Surveillance for hepatocellular carcinoma: It is time to move forward

Article information

Clin Mol Hepatol. 2022;28(4):810-813
Publication date (electronic) : 2022 September 6
doi :
Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang, Korea
Corresponding author : Joong-Won Park Division of Gastroenterology, Department of Internal Medicine, Center for Liver and Pancreatobiliary Cancer, National Cancer Center, 323 Ilsan-ro Ilsandong-gu, Goyang 10408, Korea Tel: +82-31-920-1605, Fax: +82-31-920-1520, E-mail:
Editor: Jung-Hwan Yu, Inha University Hospital, Korea
Received 2022 August 25; Accepted 2022 August 30.

Hepatocellular carcinoma (HCC) is the third leading cause of cancer-induced mortality [1,2]. Tumor stage is an important factor of determining prognosis; however, less than 20% of patients with HCC are diagnosed at very early or early stages [3-6]. Nevertheless, a small portion of patients is diagnosed early on, and persistent efforts have been made to improve outcomes. Many academic societies recommend HCC surveillance for at-risk populations [3,7-9], and the Korean government has launched a nationwide liver cancer screening program in 2003. A 16-year cohort report from one institution shows that the diagnosis rate of very early or early stages of HCC is increasing significantly [10].

Cancer screening/surveillance mainly aims to reduce disease mortality. Stage migration (i.e., the detection of cancer at its early stages) is a surrogate endpoint that cannot replace mortality [11]. Although whether screening should be performed is a critical issue for both individuals and public health, only two randomized controlled trials have been conducted for HCC surveillance in Chinese patients with chronic hepatitis B [12,13]. One of those trials compared surveillance using serum alpha-fetoprotein with no surveillance [13] and did not demonstrate any survival benefit, yet the surveillance strategy using serum alpha-fetoprotein is far less developed than the strategy currently used [13]. The other randomized controlled trial adopted serum alpha-fetoprotein and ultrasound as surveillance tests; however, they used a cluster sampling method [12]. Methodological flaws may have necessitated further evaluation with a well-designed randomized controlled trial for HCC surveillance [14]. Nevertheless, research on methods rather than the necessity of surveillance tests is needed as early detection and treatment owing to surveillance tests are conventionally known to affect the prognosis of HCC.

In this issue of Clinical and Molecular Hepatology, Sohn et al. [15] investigated the impact of the National Liver Cancer Screening Program (NLCSP) on the receipt of curative treatment for HCC and the all-cause or liver-related mortality. The surveillance group showed a significantly lower mortality rate (12 vs. 22 deaths per 1,000 person-years; adjusted hazard ratio [HR], 0.56; 95% confidence interval [CI], 0.55–0.56) and a higher proportion of receiving curative treatment for HCC than the non-surveillance group (adjusted HR, 5.64; 95% CI, 5.48–5.81). This study demonstrated the benefit of HCC surveillance in patients aged ≥40 years with chronic hepatitis B, hepatitis C, or cirrhosis.

Despite its results, a major concern of this study is its lack of capturing HCC surveillance performed by private health care providers. Some patients in the non-surveillance group may have undergone HCC surveillance, not by the NLCSP, but by private health care providers. Despite the ambiguity of the control group, the nationwide HCC surveillance program increased the probability of receiving curative treatment for HCC and decreased the overall and liver-related mortality rates [15]. Another limitation is the indirectness of the study. Ideally, surveillance for HCC should improve the detection of early-stage HCC (stage migration), yet the present study compared the rate of receiving curative treatment for HCC instead of detecting early-stage HCC. Receiving local ablation, surgical resection, or transplantation does not necessarily indicate that HCC was detected early on. However, stage migration is just one of the surrogate endpoints [11], the most important endpoint is mortality.

