Real-world Hepatocellular Carcinoma Management and Guideline Adherence in the Netherlands: A 5-Year Multicentre Prospective Cohort Study

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INTRODUCTION AND OBJECTIVES: Dutch guidelines for hepatocellular carcinoma (HCC) are based on the European Association for the Study of the Liver (EASL) guideline. With the emergence of novel therapies, this study aimed to describe real-world first-line treatment practices in the Netherlands and assess their alignment with the EASL 2018 and 2025 recommendations. METHODS: Between 2019 and 2024, treatment-naive patients with HCC were prospectively enrolled across six Dutch tertiary referral centres as part of a cohort study paired with a biobank. Staging was in accordance with the Barcelona Clinic Liver Cancer (BCLC) 2022 classification. RESULTS: A total of 619 patients (79% male; median age 71 years) were included. Cirrhosis was registered in 65%. BCLC stage distribution was 11% BCLC-0, 53% BCLC-A, 14% BCLC-B, 18% BCLC-C, 2.9% BCLC-D, and 1.1% missing data. First-line therapy was most commonly thermal ablation (TA) in BCLC-0/A (48%), transarterial chemoembolization (TACE) in BCLC-B (46%), and systemic therapy in BCLC-C (41%). Adherence to first-line treatment recommendations was 46% per EASL 2018 and 63% per EASL 2025 guidelines. TACE, transarterial radioembolization and atezolizumab + bevacizumab were applied across all stages, ahead of guideline integration. One-year overall survival was 97% (BCLC-0), 91% (BCLC-A), 79% (BCLC-B), 70% (BCLC-C), and 33% (BCLC-D). CONCLUSION: Treatment practices in the Netherlands adapt in response to emerging evidence. Guideline-adherent first-line treatment was observed in 46% of patients according to the EASL 2018 guidelines and 63% according to the EASL 2025 guidelines. Although guidelines remain the foundational framework for clinical decision-making, treatment decisions in real-world practice often extend beyond guideline recommendations.

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