title: Aggressive therapeutic strategies improve the survival of hepatocellular carcinoma patients with performance status 1 or 2: a propensity score analysis.
abstract: BACKGROUND
  Targeted therapy or chemotherapy is suggested as standard treatment for hepatocellular carcinoma (HCC) patients with performance status (PS) 1-2 according to the Barcelona Clinic Liver Cancer (BCLC) system. The underlying rationales have not been fully studied.
  
  
  METHODS
  This study enrolled 2,620 HCC patients. One-to-one matched pairs between HCC patients receiving aggressive anti-HCC treatments (resection, transplantation, ablation, and transarterial chemoembolization) and those receiving targeted therapy or chemotherapy or best supportive care were generated by using the propensity score with a matching model. Survival analysis was performed with the Kaplan-Meier method and the log-rank test. Mortality risk was calculated with the Cox proportional hazards model.
  
  
  RESULTS
  Of 793 patients with PS 1-2, 64 % received aggressive anti-HCC treatments against the suggestion of the BCLC system. The patients receiving aggressive anti-HCC treatments had significantly milder cirrhosis, a smaller tumor burden, and better long-term survival than the patients undergoing targeted therapy or chemotherapy or best supportive care (all p < 0.05). With the use of propensity scores, 166 pairs of matched HCC patients with PS 1-2 were selected from different treatment groups. After matching, patients were comparable in age, gender, severity of cirrhosis, tumor burden, and prevalence of diabetes mellitus (all p > 0.05) at baseline. In the propensity score model, patients with PS 1-2 undergoing aggressive anti-HCC treatments had significantly better long-term survival (p < 0.0001). The adjusted hazard ratio of the choice for targeted therapy or chemotherapy or best supportive care to the choice for aggressive anti-HCC treatments was 2.028 (p < 0.0001).
  
  
  CONCLUSIONS
  According to the findings, HCC patients with PS 1-2 should consider aggressive anticancer treatments if no contraindication is noted. Adjustment of the BCLC treatment allocation is needed to enhance its prognostic accuracy.
authors.affiliation: Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan.
authors.forename: Chia-Yang
authors.initials: CY
authors.lastname: Hsu
authors.forename: Po-Hong
authors.initials: PH
authors.lastname: Liu
authors.forename: Yun-Hsuan
authors.initials: YH
authors.lastname: Lee
authors.forename: Cheng-Yuan
authors.initials: CY
authors.lastname: Hsia
authors.forename: Yi-Hsiang
authors.initials: YH
authors.lastname: Huang
authors.forename: Yi-You
authors.initials: YY
authors.lastname: Chiou
authors.forename: Ya-Ju
authors.initials: YJ
authors.lastname: Tsai
authors.forename: Teddy S
authors.initials: TS
authors.lastname: Nagaria
authors.forename: Teh-Ia
authors.initials: TI
authors.lastname: Huo
mesh_terms: D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000401:mortality* / Q000473:pathology / Q000628:therapy; D003131:Combined Modality Therapy; D005260:Female; D005500:Follow-Up Studies; D006305:Health Status Indicators; D006801:Humans; D008113:Liver Neoplasms / Q000401:mortality* / Q000473:pathology / Q000628:therapy; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D009364:Neoplasm Recurrence, Local / Q000401:mortality* / Q000473:pathology / Q000628:therapy; D009367:Neoplasm Staging; D011379:Prognosis; D057216:Propensity Score; D011446:Prospective Studies; D015996:Survival Rate