BCLC strategy for prognosis prediction and treatment recommendations: The 2025 update

Abstract

The 2025 BCLC update incorporates recent advances in the field of treatment recommendations for hepatocellular carcinoma while preserving its simplicity. Each stage remains directly linked to its evidence-based first-option treatment. The BCLC algorithm provides guidance to evaluate patient prognosis and propose a therapeutic strategy according to the current scientific evidence. Tumor boards require structured methodologies to address clinical complexity. Beyond published evidence, decision-making should incorporate biological, psychosocial, and contextual factors that may affect morbidity, feasibility, and patient vulnerability. Such a multidimensional approach ensures treatments remain evidence-based and patient-centered. The updated clinical-decision-making chapter embeds the CUSE framework (Complexity, Uncertainty, Subjectivity, Emotion). CUSE turns unavoidable doubt into a shared, iterative process to: (i) define the therapeutic goal (survival, tumor control, quality of life, etc.); (ii) grade each option, noting evidence strength and gaps; (iii) align choices with comorbidities, feasibility, oncologic risk, and patient values and goals; and (iv) select a plan with regular check-ins as new information or needs arise. IMPACT AND IMPLICATIONS: The 2025 BCLC update provides the scientific justification for integrating recent advances into a cohesive, evidence-based framework that remains the global reference for prognostication and treatment allocation in HCC. By incorporating the CUSE framework, it provides multidisciplinary teams with a structured approach to navigate evidence gaps, explicitly address uncertainty, and tailor therapy to patient goals and context. These updates are particularly important for clinicians, tumor boards, and guideline developers, as well as for patients and caregivers who face complex choices in real-world practice. In practical terms, the prognostic capacity of BCLC is embedded within person-centered decision-making, fostering iterative treatment planning and laying the foundation for future studies assessing the clinical impact of CUSE, while acknowledging the need for validation and variability in implementation across healthcare settings.

Keywords: AFP; ALBI score; BCLC; CUSE; EBRT; HCC; TARE; ablation; immunotherapy; liver transplantation TACE; surgery; survival; systemic treatment.