Most liver cancer (also called hepatocellular cancer, or HCC) cases occur in patients with established risk factors for chronic liver disease, including hepatitis C virus (HCV) infection, heavy alcohol drinking, hepatitis B virus (HBV) infection, and metabolic dysfunction associated steatotic liver disease (MASLD). These HCC risk factors lead to cirrhosis, which is present in 90% of patients with HCC in the Western world.
Two large randomized controlled trials in patients with HBV and several observational cohort studies in patients with cirrhosis have shown that patients who undergo HCC surveillance have earlier-stage HCC, are more likely to receive potentially curative treatment, and have improved survival than those who presented symptomatically or had HCC detected incidentally.
Based on these data, professional societies recommend HCC surveillance every 6 months in at-risk individuals, including all patients with cirrhosis from any etiology and subgroups of patients with HBV in the absence of cirrhosis. Surveillance is not recommended in patients with Child–Pugh class C cirrhosis unless they are awaiting liver transplantation, given the low probability of treatment eligibility and limited benefits.
Liver ultrasound has been long regarded as a standard surveillance test for HCC. Ultrasound is non-invasive and relatively inexpensive. However, the performance of ultrasound can be impacted by several patient-level factors, with particularly suboptimal performance in obese patients (such as those with MASLD) and those with more advanced cirrhosis. Addition of blood-based biomarkers to ultrasound increases the sensitivity of surveillance, particularly for early tumor detection. The best-studied biomarker to date is AFP, with a level of 20 ng/mL being the most used cutoff to trigger further evaluation in clinical practice.
The pooled sensitivities of ultrasound with and without AFP for early-stage HCC are 63% (95% CI, 48%–75%) and 45% (95% CI, 30%–62%), respectively (P = .002).
HCC surveillance should be performed every 6 months. Once initiated, there is no consensus about when to stop surveillance. In general, surveillance can be stopped in patients who develop child C cirrhosis and who are not liver transplant candidates.
Despite demonstrated benefits, including early tumor detection, <20% of patients with cirrhosis undergo surveillance.