Hepatocellular carcinoma surveillance in cirrhotic patients: Beyond guidelines

Abstract

Hepatocellular carcinoma (HCC) surveillance of individuals with cirrhosis or other conditions that confer a high risk of HCC development is essential for early detection and improved overall survival. HCC surveillance is a complex process, with failure at any step in the process contributing to a gap between its efficacy and effectiveness. Biannual ultrasonography with or without alpha-fetoprotein is widely recommended as the standard method for HCC surveillance, but it has limited sensitivity in early disease and may be inadequate in certain individuals. HCC surveillance implementation can be affected by either provider or patient-related factors. Proper screening for HCC is a continuum of services, extending from initial patient screening, diagnosis, treatment and ultimately surveillance. As one may expect, there are numerous chances for failure in the delivery of cancer screening care. When considering the risk versus benefits of HCC surveillance, we must consider the possible harm to the patient. Such concerns include false-positive testing resulting in unnecessary and risk-associated procedures such as liver biopsy, overdiagnosis of HCC among patients with cirrhosis, as well as false-negative investigations resulting in delayed diagnosis of HCC. The development of tools to enhance our ability in optimizing available surveillance is likely to improve the prognosis of patients with HCC. This review article will provide a comprehensive overview of the rationale behind current HCC surveillance guidelines, their utilisation, effectiveness, limitations, benefits, and harms as well as methods to improve the outcome of HCC surveillance.