AGA Clinical Practice Update on Risk Stratification and Emerging Surveillance Strategies for Hepatocellular Carcinoma: Expert Review

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related death in patients with cirrhosis. Although advancements in surgical, locoregional, and systemic therapies have improved outcomes for patients with early-stage HCC, most cases are diagnosed at later stages due to both the limitations of currently recommended surveillance modalities and their underuse, with fewer than 1 in 4 patients with cirrhosis receiving surveillance for this tumor. Current guidelines recommend semiannual surveillance with ultrasound and α-fetoprotein, but this strategy has suboptimal sensitivity, and alternative imaging techniques (eg, computed tomography and magnetic resonance imaging) have their own risks and challenges with implementation. HCC surveillance has established benefits in certain at-risk populations, including patients with cirrhosis (of any etiology) and selected patients with chronic hepatitis B virus. The burden of HCC is rising most rapidly among patients with nonviral liver diseases, including metabolic dysfunction-associated steatotic liver disease and alcohol-associated liver disease, among whom the annual incidence rate of HCC is significantly lower than was previously observed in patients with viral hepatitis. This underscores the need for better biomarker and risk-stratification tools to detect HCC earlier and improve surveillance efficiency, although integrating them into routine clinical practice presents a significant challenge. This American Gastroenterological Association (AGA) Clinical Practice Update aims to provide Best Practice Advice on emerging strategies for HCC risk stratification and surveillance.