BCLC strategy and the Child-Pugh score for liver cancer
The stage of 
liver cancer tells you how big it is and whether it has spread to other parts of the body. This helps your doctor recommend the best treatment for you.
There are different staging systems that doctors can use for liver cancer. One of these is the Barcelona Clinic Liver Cancer (BCLC) strategy. The BCLC looks at:
- the number and size of tumours in your liver
- your general health and fitness - this is called your performance status or PS
- your levels of a tumour marker called alpha fetoprotein (AFP)
- how well your liver is working (liver function) including a system called the Child-Pugh score
The BCLC strategy is for staging . HCC is different to cancer that spreads to your liver from somewhere else in your body. This is called secondary liver cancer or liver metastases.
Performance status (PS)
Performance status (PS) is a scale to grade how well you are, your cancer related symptoms, and what activities you are able to do. The BCLC strategy uses the Eastern Cooperative Oncology Group (ECOG) scale:
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PS 0 – you are fully active, more or less as you were before your illness
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PS 1 – you can’t carry out heavy physical work, but can do anything else
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PS 2 – you are up and about more than half the day. You can look after yourself but can’t work
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PS 3 – you are in bed or a chair for more than half the day. You need help to look after yourself
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PS 4 – you are in bed or a chair all the time and need complete care
How well your liver is working
When deciding on treatment your doctor has to think about how well your liver is working. This is especially the case if you have liver damage (cirrhosis). Unfortunately, people with severe liver damage may be too unwell to have treatment for their cancer.
Your doctor can use different tests to find out how well your liver is working. These include:
- testing the amount of albumin and bilirubin in your blood (ALBI score)
- tests of how well you kidneys and liver are working together (MELD score)
- looking at liver tests and symptoms together (Child-Pugh score)
The Child-Pugh score
The Child-Pugh score looks at the following 5 things that tell how well the liver is working:
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bilirubin levels in the blood
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albumin levels in the blood (albumin is a protein made by the liver)
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how quickly the blood clots (prothrombin time)
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if there is fluid in the abdomen (ascites)
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if the liver disease is affecting brain function (encephalopathy)
Each one is given a number score, and based on that score, people fall into 1 of 3 classes:
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class A means the liver is working normally
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class B means mild to moderate damage
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class C means there is severe liver damage - unfortunately you may be too sick to have treatment for the cancer
The BCLC strategy
There are 5 stages to the BCLC strategy:
Stage 0
This means there is 1 tumour which is is less than 2cm. You feel well (PS 0) and your liver is working normally.
Stage A
This means there are up to 3 tumours all less than 3 cm. You feel well (PS 0), and your liver is working well.
Stage B
This means there are many tumours in the liver, but you feel well (PS 0) and your liver is working well.
Stage C
This means the cancer has spread into the blood vessels, or other body organs. You do not feel well and are less active (PS 1 or 2) but your liver is still working well.
Stage D
The tumour can be any size. You have severe liver damage, or you are not well and need help to look after yourself (PS 3 or 4).
Treatment options
The stage of your cancer helps your doctor to decide which treatment you need. Treatment also depends on:
- where the cancer is in your liver
- other health conditions
- your wishes
For cancer that is only in the liver, it might be possible to remove it with surgery. This might be surgery to remove part of your liver (liver resection) or a liver transplant.
You might have a local treatment into your liver if you can't have surgery. This could be:
- radiofrequency ablation (RFA) or microwave ablation (MWA)
- chemoembolisation (TACE) or embolisation (TAE)
- selective internal radiotherapy (SIRT)
- stereotactic ablative radiotherapy (SABR)
For liver cancer that has spread you might have targeted or immunotherapy drugs.
If you have severe liver damage, you are usually too unwell to have treatment for your cancer. But your doctor will give you different treatments to help control your symptoms.