Observational studies without randomization are prone to bias and uncontrolled confounding. Allocating patients into the surveillance group or determining the effect of surveillance is sometimes complicated. Previously, a matched case-control study on patients with cirrhosis found no association between HCC surveillance and reduction of HCC-related mortality [16]. This study has been criticized in that cases comprised patients who received abdominal ultrasound or serum alpha-fetoprotein tests 4 years before diagnosis. However, the present study by Sohn et al. [15] considered HCC surveillance as a time-varying variable to control immortal time bias and limited the effect of HCC surveillance until 6 months after surveillance, since surveillance for HCC is recommended every 6 months. Moreover, the analyses were adjusted rigorously to control for potential confounders, including antiviral therapy, type of liver disease, comorbidities, and socioeconomic status, in addition to baseline demographics.

Randomized controlled studies provide the highest level of evidence; however, they require time and several thousand patients [14]. Moreover, the recall strategy should be optimized, and follow-up cross-sectional imaging should be performed on time [17]. Most patients diagnosed with early-stage HCC through surveillance should be curable and receive the standard of care throughout the follow-up period. Such studies are also seemingly unfeasible since more than 99% of informed patients declined participating in a randomized controlled trial for HCC surveillance [18]. This Australian study has been criticized for not providing sufficient information on the potential harm of HCC surveillance. However, a recent multicenter prospective study from the United States also supported the patients’ preference for surveillance benefits over surveillance-related harms or inconvenience [19].

It is time to move forward from debating about whether randomized controlled trials on the necessity of HCC surveillance should be performed. In most clinical practice guidelines, at-risk populations commonly include patients with cirrhosis and hepatitis B virus infection [3,7-9,20]. There has been a debate on HCC surveillance for patients with chronic hepatitis C and nonalcoholic fatty liver disease without cirrhosis [21]. Despite some concerns, the present study enrolled patients aged ≥40 years with chronic hepatitis B, hepatitis C, or cirrhosis since they are the target population of the NLCSP in Korea and demonstrated the overall survival benefit of patients receiving the NLCSP compared with patients in the non-surveillance group [15]. The survival benefit was observed across etiology subgroups in the present study. However, further studies are warranted to confirm the benefit of HCC surveillance in patients with chronic hepatitis C without cirrhosis.

It is recognized that a small portion of patients will develop HCC even in traditional at-risk populations. Risk stratification can help refine the surveillance strategy [20,22,23]. Patients with very low risk may be exempted from repeated (and life-long) surveillance, while patients with very high risk may need more intensive surveillance. The benefit of HCC surveillance in patients with nonalcoholic fatty liver disease or advanced fibrosis (F3) after hepatitis C virus (HCV) viral eradication is unclear. The annual incidence of HCC has been reported to be 0.5% in patients with F3 fibrosis after HCV virologic cure and 2.1% in patients with cirrhosis [24]. The annual incidence has been reported to be 3.78% and 0.03% in patients with cirrhotic and non-cirrhotic nonalcoholic liver disease, respectively [25]. The incidence of HCC in non-cirrhotic patients with virologically cured hepatitis C or nonalcoholic fatty liver disease was lower than thresholds. Even in patients with chronic hepatitis B, some had minimal risk of developing HCC (annual incidence of <0.1%) [26,27]. In contrast, high-risk patients are recommended to undergo HCC surveillance at shorter intervals or with more sensitive tools, such as computed tomography (CT) or magnetic resonance imaging (MRI) [9]. Given that ultrasound has advantages in that it does not require contrast agents or radiation hazards, its low sensitivity leads to the development of a more effective imaging tool. Moreover, ultrasound has the limited ability to visualize the liver in patients with obesity [28] or a very nodular liver. Although contrast-enhanced low-dose CT may be an option for HCC surveillance [29], the risks of radiation hazards and contrast agents still exist. Non-enhanced MRI would be a viable option since there is no risk of exposure to radiation or contrast. A recent meta-analysis demonstrated much higher sensitivity (86.8%) and specificity (90.3%) in abbreviated non-contrast MRI [30]. A long scan time and high cost limit the widespread use of MRI; however, semiannual contrast-enhanced MRI can be cost-effective for patients with sufficient risk of developing HCC (annual incidence of 3%) [31]. Abbreviated MRI requires less time and cost than conventional contrast-enhanced MRI; therefore, abbreviated MRI may serve as a surveillance tool in the future. However, the optimal sequence and definition of patients with “sufficient” high risk remain to be assessed.

