Surveillance for Hepatocellular Carcinoma in Patients at High Risk

Hepatocellular carcinoma (HCC) is the third leading cause of cancer-related mortality worldwide and most often arises in patients with chronic liver disease and cirrhosis. Since curative treatment options are largely limited to early-stage disease, effective surveillance strategies are essential to improve outcomes. Current guidelines recommend semiannual US combined with serum α-fetoprotein level testing as the standard surveillance approach for most patients at high risk. Liver Imaging Reporting and Data System 2024 guidance provides a structured framework for interpretation of surveillance US and highlights the importance of examination quality assessment and reporting by incorporating it into the management decision-making algorithm. US surveillance improves early tumor detection and survival but demonstrates suboptimal sensitivity in certain high-risk subgroups, particularly patients with obesity, hepatic steatosis, and advanced cirrhosis. Growing evidence supports the use of alternative strategies including biomarker panel results and abbreviated MRI protocols in selected patient subgroups because these approaches demonstrate higher sensitivity and favorable cost-effectiveness when applied to appropriately risk-stratified populations. Furthermore, cost-effectiveness analyses consistently indicate that surveillance efficiency strongly depends on individual HCC risk, imaging costs, surveillance use, and societal willingness-to-pay thresholds, supporting a departure from uniform "one-size-fits-all" strategies in favor of personalized, risk-adapted surveillance paradigms. Despite advances in diagnostic performance, surveillance use remains suboptimal in clinical practice due to patient-, provider-, and system-level barriers. The authors aim to synthesize current evidence on HCC surveillance including identifying target populations; evaluating the diagnostic performance of available modalities; and considering cost-effectiveness, emerging technologies, and real-world barriers to implementation of surveillance protocols.