Real-world adherence to BCLC treatment guidelines in hepatocellular carcinoma significantly impacts patient survival.

• Overall adherence was only 47.8%, with the best rates (93.5%) in stage D and the lowest (23.1%) in stage C.
• Patients following BCLC recommendations lived longer: 722 days versus 535 days for non-adherents.

Improving adherence, especially in early and advanced stages, is crucial for enhancing patient outcomes.

• Key predictors of adherence included Child-Pugh scores B/C and ECOG > 0.