EASL Clinical Practice Guidelines

Introduction

EASL–EORTC Clinical Practice Guidelines (CPG) on the management of hepatocellular carcinoma (HCC) define the use of surveillance, diagnosis, and therapeutic strategies recommended for patients with this type of cancer. This is the first European joint effort by the European Association for the Study of the Liver (EASL) and the European Organization for Research and Treatment of Cancer (EORTC) to provide common guidelines for the management of hepatocellular carcinoma. These guidelines update the recommendations reported by the EASL panel of experts in HCC published in 2001 [1]. Several clinical and scientific advances have occurred during the past decade and, thus, a modern version of the document is urgently needed.

The purpose of this document is to assist physicians, patients, health-care providers, and health-policy makers from Europe and worldwide in the decision-making process according to evidence-based data. Users of these guidelines should be aware that the recommendations are intended to guide clinical practice in circumstances where all possible resources and therapies are available. Thus, they should adapt the recommendations to their local regulations and/or team capacities, infrastructure, and cost–benefit strategies. Finally, this document sets out some recommendations that should be instrumental in advancing the research and knowledge of this disease and ultimately contribute to improve patient care.

The EASL–EORTC CPG on the management of hepatocellular carcinoma provide recommendations based on the level of evidence and the strength of the data (the classification of evidence is adapted from National Cancer Institute [2]) (Table 1A) and the strength of recommendations following previously reported systems (GRADE systems) (Table 1B).


Table 1A
Levels of evidence according to study design and end-points National Cancer Institute: PDQ Levels of Evidence for Adult and Pediatric Cancer Treatment Studies. Bethesda [2]¶.



¶National Cancer Institute: PDQ® Levels of Evidence for Adult and Paediatric Cancer Treatment Studies. Bethesda, MD: National Cancer Institute. Date last modified 26/August/2010. Available at: http://cancer.gov/cancertopics/pdq/levels-evidence-adult-treatment/HealthProfessional. Accessed .
∗The randomized, double-blinded controlled clinical trial (1i) is the gold standard of study design. Meta-analyses of randomized studies are placed in the same category of strength of evidence as are randomized studies.
∗∗This category includes trials in which treatment allocation was made by birth date, chart number (so-called quasi randomized studies) or subset analyses of randomized studies (or randomized phase II studies).
∗∗∗All other prospective (cohort studies) or retrospective studies (case–control studies, case series).
#These end-points may be subjected to investigator interpretation. More importantly, they may, but do not automatically, translate into direct patient benefit such as survival or quality of life. Nevertheless, it is rational in many circumstances to use a treatment that improves these surrogate end-points while awaiting a more definitive end-point to support its use.

Table 1B
Grading evidence and recommendations (adapted from GRADE system).