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Background: Over the past decade, the U.S. Department of Veterans Affairs (VA) has seen a more than 6-fold increased prevalence in hepatcocellular carcinoma (HCC). However, the treatment outcome of HCC in this population is not well characterized. Aim:Using intentionto-treat analysis to compare overall survival among patients with HCC treated by different modalities at a single VA center. Methods: 127 consecutive HCC patients, referred for consideration of therapy at the San Francisco VA between 4/2003 to 9/2007 were included, and their outcomes were reviewed in 10/2011. Based on their “intention-to-treat”, these patients were grouped into four categories: surgical resection, transplantation, curative radiofrequency ablation (RFA), and palliative treatment (palliative RFA, transarterial embolization, percutaneous ethanol injection, or none). Baseline patient characteristics, disease stage, and survival outcome using Cox proportional hazard models stratified by BCLC stages were compared. Results: The median age was 58 at initial presentation; 4% were at BCLC stage 0, 25% stage A, 54% stage B, 15% stage C, and 2% stage D. Median MELD score was 10 (range 6 to 30). Initial treatment plans were: 32 (25%) resection, 19 (15%) transplantation, 15 (12%) RFA, and 61 (48%) palliation. In this cohort, 28/32 (88%) of the resection group actually underwent resection and 12/19 (63%) of the transplant group were actually transplanted. At study end, 22 (19%) patients (10 transplant, 11 resections, 1 RFA) were alive, and 94 (80%) had died, and 1 was lost to follow-up. Mean follow-up was 29.8 months, but varied from 56.5 months in the transplant group to 16.3 months in the palliative group (p