Surveillance for hepatocellular carcinoma in patients with advanced liver fibrosis

Surveillance is the only pragmatic approach to improve treatment of hepatocellular carcinoma (HCC) owing to the fact that it allows detection of the tumor at an early and better curable stage. International liver societies recommend surveillance with biannual abdominal ultrasound (US) for patients with cirrhosis of any etiology because of their high risk of developing HCC. This strategy is considered cost-effective, as surveillance requires an articulated and costly set of interventions, including linkage to care of patients with an early detected tumor. However, as transition to HCC is increasingly being observed in noncirrhotic patients, the majority of which does not reach the threshold of cost effectiveness for screening. The European and Japanese liver societies elected to confine recommendations for HCC screening to noncirrhotic patients with advanced fibrosis due to hepatitis C or hepatitis B only. These latter recommendations, however, are challenged by the increasing number of patients with viral hepatitis in whom HCC risk has been attenuated but not eradicated by successful antiviral therapy. In this set of patients, entry criteria of surveillance need to be refined in the light of the suboptimal diagnostic accuracy of non invasive tests that are employed to identify the ideal candidates for surveillance.