Accumulating studies indicate that HCC surveillance is of value and provides a survival benefit [32]. Clearly, more evidence is needed. However, it is obvious that our focus should not be on whether HCC surveillance is necessary, but on whom should be exempted from it and whom should undergo intensive strategies.


Authors’ contributions

Study conceptualization: BHK and JWP; Drafting of the manuscript: BHK; Critical revision of the manuscript: BHK, YC, and JWP

Conflicts of Interest

The authors have no conflicts to disclose.



confidence interval


computed tomography


hepatocellular carcinoma


hepatitis C virus


hazard ratio


magnetic resonance imaging


National Liver Cancer Screening Program


1. Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2021;71:209–249.
2. Chon YE, Jeong SW, Jun DW. Hepatocellular carcinoma statistics in South Korea. Clin Mol Hepatol 2021;27:512–514.
3. European Association for the Study of the Liver. EASL clinical practice guidelines: management of hepatocellular carcinoma. J Hepatol 2018;69:182–236.
4. Yoon JS, Lee HA, Park JY, Kim BH, Lee IJ, Chon YE, et al. Hepatocellular carcinoma in Korea between 2008 and 2011: an analysis of Korean nationwide cancer registry. J Liver Cancer 2020;20:41–52.
5. Chon YE, Lee HA, Yoon JS, Park JY, Kim BH, Lee IJ, et al. Hepatocellular carcinoma in Korea between 2012 and 2014: an analysis of data from the Korean nationwide cancer registry. J Liver Cancer 2020;20:135–147.
6. Yoon JS, Lee HA, Kim HY, Sinn DH, Lee DH, Hong SK, et al. Hepatocellular carcinoma in Korea: an analysis of the 2015 Korean nationwide cancer registry. J Liver Cancer 2021;21:58–70.
7. Marrero JA, Kulik LM, Sirlin CB, Zhu AX, Finn RS, Abecassis MM, et al. Diagnosis, staging, and management of hepatocellular carcinoma: 2018 practice guidance by the American Association for the Study of Liver Diseases. Hepatology 2018;68:723–750.
8. Korean Liver Cancer Association, ; National Cancer Center. 2018 Korean Liver Cancer Association-National Cancer Center Korea practice guidelines for the management of hepatocellular carcinoma. Gut Liver 2019;13:227–299.
9. Kokudo N, Takemura N, Hasegawa K, Takayama T, Kubo S, Shimada M, et al. Clinical practice guidelines for hepatocellular carcinoma: the Japan Society of Hepatology 2017 (4th JSH-HCC guidelines) 2019 update. Hepatol Res 2019;49:1109–1113.
10. Choi SI, Cho Y, Ki M, Kim BH, Lee IJ, Kim TH, et al. Better survival of patients with hepatitis B virus-related hepatocellular carcinoma in South Korea: changes in 16-years cohorts. PLoS One 2022;17e0265668.
11. Sherman M. Surveillance for hepatocellular carcinoma. Best Pract Res Clin Gastroenterol 2014;28:783–793.
12. Zhang BH, Yang BH, Tang ZY. Randomized controlled trial of screening for hepatocellular carcinoma. J Cancer Res Clin Oncol 2004;130:417–422.
13. Chen JG, Parkin DM, Chen QG, Lu JH, Shen QJ, Zhang BC, et al. Screening for liver cancer: results of a randomised controlled trial in Qidong, China. J Med Screen 2003;10:204–209.
14. Jepsen P, West J. We need stronger evidence for (or against) hepatocellular carcinoma surveillance. J Hepatol 2021;74:1234–1239.
15. Sohn W, Kang D, Kang M, Guallar E, Cho J, Paik YH. Impact of nationwide hepatocellular carcinoma surveillance on the prognosis in patients with chronic liver disease. Clin Mol Hepatol 2022;28:851–863.
16. Moon AM, Weiss NS, Beste LA, Su F, Ho SB, Jin GY, et al. No association between screening for hepatocellular carcinoma and reduced cancer-related mortality in patients with cirrhosis. Gastroenterology 2018;155:1128–1139. e6.
