Current and new strategies for hepatocellular carcinoma surveillance

Hepatocellular carcinoma (HCC) remains a leading cause of cancer-related mortality worldwide, particularly among individuals with chronic liver diseases. Early detection through surveillance significantly improves survival rates and current guidelines recommend semiannual ultrasound, with or without alpha-fetoprotein (AFP) testing, for high-risk populations. However, limitations in ultrasound sensitivity, physician adherence, and patient compliance affect the effectiveness of these surveillance efforts. This review explores both current and emerging strategies for HCC surveillance. Individualized surveillance approaches, utilizing risk stratification tools such as the aMAP and PAGE-B scores, enable tailored monitoring based on individual risk profiles, potentially reducing unnecessary screening in low-risk groups. Advanced imaging techniques, including contrast-enhanced ultrasound and abbreviated magnetic resonance imaging, demonstrate improved sensitivity over traditional ultrasound, particularly for early-stage HCC detection. Additionally, combining clinical characteristics with novel HCC biomarkers-such as the Gender, Age, AFP-L3, AFP, and Des-gamma-carboxy prothrombin (GALAD) score; HCC early detection screening score version 2 (HES V2.0) score; Gender, Age, AFP, and Des-gamma-carboxy prothrombin (GAAD) score; and AFP, Sex, Age, and Protein induced by vitamin K absence-II (ASAP) score-has shown higher sensitivity for early detection, with GALAD and HES V2.0 performing particularly well in phase 3 biomarker studies. Emerging molecular diagnostics, including liquid biopsy and genetic markers, also show promise in refining future HCC surveillance protocols. Despite these advancements, a limited number of at-risk patients currently undergo surveillance. Therefore, solutions must focus on enhancing awareness, adherence, and accessibility to surveillance tools. This review discusses various strategies for optimizing HCC surveillance, emphasizing a multifaceted approach that integrates risk-assessment tools, advanced imaging, and novel biomarkers to improve early detection and reduce mortality.