Treatment patterns and clinical outcomes of patients with hepatocellular carcinoma—a cohort study of 1020 patients in Sweden

Hepatocellular carcinoma (HCC) is a significant global health burden. Examining treatment sequencing before the introduction of immune-based therapies is important for understanding the role and necessity of modern treatment approaches. This retrospective study analysed 1020 patients with HCC treated at Karolinska University Hospital, Stockholm, between 2010 and 2017 to explore treatment sequencing, and clinical outcomes. Treatment decisions followed a modified Barcelona Clinic Liver Cancer (BCLC) algorithm, and patients were stratified by disease stage and by type of treatment. Initial treatment strategies included best supportive care (BSC, 32%), ablation (20%), transarterial chemoembolization (TACE, 22%), systemic therapy (12%), resection (12%), and liver transplantation (3%). Median survival ranged from 4.8 years in BCLC 0 to 2.3 months in BCLC D. Curative treatments, particularly liver transplantation, achieved the highest five-year survival (82%), whereas systemic therapy and BSC had the poorest five-year survival (2% and 0%). Despite curative intent, disease recurrence was common, necessitating further treatment in most patients. Treatment sequencing revealed that 37% of patients required a second treatment, and 18% progressed to a third line of therapy. This study underscores the challenges of managing HCC in a real-world setting, including late diagnosis and high recurrence rates following curative treatments. Real-world treatment deviations from guidelines were observed, often influenced by patient comorbidities, performance status, or other clinical considerations. This study examined treatment patterns and outcomes for liver cancer patients in Stockholm, Sweden, before immune-based therapies were available. Most patients were diagnosed late, with supportive care being the most common initial treatment. While potentially curative treatments like liver transplantation offered the best long-term survival, many patients experienced disease progression, highlighting the need for earlier diagnosis and improved therapies.