Background: Real life management of hepatocellular carcinoma occasionally deviates from guidelines forrecommended therapy. Aims: To evaluate how frequent this deviation happens in our center and assess itsimpact on outcome. Materials and Methods: The treatment of 770 patients (87% males, mean age 57.8 years)was analyzed and the effect of deviation on outcome over 36 months was examined. Results: Of Barcelona Clinicliver cancer stages 0 and A patients, 65.8% received resection, ablation, liver transplantation or transarterialchemoembolisation for unresectable tumors more than 5 cm in diameter, and 34.2% received treatmentrecommended for later stages. Of stage B patients, 62.2% received recommended therapy, 34.3% of patientsreceived supportive therapy or sorafenib and 3.5% received upward treatment stage migration. Among stage Cpatients, 7.6% received sorafenib, and most (79.2%) were given supportive care. Deviation from recommendedtherapy occurred in 34.2%, 37.7%, and 92.4% in stages 0-A, B and C. Survival of stage 0-A patients who receiveddownwards treatment stage migration was lower than those who received recommended treatment (p <0.001).Upward treatment stage migration in stages B, C and D did not improve survival compared to those who receivedrecommended treatment. Conclusions: Deviation from recommended therapy had a negative impact on survivalin Barcelona Clinic liver cancer stage A patients.