Systematic review of overall survival with external beam radiotherapy for hepatocellular carcinoma: individual patient data

External beam radiation therapy (EBRT) has gained delayed acceptance as first-line treatment for hepatocellular carcinoma (HCC), given limited evidence that it improves overall survival (OS). Analysis of 4913 HCC patients treated with EBRT with a median follow-up time of 5.0 years in multiple studies found a median OS of 6.8 years (95% CI 5.7-8.7) for Barcelona Clinic Liver Cancer stage 0 patients and 4.6 years (4.1-5.1) for BCLC-A stage patients. Among treatment-naïve patients, the median OS was not reached (95% CI 8.6-NR) for BCLC-0 and 5.4 years (4.5-6.7) for BCLC-A. In multivariable models, more advanced BCLC stage, higher tumor burden, worse performance status, and Child-Pugh class B or C were associated with a higher risk of death, whereas ablative radiation dose and more recent year of treatment were associated with a reduced risk of death. The authors conclude that outcomes with EBRT for very early-stage and early-stage HCC appear to be comparable to outcomes with resection, thermal ablation, and other ablative locoregional therapies.