**5. Quality of life with SBRT in hepatocellular carcinoma**

The available evidence is limited, and the assessment tools vary from study to study. There are no studies limited to the evaluation of quality of life in patients with primary and secondary liver tumors. Moreover, there are differences in these pathologies that make it difficult to group them together. However, the change in quality of life in oncology patients after treatment can be substantial.

A systematic review published by Mutsaers et al [49] evaluated the quality of life of patients after treatment with SBRT in primaries or liver metastases. A total of 392 patients from four prospective studies and one abstract were analyzed. The review concludes that quality of life is preserved after SBRT treatment.

The prospective longitudinal study by Klein et al [50] using the FACT-Hep and QLQ-C30 quality of life questionnaires included 99 patients with hepatocellular carcinoma. Loss of appetite and asthenia worsened at 1 month, but recovered by 3 months, with no significant changes in quality of life in the series. Shun et al [51] found factors, including depression, functional status, and symptom severity associated with changes in quality of life. Nutritional status and mental health during treatment could affect quality of life. The most common changes were asthenia and nutritional status.

There is little evidence to compare quality of life data from SBRT with other treatments such as radiofrequency, TACE, or surgery. If we review quality of life after other local treatments, the studies by Rees et al [52] (liver resection) and Toro et al [53] (liver resection, TACE, radiofrequency, or no treatment) suggest a stable score; however, the studies by Eid et al [54] (liver resection or ablation) and Huang et al [55] (resection vs. radiofrequency) suggest a worsening. Similar variations are seen postchemo/Yttrium-90 [56]. Based on this limited data analysis, SBRT is a comparable or favorable alternative to other techniques.
