Performance status in patients with hepatocellular carcinoma: determinants, prognostic impact, and ability to improve the Barcelona Clinic Liver Cancer system.
Performance status is included in the Barcelona Clinic Liver Cancer (BCLC) system for hepatocellular carcinoma (HCC). Few studies specifically evaluated the role of performance status in patients with HCC. This study investigated its distribution, determinants, and prognostic impact, aiming to improve the performance of the BCLC system. A total of 2,381 HCC patients were enrolled. Performance status was determined according to the Eastern Cooperative Oncology Group scale. The prognostic ability of the original and three modified BCLC systems in HCC patients was compared by the Akaike information criterion (AIC). There were 60, 17, 11, 8, and 4% of patients who were classified as performance status 0, 1, 2, 3, and 4, respectively. A worse performance status significantly correlated with age, alcoholism, hypoalbuminemia, hyperbilirubinemia, renal insufficiency, hyponatremia, and prothrombin time prolongation (all P < 0.001). Larger tumor burden, poorer residual liver function, more frequent vascular invasion, and diabetes mellitus were also observed in patients with worse performance status (all P < 0.001). Patients with poorer performance status more often received best supportive care (P < 0.001). In the Cox proportional hazards model, performance status was an independent prognostic predictor and the long-term survival tended to be worse in patients with progressively poor performance status (all P < 0.05). Reassigning patients with performance status 0 or 1 to stage B provided the lowest AIC among the four BCLC-based staging systems.


CONCLUSIONS
Performance status is strongly associated with both tumoral and cirrhotic factors and accurately predicts long-term survival in HCC patients. Modification of the BCLC system based on performance status may further enhance its prognostic ability in patients with early to advanced cancer stage.
Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan.
Chia-Yang
CY
Hsu
Yun-Hsuan
YH
Lee
Cheng-Yuan
CY
Hsia
Yi-Hsiang
YH
Huang
Chien-Wei
CW
Su
Han-Chieh
HC
Lin
Rheun-Chuan
RC
Lee
Yi-You
YY
Chiou
Fa-Yauh
FY
Lee
Teh-Ia
TI
Huo
D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000401:mortality* / Q000473:pathology; D005260:Female; D006801:Humans; D008113:Liver Neoplasms / Q000401:mortality* / Q000473:pathology; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D011379:Prognosis; D012189:Retrospective Studies; D012720:Severity of Illness Index; D016019:Survival Analysis; D013624:Taiwan / Q000453:epidemiology