17. Singal AG, Nehra M, Adams-Huet B, Yopp AC, Tiro JA, Marrero JA, et al. Detection of hepatocellular carcinoma at advanced stages among patients in the HALT-C trial: where did surveillance fail? Am J Gastroenterol 2013;108:425–432.
18. Poustchi H, Farrell GC, Strasser SI, Lee AU, McCaughan GW, George J. Feasibility of conducting a randomized control trial for liver cancer screening: is a randomized controlled trial for liver cancer screening feasible or still needed? Hepatology 2011;54:1998–2004.
19. Woolen SA, Singal AG, Davenport MS, Troost JP, Khalatbari S, Mittal S, et al. Patient preferences for hepatocellular carcinoma surveillance parameters. Clin Gastroenterol Hepatol 2022;20:204–215.e6.
20. Yu JH, Cho SG, Jin YJ, Lee JW. The best predictive model for hepatocellular carcinoma in patients with chronic hepatitis B infection. Clin Mol Hepatol 2022;28:351–361.
21. Shim JH. Should you advocate for hepatocellular carcinoma surveillance in patients with alcohol-related liver disease or non-alcoholic fatty liver disease? Clin Mol Hepatol 2020;26:183–184.
22. Wu JW, Kao JH, Tseng TC. Three heads are better than two: hepatitis B core-related antigen as a new predictor of hepatitis B virus-related hepatocellular carcinoma. Clin Mol Hepatol 2021;27:524–534.
23. Liang LY, Lee HW, Wong VW, Yip TC, Tse YK, Hui VW, et al. Serum fibrosis index-based risk score predicts hepatocellular carcinoma in untreated patients with chronic hepatitis B. Clin Mol Hepatol 2021;27:499–509.
24. Lockart I, Yeo MGH, Hajarizadeh B, Dore GJ, Danta M. HCC incidence after hepatitis C cure among patients with advanced fibrosis or cirrhosis: a meta-analysis. Hepatology 2022;76:139–154.
25. Orci LA, Sanduzzi-Zamparelli M, Caballol B, Sapena V, Colucci N, Torres F, et al. Incidence of hepatocellular carcinoma in patients with nonalcoholic fatty liver disease: a systematic review, meta-analysis, and meta-regression. Clin Gastroenterol Hepatol 2022;20:283–292.e10.
26. Kim HY, Lampertico P, Nam JY, Lee HC, Kim SU, Sinn DH, et al. An artificial intelligence model to predict hepatocellular carcinoma risk in Korean and Caucasian patients with chronic hepatitis B. J Hepatol 2022;76:311–318.
27. Jeon MY, Kim BK, Lee JS, Lee HW, Park JY, Kim DY, et al. Negligible risks of hepatocellular carcinoma during biomarker-defined immune-tolerant phase for patients with chronic hepatitis B. Clin Mol Hepatol 2021;27:295–304.
28. Esfeh JM, Hajifathalian K, Ansari-Gilani K. Sensitivity of ultrasound in detecting hepatocellular carcinoma in obese patients compared to explant pathology as the gold standard. Clin Mol Hepatol 2020;26:54–59.
29. Yoon JH, Lee JM, Lee DH, Joo I, Jeon JH, Ahn SJ, et al. A comparison of biannual two-phase low-dose liver CT and US for HCC surveillance in a group at high risk of HCC development. Liver Cancer 2020;9:503–517.
30. Chan MV, Huo YR, Trieu N, Mitchelle A, George J, He E, et al. Noncontrast MRI for hepatocellular carcinoma detection: a systematic review and meta-analysis - a potential surveillance tool? Clin Gastroenterol Hepatol 2022;20:44–56.e2.
31. Kim HL, An J, Park JA, Park SH, Lim YS, Lee EK. Magnetic resonance imaging is cost-effective for hepatocellular carcinoma surveillance in high-risk patients with cirrhosis. Hepatology 2019;69:1599–1613.
32. Singal AG, Zhang E, Narasimman M, Rich NE, Waljee AK, Hoshida Y, et al. HCC surveillance improves early detection, curative treatment receipt, and survival in patients with cirrhosis: a meta-analysis. J Hepatol 2022;77:128–139.

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