title: Development of Hong Kong Liver Cancer staging system with treatment stratification for patients with hepatocellular carcinoma.
abstract: OBJECTIVE
  We aimed to develop a prognostic classification scheme with treatment guidance for Asian patients with hepatocellular carcinoma (HCC).
  
  
  METHODS
  We collected data from 3856 patients with HCC predominantly related to hepatitis B treated at Queen Mary Hospital in Hong Kong from January 1995 through December 2008. Data on patient performance status, Child-Pugh grade, tumor status (size, number of nodules, and presence of intrahepatic vascular invasion), and presence of extrahepatic vascular invasion or metastasis were included, and randomly separated into training and test sets for analysis. Cox regression and classification and regression tree analyses were used to account for the relative effects of factors in predicting overall survival times and to classify disparate treatment decision rules, respectively; the staging system and treatment recommendation then were constructed by integration of clinical judgments. The Hong Kong Liver Cancer (HKLC) classification was compared with the Barcelona Clinic Liver Cancer (BCLC) classification in terms of discriminatory ability and effectiveness of treatment recommendation.
  
  
  RESULTS
  The HKLC system had significantly better ability than the BCLC system to distinguish between patients with specific overall survival times (area under the receiver operating characteristic curve values, approximately 0.84 vs 0.80; concordance index, 0.74 vs 0.70). More importantly, HKLC identified subsets of BCLC intermediate- and advanced-stage patients for more aggressive treatments than what were recommended by the BCLC system, which improved survival outcomes. Of BCLC-B patients classified as HKLC-II in our system, the survival benefit of radical therapies, compared with transarterial chemoembolization, was substantial (5-year survival probability, 52.1% vs 18.7%; P < .0001). In BCLC-C patients classified as HKLC-II, the survival benefit of radical therapies compared with systemic therapy was even more pronounced (5-year survival probability, 48.6% vs 0.0%; P < .0001).
  
  
  CONCLUSIONS
  We collected data from patients with HCC in Hong Kong to create a system to identify patients who are suitable for more aggressive treatment than the currently used BCLC system. The HKLC system should be validated in non-Asian patient populations and in patients with different etiologies of HCC.
authors.affiliation: Department of Surgery and State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong.
authors.forename: Thomas
authors.initials: T
authors.lastname: Yau
authors.affiliation: Department of Surgery and State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong; Clinical Trials Centre, The University of Hong Kong, Hong Kong.
authors.forename: Vikki Y F
authors.initials: VY
authors.lastname: Tang
authors.affiliation: Clinical Trials Centre, The University of Hong Kong, Hong Kong.
authors.forename: Tzy-Jyun
authors.initials: TJ
authors.lastname: Yao
authors.affiliation: Department of Surgery and State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong.
authors.forename: Sheung-Tat
authors.initials: ST
authors.lastname: Fan
authors.affiliation: Department of Surgery and State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong.
authors.forename: Chung-Mau
authors.initials: CM
authors.lastname: Lo
authors.affiliation: Department of Surgery and State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong. Electronic address: poontp@hku.hk.
authors.forename: Ronnie T P
authors.initials: RT
authors.lastname: Poon
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019540:Area Under Curve; D044466:Asian People; D006528:Carcinoma, Hepatocellular / Q000208:ethnology / Q000401:mortality / Q000473:pathology* / Q000628:therapy*; D016009:Chi-Square Distribution; D003661:Decision Support Techniques; D003663:Decision Trees; D005260:Female; D006723:Hong Kong; D006801:Humans; D053208:Kaplan-Meier Estimate; D008113:Liver Neoplasms / Q000208:ethnology / Q000401:mortality / Q000473:pathology* / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging / Q000379:methods*; D018579:Patient Selection; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D012372:ROC Curve; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult
keywords: Outcome; Overall Survival; Prediction Model; TACE