Hepatocellular carcinoma (HCC) treatment strategies continue to evolve as multidisciplinary approaches become increasingly integrated into clinical practice. Although external beam radiation therapy (EBRT) has historically had delayed acceptance in HCC management, expanding clinical evidence has renewed interest in its role, particularly for patients who are not ideal candidates for surgery or thermal ablation.
A new multinational individual patient data analysis published in May 2026 provides one of the most comprehensive evaluations to date of overall survival outcomes among patients with hepatocellular carcinoma treated with EBRT.
The study was published online on May 15, 2026, in the Journal of Clinical Oncology.
Title: Overall Survival Among Patients With Hepatocellular Carcinoma Treated With External Beam Radiation Therapy: Individual Patient Data Outcomes From a Multinational Cohort
The study was conducted by Andrew M. Moon, Ted K. Yanagihara, Laura A. Dawson, Jeong Il Yu, Theodore S. Lawrence, Tae Hyun Kim, Michael Yan, Hiromitsu Iwata, Nima Nabavizadeh, Smith Apisarnthanarax, Emma M. Dunne, Michael I. Lock, Michael D. Chuong, Chi Leung Chiang, Marta Scorsetti, Norio Katoh, Shirin Sioshansi, Kazushi Numata, Howard Yu-hao Liu, Hideki Iwamoto, Masaru Wakatsuki, Yixing Chen, Erqi L. Pollom, Eleni Gkika, Salma K. Jabbour, Pablo Munoz-Schuffenegger, Debnarayan Dutta, Carla Hajj, Masayuki Ueno, Christopher L. Hallemeier, Aharon M. Feldman, Alejandra Méndèz Romero, Xianming Tan, Meritxell Molla, Joel E. Tepper, Ferran Torres, and Maria Reig, for the EBRT Collaboration Group.
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Study Design and Objectives
The investigators performed a systematic review of studies evaluating EBRT in HCC that met predefined technical quality standards and reported overall survival outcomes. Authors from eligible studies were invited to contribute individual patient data for pooled analysis.
The analysis included 4,913 patients with HCC treated with EBRT across multiple international centers, making it the largest multinational cohort evaluating this treatment modality in HCC to date. Median follow-up was 5.0 years.
Researchers evaluated overall survival using Kaplan-Meier analyses and restricted mean survival time according to Barcelona Clinic Liver Cancer (BCLC) stage and prior treatment status. Multivariable Cox proportional hazards models were also used to identify clinical factors associated with mortality risk.
Overall Survival Outcomes
The study reported long-term survival outcomes, particularly among patients with very early- and early-stage disease. For patients with BCLC-0 disease, median overall survival reached 6.8 years (95% CI, 5.7–8.7 years). Patients with BCLC-A disease had a median overall survival of 4.6 years (95% CI, 4.1–5.1 years).
Among treatment-naïve patients, outcomes were even more notable. Median overall survival was not reached for treatment-naïve BCLC-0 patients, while treatment-naïve BCLC-A patients achieved a median overall survival of 5.4 years (95% CI, 4.5–6.7 years).
These findings suggest that EBRT may provide survival outcomes comparable to established curative-intent local therapies in selected patients with early-stage HCC.
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Factors Associated With Survival
Several clinical characteristics were independently associated with worse survival outcomes in multivariable analyses.
Higher mortality risk was linked to:
- More advanced BCLC stage
- Greater tumor burden
- Poorer performance status
- Child-Pugh class B or C liver function
Conversely, ablative radiation dose and more recent year of treatment were associated with reduced risk of death.
Why These Findings Matter
EBRT has had delayed acceptance as a recommended first-line treatment modality for HCC because evidence supporting overall survival outcomes has been limited. This large multinational analysis provides substantial long-term survival data supporting the integration of EBRT into modern HCC treatment algorithms, particularly for patients with very early- or early-stage disease who may not be candidates for other local therapies.
The authors concluded that overall survival outcomes with EBRT appear comparable to resection, thermal ablation, and other ablative locoregional approaches in selected patients with early-stage HCC, supporting broader inclusion of EBRT within the BCLC clinical decision-making framework.
The full article is available on the Journal of Clinical Oncology.
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