Comparison of five staging systems in predicting the survival rate of patients with advanced hepatocellular carcinoma

Abstract

Objective To evaluate the five current staging systems, including Advanced Liver Cancer Prognostic System (ALCPS), Chinese University Prognostic Index (CUPI) , OKUDA staging system, Groupe d'Etude et de Traitement du Carcinome Hepatocellulaire (GETCH) and Barcelona Clinic Liver Cancer (BCLC) in predicting the 3-month survival rate and cumulative survival rate of patients with advanced hepatocellular carcinoma (HCC). Methods The subjects of this retrospective study were 255 patients (220 males and 35 females with the median age of 56 years old who did not receive any standard anti-cancer treatment in the Third Affiliated Hospital of Sun Yat-sen University from September 1, 2008 to June 1, 2010. The informed consents of all patients were obtained and the ethical committee approval was received. All the patients were scored according to ALCPS, CUPI, OKUDA, GETCH and BCLC staging system at their first diagnosis and were followed up afterwards. Receiver operating characteristic (ROC) curve analysis was carried out to find out the cut-off point of each scoring curve with best sensitivity and specificity. Nonparametric method Delong test was used to compare Area under curve (A) of ROC in order to evaluate different staging systems in predicting the patients' 3-month survival rate. Kaplan-Meier survival curve and Log-rank test were used to compare the cumulative survival rate of advanced HCC patients’ of different staging systems and the likelihood ratio test (LRT) was used to assess the prediction value of 5 systems. Results The A value of ALCPS was 0.823, which was the highest among the 5 staging systems. The cut-off point is 14 with the corresponding sensitivity of 0.76 and specificity of 0.79. The A value of CUPI was 0.779. The cut-off point was 5 with the corresponding sensitivity of 0.67 and specificity of 0.78. The A value of OKUDA was 0.756. The cut-off point was 1 with the corresponding sensitivity of 0.79 and specificity of 0.62. The A value of GETCH was 0.687. The cut-off point was 4 with the corresponding sensitivity of 0.59 and specificity of 0.67. The A value of BCLC was 0.615. The cut-off point was stage C with the corresponding sensitivity of 0.49 and specificity of 0.74. There were significant differences between the A value of ALCPS and that of CUPI, OKUDA, GETCH and BCLC (Z=2.251, 2.577, 4.600, 5.906; P<0.05). The A value of CUPI was significantly higher than GETCH and BCLC and that of OKUDA was significantly higher than BCLC (Z=3.059, 4.715; P<0.05). There were significant differences for the survival curve among the subgroups of ALCPS, OKUDA and GETCH (P<0.05) . There was no cross among the subgroups survival curves with distinguishable value. The differences among the subgroups survival curve of CUPI and BCLC are statistically significant(P<0.05) . Some crosses were observed among the subgroups survival curve of CUPI and BCLC and the distinguishable value was poor. The LRT result showed that the χ2 value of ALCPS, CUPI, OKUDA, GETCH and BCLC were 75.70, 52.82, 45.22, 16.87, 14.36 respectively. The χ2 value of ALCPS was the highest, which indicated the best predicting value of cumulative survival. Conclusions The ALCPS staging system is the best in predicting 3-month survival rate of advanced HCC and can serve as an inclusion criteria for clinical trials of advanced HCC. The ALCPS staging system is also the best in predicting cumulative survival rate of advanced HCC and can be used as a prognostic index for patient's long-term outcome. Key words: Carcinoma, hepatocellular; Survival rate; Advanced Liver Cancer Prognostic System; Chinese University Prognostic Index; OKUDA staging system; Groupe d'Etude et de Traitement du Carcinome Hepatocellulaire; Barcelona Clinic Liver Cancer Staging System