Liver cancer surveillance is recommended for all patients with Child-Turcotte-Pugh (CTP) Class A and B cirrhosis and patients with CTP Class C cirrhosis listed for liver transplantation who are eligible for curative or palliative (surgical, locoregional, or systemic) therapies for hepatocellular carcinoma (HCC).

Key concepts

• HCC occurs most often (>80% of the time) in patients with advanced fibrosis/cirrhosis
• Screening (or more accurately, surveillance for this at-risk population) will result in earlier stage at diagnosis and greater chance of cure
• Most guidelines call for ultrasound every 6 months with or without alpha-fetoprotein (AFP) screening in all patients with cirrhosis
• There is significant variability in practice with respect to awareness of surveillance guidelines, surveillance rates, and imaging modalities; this field is likely to evolve significantly in the future

Key recommendations

• The HCC guidelines published by the American Society for the Study of Liver Disease (AASLD) in 2018 recommend:
  • Surveillance of adults with cirrhosis because it improves overall survival (Quality/Certainty of Evidence: Moderate; Strength of Recommendation: Strong)
  • Surveillance using ultrasound, with or without AFP screening, every 6 months (Quality/Certainty of Evidence: Low; Strength of Recommendation: Conditional)
  • No surveillance of patients with cirrhosis with CTP Class C unless they are on the transplant waiting list, given low anticipated survival for patients with this degree of hepatic dysfunction (Quality/Certainty of Evidence: Low; Strength of Recommendation: Conditional)
• The U.S. Preventive Services Task Force has not issued guidance on surveillance for HCC, and primary care providers may not be aware of specialty guidelines

Ultrasound for HCC screening is cost-effective

• Ultrasound is cost-effective as a surveillance modality; however, it is operator-dependent and results are often affected by body habitus
• Contrast-enhanced dynamic imaging with CT or MRI is reserved for diagnostic purposes and should not be used for surveillance
• If a quality sonogram cannot be obtained due to limitation of local resources or as determined by the sonographer/radiologist, contrast-enhanced imaging is advised
• AFP screening alone is not effective for surveillance

Patients with chronic hepatitis B: a special population

• Patients with chronic hepatitis B are at risk of liver cancer even in the absence of cirrhosis
• Ultrasound surveillance is advised every 6 months in the following populations (regardless of stage of fibrosis):
  • Patients with cirrhosis
  • African decent over 20 years of age (born in Africa or children of immigrants from this region)
  • ALL males over 40 years of age
  • Asian females over 50 years of age
  • In cases of family history (in a first-degree relative) of HCC in persons with chronic hepatitis B, surveillance should start 10 years before the age at which the first-degree relative developed HCC
  • Persons at a high risk for HCC who live in areas where ultrasound is not readily available, screen with AFP every 6 months

Populations for which there is no guidance

• HCC is increasingly being reported in patients with nonalcoholic steatohepatitis (NASH) without cirrhosis; the pathogenesis of HCC in this population may be different than in the population with viral hepatitis; there are currently no recommendations for surveillance in this population
• Several studies have reported that patients with cirrhosis who have achieved sustained viralogic response (SVR) after direct-acting antiviral (DAA) therapy for hepatitis C may experience decreased risk of HCC and/or regression of fibrosis; the natural history of cancer risk and regression of fibrosis in this population is still being studied; therefore, patients with stage 3 or 4 fibrosis at the time of initiation of DAA therapy should continue HCC surveillance until more data are available