 0.909 (95% CI, 0.903-0.915) in the training set and 0.802 (95% CI, 0.788-0.817) in the validation set. At a threshold of 0.5, validation accuracy, sensitivity, specificity, and F1 score were 0.730, 0.758, 0.698, and 0.753, respectively. Decision curve analysis showed that XGBoost provided the greatest net clinical benefit across a broad range of threshold probabilities. SHAP analysis identified serum sialic acid, the aspartate aminotransferase-to-alanine aminotransferase ratio, alkaline phosphatase, basophil percentage, and monocyte-to-lymphocyte ratio as the leading predictors.

XGBoost showed good discrimination and interpretability for liver cancer prediction in a hospitalized real-world cohort using routinely available clinical and laboratory data. The findings support the feasibility of leveraging large-scale inpatient laboratory data for risk-stratification model development. Serum sialic acid, the aspartate aminotransferase-to-alanine aminotransferase ratio, and alkaline phosphatase were important predictors. Prospective validation in outpatient, first-visit, high-risk, and external populations is required before broader clinical or screening application.