Systemic treatment of hepatocellular carcinoma. An EASL position paper

The last five years have witnessed relevant advances in the systemic therapy of hepatocellular carcinoma. New data have emerged since the development of the EASL Clinical Practice Guidelines on the management of hepatocellular carcinoma in 2018. Drugs licensed in some countries now include four oral multi-tyrosine kinase inhibitors (sorafenib, lenvatinib, regorafenib and cabozantinib), one antiangiogenic antibody (ramucirumab) and four immune checkpoint inhibitors, alone or in combination (atezolizumab in combination with bevacizumab, ipilimumab in combination with nivolumab, nivolumab and pembrolizumab in monotherapy). Prolonged survival in excess of two years can be expected in most patients with sensitive tumours and a well-preserved liver function that render them fit for sequential therapies. With different choices available in any given setting, the robustness of the evidence of efficacy and a correct matching of the safety profile of a given agent with patient characteristics and preferences are key in making sound therapeutic decisions. The recommendations in this document amend the previous EASL Clinical Practice Guidelines and aim to help providing the best possible care for patients today. In view of several ongoing and promising trials further advances in systemic therapy of HCC are foreseen in the near future and these recommendations will have to be updated regularly.