Performance status in patients with hepatocellular carcinoma: Determinants, prognostic impact, and ability to improve the Barcelona Clinic Liver Cancer system

Authors

  • Chia-Yang Hsu,

    1. Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
    2. Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
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  • Yun-Hsuan Lee,

    1. Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
    2. Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
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  • Cheng-Yuan Hsia,

    1. Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
    2. Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
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  • Yi-Hsiang Huang,

    1. Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
    2. Institute of Clinical Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
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  • Chien-Wei Su,

    1. Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
    2. Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
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  • Han-Chieh Lin,

    1. Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
    2. Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
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  • Rheun-Chuan Lee,

    1. Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
    2. Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
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  • Yi-You Chiou,

    1. Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
    2. Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
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  • Fa-Yauh Lee,

    1. Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
    2. Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
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  • Teh-Ia Huo

    Corresponding author
    1. Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
    2. Institute of Pharmacology, National Yang-Ming University School of Medicine, Taipei, Taiwan
    • Professor of Medicine, Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei 112, Taiwan
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    • fax: +886 2 2873 9318


  • Potential conflict of interest: Nothing to report.

  • Supported by grants from the Center of Excellence for Cancer Research at Taipei Veterans General Hospital (DOH101-TD-C-111-007), Taiwan, from Taipei Veterans General Hospital (V101C-170), Taipei, Taiwan, and from the Ministry of Education, Aim for the Top University Plan (101AC-D101), Taiwan.

Abstract

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.

Conclusion:

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. (HEPATOLOGY 2013)

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