Merits and boundaries of the BCLC staging and treatment algorithm: Learning from the past to improve the future with a novel proposal

This Expert Opinion article thoroughly analyses the Barcelona Clinic Liver Cancer (BCLC) staging and treatment algorithm for hepatocellular carcinoma (HCC) that, since 1999, has standardised the HCC management, offering a structured approach for the prognostic evaluation and treatment recommendations of patients with HCC. The first part of the article presents the strengths and evolutionary improvements of the BCLC staging system. Nevertheless, both patient characteristics and treatments available have changed in the last two decades, limiting the role of the BCLC for treatment allocation in a growing number of patients. As therapeutic options expand and become more effective, the stage-linked treatment decision-making algorithm may lead to undertreatment and suboptimal outcomes for patients with disease beyond early-stage HCC. Consequently, strict adherence to BCLC is limited in expert centres, particularly for patients diagnosed beyond early-stage HCC. Although the BCLC system remains the benchmark against which other therapeutic frameworks must be judged, the era of precision medicine requires patient-tailored therapeutic choices formulated by a multidisciplinary tumour board rather than a stage-dictated allocation of treatment. Acknowledging this conceptual difference in clinical management, the second part of the article describes a novel "multiparametric therapeutic hierarchy", which integrates a comprehensive patient clinical assessment, biomarkers, technical aspects and considerations on resource availability. Lastly, considering the increasing efficacy of locoregional and systemic treatments, the concept of “converse therapeutic hierarchy” is introduced. These treatments can increase the feasibility (conversion approach) and effectiveness (adjuvant approach of systemic therapy) of potentially curative approaches, improving the outcome of HCC management.