Decorative image

BCLC staging system and the Child-Pugh system

Doctors need to know the size and position of the liver cancer to make decisions about your treatment. They also need to know how well your liver is working, especially if you also have scarring of the liver (cirrhosis).

For this, they often use a system called the Barcelona Clinic Liver Cancer (BCLC) staging system.

The Child-Pugh system

The Child-Pugh system looks at the following 5 things that tell how well the liver is working:

  • bilirubin levels in the blood
  • albumin levels in the blood (albumin is a protein made by the liver)
  • how quickly the blood clots (prothrombin time)
  • if there is fluid in the abdomen (ascites)
  • 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:

  • class A means the liver is working normally
  • class B means mild to moderate damage
  • class C means there is severe liver damage - unfortunately you may be too sick to have treatment for the cancer

Performance status (PS)

Performance status (PS) is a scale to grade how well you are. The BCLC staging system uses the Eastern Cooperative Oncology Group (ECOG) scale:

  • PS 0 – you are fully active, more or less as you were before your illness
  • PS 1 – you can’t carry out heavy physical work, but can do anything else
  • PS 2 – you are up and about more than half the day. You can look after yourself but can’t work
  • PS 3 – you are in bed or a chair for more than half the day. You need help to look after yourself
  • PS 4 – you are in bed or a chair all the time and need complete care

The BCLC staging system

The BCLC staging system looks at the number and size of tumours in the liver and at how well you are overall (your performance status - PS), as well as your liver function. To assess how bad the liver disease is, doctors usually use the Child-Pugh score (see below).

There are 5 stages to the BCLC staging system.

Stage 0 (Very early stage)

This means the tumour is less than 2cm, you feel well (PS 0) and your liver is working normally (Child-Pugh A).

Stage A (Early stage)

This means there is a single tumour of any size, or up to 3 tumours all less than 3 cm. You feel well and are active (PS 0), and your liver is working well (Child-Pugh A or B).

Stage B (Intermediate Stage)

This means there are many tumours in the liver, but you feel well (PS 0) and your liver is working well (Child-Pugh A or B).

Stage C (Advanced stage)

This means the cancer has spread into the blood vessels, lymph nodes or other body organs. Or you do not feel well and are less active (PS 1 or 2). Your liver is still working well. (Child-Pugh A or B).

Stage D

This means you have severe liver damage (Child-Pugh C), or you are not well and need help in being looked after (PS 3 or 4).


The stage of your cancer helps your doctor to decide which treatment you need. Treatment also depends on:

  • where the cancer is 
  • other health conditions that you have
  • your wishes

For cancer that is only in the liver, it might be possible to have surgery to remove the tumour. 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 such as:

  • radiofrequency ablation (RFA) or microwave ablation (MWA)
  • chemoembolisation (TACE)
  • percutaneous ethanol injection (PEI)

For liver cancer that has spread (advanced liver cancer) you might have a targeted cancer drug, such as sorafenib.

If you have severe liver damage, you are usually too unwell to have treatment for the cancer. But your doctor will give you different treatments to help control your symptoms.

Other stages

Last reviewed: 
02 Jan 2019
  • EASL Clinical Practice Guidelines: Management of hepatocellular carcinoma
    European Association for the Study of the Liver
    Journal of Hepatology, 2018. Volume 69, Pages 182-236

  • Hepatocellular carcinoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow up
    A Vogel and others
    Annals of Oncology, 2018. Volume 29, Supplement 4, Pages 238-255

  • Hepatocellular carcinoma
    A Forner and others
    Lancet, 2018. Volume 391, Pages 1301-1314

Information and help