After HBsAg clearance, who still needs liver cancer surveillance?

Clinical takeaway: Consider age at HBsAg seroclearance, sex, cirrhosis, and other HCC risk factors when reassessing surveillance. Men younger than 40 years and women younger than 50 years who clear HBsAg and do not have cirrhosis may have HCC risk approaching that of the general population; surveillance should continue for patients with cirrhosis and those with additional risk factors.

Hepatitis B surface antigen (HBsAg) seroclearance is considered a functional cure, but uncertainty about residual hepatocellular carcinoma (HCC) risk has led many patients to continue lifelong surveillance. These findings may help clinicians identify a very-low-risk group in whom routine screening could potentially be discontinued.

Researchers analyzed territory-wide health data from Hong Kong for 13,379 adults with chronic hepatitis B (CHB) who achieved HBsAg seroclearance between 2000 and 2022. At the time of seroclearance, the mean age was approximately 60 years, 60% were men, and nearly 15% had cirrhosis.

During long-term follow-up, 274 patients, or 2%, developed hepatocellular carcinoma (HCC), typically about 5.6 years after HBsAg loss. Risk varied substantially by age, sex, and cirrhosis status.

Among patients without cirrhosis who cleared HBsAg before age 50, the annual HCC incidence was 0.03%—the same rate observed in the general population. Annual incidence was 0.02% among men who cleared HBsAg before age 40 and 0.09% among men aged 40 to 49 years.

No HCC cases occurred during as long as 15 years of follow-up among 1,317 women without cirrhosis who cleared HBsAg before age 50. Among women aged 50 to 59 years, annual incidence remained low at 0.06%.

By contrast, patients with cirrhosis remained at appreciable risk regardless of age: annual HCC incidence was 0.43% for those younger than 50 years and 0.62% for those aged 50 years or older.

The authors concluded, “Patients with CHB who clear HBsAg at younger ages, particularly men <40 years and women <50 years without cirrhosis or additional risk factors, have very low HCC risk and may not require routine surveillance.”

Source: El-Debeiky S, et al. (2026 July 13) Gastroenterology. Long-term incidence of hepatocellular carcinoma after hepatitis B surface antigen seroclearance