The first 60 days: Advanced hepatocellular carcinoma (BCLC C)
Advanced hepatocellular carcinoma has invaded the liver's veins or spread beyond it. Sorafenib was the only drug for a decade; now the combination of the immunotherapy atezolizumab with the anti-angiogenic antibody bevacizumab, or the two-antibody regimen durvalumab with tremelimumab, is standard first line, and several further drugs follow it. Below, week by week, is what OnCo's record of Advanced hepatocellular carcinoma (BCLC C) says about the first two months: the order is typical, the timing is yours to ask about. Sections appear only where the record has something to say. Orientation, not medical advice.
What happens now
Staging tests establish exactly what and where the cancer is. Everything else follows from the answers.
Ask which of these were tested and what the results were; see the report reader for what each value means.
These specialties appear in the standard of care for this cancer. In most centres they meet weekly as a tumour board to agree each plan; you can ask when yours was discussed and what was decided.
- PathologistNamed in the standard of care for: First line, Portal vein tumour thrombus.
- Medical oncologistNamed in the standard of care for: First line, First line when immunotherapy is unsuitable, Second line and beyond, Portal vein tumour thrombus and 1 more.
- Clinical oncologist (radiotherapy)Named in the standard of care for: Portal vein tumour thrombus.
- Transplant and cell therapy teamNamed in the standard of care for: First line when immunotherapy is unsuitable.
A second opinion from a centre that treats many similar cases is normal, not rude; the standard of care tells you what to compare it against.
Each row is a setting from the standard of care, in the order it usually arises. Not all will apply to you; your stage and biomarkers decide which do. The guideline grade, where recorded, says how strong the evidence is.
Atezolizumab with bevacizumab (IMbrave150) after endoscopic assessment of varices, or durvalumab with a single dose of tremelimumab (HIMALAYA); nivolumab with ipilimumab (CheckMate 9DW) where approved.
Lenvatinib (REFLECT) or sorafenib (SHARP), for example after liver transplantation or with active autoimmune disease.
Radiotherapy or radioembolisation to the thrombus alongside systemic therapy; hepatic artery infusion chemotherapy in Asian centres.
Antiviral therapy for hepatitis B, variceal management and monitoring of liver function, which decides whether further lines are possible.
Lenvatinib or sorafenib after immunotherapy; regorafenib (RESORCE), cabozantinib (CELESTIAL) or ramucirumab when alpha-fetoprotein is 400 or above, all proven after sorafenib.
Generated from this cancer's standard of care, biomarkers and open problems. Take the group that matches where you are. To tick, add your own and print, open the one-page appointment sheet.
Newly diagnosed
- What is my exact diagnosis, stage, and grade, and which tests established them?Everything else follows from an accurate stage and subtype.
- Which biomarkers have been tested on my tumour (for example Child-Pugh A and ALBI grade, Alpha-fetoprotein 400 or above, Portal vein tumour thrombus extent, Varices on endoscopy before bevacizumab, Hepatitis B DNA and antiviral cover), and what were the results?These results decide eligibility for targeted therapy, immunotherapy, and trials.
- Which subtype is my cancer, and does that change the recommended treatment?Recognised subtypes for this cancer include HCC with portal vein invasion, HCC with extrahepatic spread, Symptomatic HCC with preserved liver function.
- Is germline (inherited) genetic testing recommended for me or my family?Inherited variants can change treatment and matter for relatives.
First line
- For my situation (first line), which of the standard options do you recommend and why?Guideline options include: Atezolizumab with bevacizumab (IMbrave150) after endoscopic assessment of varices, or durvalumab with a single dose of tremelimumab (HIMALAYA); nivolumab with ipilimumab (CheckMate 9DW) where approved.
- Am I a candidate for Atezolizumab, Bevacizumab, Durvalumab or related drugs, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of IMbrave150 and HIMALAYA apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
First line when immunotherapy is unsuitable
- For my situation (first line when immunotherapy is unsuitable), which of the standard options do you recommend and why?Guideline options include: Lenvatinib (REFLECT) or sorafenib (SHARP), for example after liver transplantation or with active autoimmune disease.
- Am I a candidate for Lenvatinib, Sorafenib, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of REFLECT and SHARP apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Second line and beyond
- For my situation (second line and beyond), which of the standard options do you recommend and why?Guideline options include: Lenvatinib or sorafenib after immunotherapy; regorafenib (RESORCE), cabozantinib (CELESTIAL) or ramucirumab when alpha-fetoprotein is 400 or above, all proven after sorafenib.
- Am I a candidate for Regorafenib, Cabozantinib, Ramucirumab or related drugs, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of RESORCE and CELESTIAL apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Portal vein tumour thrombus
- For my situation (portal vein tumour thrombus), which of the standard options do you recommend and why?Guideline options include: Radiotherapy or radioembolisation to the thrombus alongside systemic therapy; hepatic artery infusion chemotherapy in Asian centres.
Liver disease during treatment
- For my situation (liver disease during treatment), which of the standard options do you recommend and why?Guideline options include: Antiviral therapy for hepatitis B, variceal management and monitoring of liver function, which decides whether further lines are possible.
Any stage
- Are there clinical trials I could join, for example of CheckMate 9DW, Camrelizumab + rivoceranib, Ivonescimab, Livmoniplimab?Trials are how the next standard of care is set; asking early keeps options open.
- Would a second opinion at a high-volume centre change anything, and can you help arrange it?Rare or high-stakes decisions benefit from a centre that treats many similar patients.
- What supportive care (symptom control, nutrition, exercise, mental health, financial help) is available from the start?Supportive care improves quality of life and helps patients complete treatment.
- I read that “No trial has defined the best drug after progression on immunotherapy”. How does that affect my plan?Open problems are where trials and second opinions matter most.
- I read that “Patients with Child-Pugh B liver function are excluded from trials yet make up a large share of the clinic”. How does that affect my plan?Open problems are where trials and second opinions matter most.
Much of what helps in the first weeks is free if you know to ask: testing, helplines, rides and lodging, second opinions, trial travel.
- Advanced hepatocellular carcinoma (BCLC C): the full pageAdvanced hepatocellular carcinoma has invaded the liver's veins or spread beyond it. Sorafenib was the only drug for a decade; now the combination of the immunotherapy atezolizumab with the anti-angiogenic antibody bevacizumab, or the two-antibody regimen durvalumab with tremelimumab, is standard first line, and several further drugs follow it.
- One-page appointment sheetYour questions, the words you may hear, what to bring, and space for the answers. Print it.
- Treatment sequencingWhich treatment tends to follow which, line by line.
- NavigatorStandard of care for your stage, what you have tried, and trials near you.
- Child-Pugh score: A score of how well a damaged liver is still working, from five simple measures (bilirubin, albumin, clotting, fluid in the abdomen, confusion).
- Hepatitis B and C as cancer causes: Two viruses cause most liver cancer worldwide.
- Portal vein tumour thrombus (macrovascular invasion): Liver cancer growing into the main vein that brings blood from the gut to the liver.
- Alpha-fetoprotein (AFP): Alpha-fetoprotein is a protein made by the fetal liver that a substantial share of hepatocellular carcinomas switch back on.
Every term links to the glossary.