Subset of Child-Pugh Score 7 Shows Comparable Survival Outcomes to Child-Pugh Score 6 in Patients with Hepatocellular Carcinoma Treated with Atezolizumab and Bevacizumab

Purpose: Given the limited data on the effectiveness of atezolizumab plus bevacizumab (Ate/Bev) in patients with hepato-cellular carcinoma with a Child-Pugh score (CPS) of 7, this study aims to evaluate the treatment’s efficacy in this population and identify specific CPS 7 subgroups that may benefit from it. Experimental Design: This study included patients with advanced hepatocellular carcinoma who received Ate/Bev as first-line therapy between September 2020 and December 2023 at seven university hospitals. The primary outcome was overall survival (OS), whereas secondary outcomes included progression-free survival (PFS) and treatment response. Results: Among the 374 included patients, those with CPS 5 (n ¼ 169) demonstrated the highest OS and PFS, followed by patients with CPS 6 (n ¼ 105) and CPS 7 (n ¼ 100; P < 0.05). For the variables comprising CPS, the HR for OS increased with elevated total bilirubin levels and was lower in patients with mild ascites (P < 0.05). The HR for OS tended to increase as albumin levels dropped to 2.8 g/dL. Based on these findings, patients with CPS 7 were further classified into two subgroups: favorable (total bilirubin <2 mg/dL, 3.5 ≥ albumin ≥ 2.8 g/dL, mild ascites, and absence of hepatic encephalopathy) and unfavorable (other CPS 7). Compared with patients with CPS 6, those in the favorable CPS 7 group exhibited comparable OS and PFS, whereas patients with unfavorable CPS 7 had significantly lower OS and PFS (P < 0.05). These findings were consistently observed in the multivariate analysis. Conclusions: This study suggests that Ate/Bev treatment can be effective in a subset of patients with CPS 7, highlighting the potential to broaden treatment eligibility for this population. See related commentary by Li and Kelley, p. 4220.