Hepatocellular carcinoma surveillance in Europe: challenges and lessons from global practice

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality worldwide and a public health concern, with 75% of cases considered preventable. Biannual liver ultrasound, with or without serum alpha-fetoprotein, is recommended as surveillance for patients at high risk of HCC. While the rationale for surveillance is strong and it continues to be recommended by all professional societies, there is ongoing debate about the strength and relevance of the evidence supporting surveillance for all populations with cirrhosis. European surveillance uptake is suboptimal, with high rates of late-stage diagnosis and subsequent poor prognosis. In this paper, we provide an overview of surveillance focusing on Europe and draw lessons from across the world. We discuss lessons learnt from the implementation of national and coordinated surveillance programmes in Asian countries and the global challenges resulting from the changing epidemiology of chronic liver disease, particularly the rise of MASLD. We consider the patient perspective, including stigma and inequalities in access and delivery. We explore emerging approaches to surveillance, including biomarkers, abbreviated MRI and risk-stratification, which may improve early diagnosis. Finally, we address the lack of funding and political willpower arising from an insufficient evidence base.