A proposed five-step simplified algorithm for the management of hepatocellular carcinoma in India

Hepatocellular carcinoma (HCC) is the eighth-most frequent cause of cancer mortality in India. The staging system most often used for treatment decisions in India is the Barcelona clinic liver cancer (BCLC) system. However, this staging system is often criticised for several reasons, such as heterogeneity of patient prognosis in each BCLC stage, limited guidance on expanding the role of liver transplantation (LT), no recommendation on combination therapies, no guidance on downstaging and limited treatment options for late presenters (stages C or D). Hence, we propose a simplified five-step algorithm for making treatment decisions for HCC patients in India. This algorithm incorporates evidence-based treatment allocations based on the step-by-step assessment of major prognostic and treatment-related parameters. The five steps of the algorithm are – Step 1: assessment of performance status, Step 2: assessment of extrahepatic spread and macrovascular invasion, Step 3: assessment for living donor LT, Step 4: assessment for the eligibility of liver resection and Step 5: assessment for appropriate locoregional therapy. Each of these steps does not require any separate investigations, and the initial workup for the diagnosis of HCC (dynamic computed tomography/magnetic resonance imaging and routine laboratory tests) would suffice in this five-step algorithm. We hope that this algorithm will not only simplify the management approach to HCC patients in India, but also it will bring uniformity in the treatment protocol for HCC in India.