A North American expert panel has proposed a new framework for allocating treatment in hepatocellular carcinoma (HCC), and in a pilot exercise published in Hepatology, treatment choices made by independent specialists agreed with the framework in 28 of 29 cases (96.6%). The same choices agreed with Barcelona Clinic Liver Cancer (BCLC) 2025 recommendations in 21 of 29 cases (72.4%).
HCC is the third leading cause of cancer-related death worldwide and the leading cause of cancer death among patients with cirrhosis, the authors wrote, and five-year survival remains below 25% despite improvements in screening and treatment.
“BEACON-HCC incorporates detailed assessments of tumor burden, current understanding of tumor biology, and recent changes in treatment,” said corresponding authors Amit G. Singal, MD, MS, of the Department of Internal Medicine at UT Southwestern Medical Center, Dallas, and Mark Yarchoan, MD, of the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore.
How the framework was built
The Best Evidence and North American Consensus on Treatment Allocation for Hepatocellular Carcinoma, known as BEACON-HCC, is a consensus statement developed by 20 specialists in hepatology, medical oncology, surgery, diagnostic and interventional radiology, and radiation oncology on behalf of the HCC-Live Steering Committee. It is not a society guideline.
The panel convened in February 2025 and worked through four one-hour teleconferences and email using a modified Delphi method. Chairs drafted initial recommendations from a literature review, the panel discussed and revised them across two rounds of meetings, and voting was held in June 2025. Under an a priori rule, any statement drawing more than 20% disagreement was revised, rediscussed, and put to a repeat vote.
BEACON-HCC considers tumor number, size, and distribution; the extent of vascular invasion; extrahepatic spread; liver function; and adverse prognostic features. It distinguishes solitary from multifocal disease and limited vascular involvement from invasion of major portal or hepatic veins.
That structure departs from BCLC, which the authors said places most patients with macrovascular invasion into a single advanced-disease category. Under BEACON-HCC, selected patients with limited vascular invasion may still be considered for surgery, radiation-based treatment, or downstaging followed by transplantation. Patients with extensive intrahepatic or metastatic disease are generally directed toward systemic therapy.
Laboratory and pathology findings also inform allocation. An alpha-fetoprotein (AFP) level above 1,000 ng/mL, a tumor larger than 8 cm, and poor differentiation on biopsy are classified as adverse features. Among patients with solitary tumors carrying such features, the panel said transplantation is considered only after a response to downstaging that includes a decline in AFP to below 500 ng/mL.
The authors noted that AFP-L3 above 15%, des-gamma-carboxy prothrombin above 7.5 ng/mL, and imaging features such as corona enhancement may carry additional prognostic value, but wrote that further validation is required before these markers are used routinely to guide treatment.
Resection is generally preferred in patients without cirrhosis or those with Child-Pugh A cirrhosis without clinically significant portal hypertension. Transplantation is favored for eligible patients with portal hypertension or hepatic decompensation.
For small, solitary tumors, options include resection, transplantation, and ablation. BEACON-HCC also gives transarterial radioembolization and stereotactic body radiation therapy a larger first-line role than BCLC. Systemic therapy remains central for extensive multifocal, major vascular, or metastatic disease. Combined systemic and locoregional treatment may be considered in selected cases but is not routinely recommended for all patients with liver-confined disease.
The framework further encourages clinicians to reconsider potentially curative treatment during follow-up, with patients who respond to systemic or locoregional therapy reassessed for resection or transplantation.
“Rather than providing one rigid treatment pathway, the framework presents potential options and identifies those supported by higher-level evidence or preferred by experts,” Dr. Singal and Dr. Yarchoan said. “It places greater emphasis on potentially curative therapies when appropriate, both at initial presentation and during follow-up, while supporting individualized treatment decisions.”
Pilot validation
Panel members each submitted one to three de-identified cases from their institutions, yielding 29 cases with clinical vignettes and representative imaging. The writing group first tested the framework internally. Anticipating that this step would overestimate performance, the authors then recruited 18 North American HCC specialists who had not helped develop BEACON-HCC and who completed the exercise without access to the framework.
Both groups selected a preferred initial treatment from a fixed list of options. Concordance was defined by comparing the most frequently selected treatment among reviewers with the framework’s recommendation; ties counted as concordant if one tied option matched.
External expert consensus agreed with BEACON-HCC in 28 of 29 cases and with BCLC 2025 in 21 of 29. The single BEACON-discordant case involved a patient with vascular invasion extending into the right atrium, for whom the experts chose combined systemic and locoregional therapy. Four of the eight BCLC-discordant cases also involved vascular invasion, with experts again selecting combined therapy where BCLC recommends systemic therapy alone. Across all 29 cases, the external group chose combined systemic and local therapy seven times, which the authors said demonstrates that the framework can accommodate multimodality approaches.
Limitations
The authors wrote that BEACON-HCC has not undergone prospective validation and that expert consensus is not a surrogate for improved clinical outcomes. They noted that the pilot was limited by a modest number of cases and may be subject to case selection and confirmation bias, and that efforts to ensure geographic and multidisciplinary diversity do not eliminate the potential for systematic bias. Validation using empiric clinical data is necessary before widespread adoption, they wrote, adding that the framework may help guide consistent decision-making if sufficiently validated.
“BEACON-HCC is based on expert assessment of the available treatment evidence and has been evaluated in only 29 real-world cases,” Dr. Singal and Dr. Yarchoan said. “We plan to compare its performance with other treatment-allocation systems, validate it in larger cohorts, and refine it as evidence on emerging treatments becomes available.”
Disclosures: Multiple authors reported consulting, research, advisory, speaker, royalty, patent, or ownership relationships with pharmaceutical, biotechnology, diagnostic, imaging, and medical-device companies. Industry sponsors of the HCC-Live conference had no role in the study.