Gastroenterology
Prevent cirrhosis, personalize surveillance: AGA updates HCC risk strategy
Clinical takeaway: Focus on preventing cirrhosis and continue semiannual ultrasound plus AFP for at-risk patients—while reserving new biomarkers and MRI strategies for future adoption pending validation.
The AGA’s latest Clinical Practice Update emphasizes that the most effective way to reduce hepatocellular carcinoma (HCC) mortality is to prevent cirrhosis in the first place—through aggressive treatment of viral hepatitis, management of metabolic disease, and alcohol use disorder interventions. Antiviral therapy for HBV (eg, tenofovir or entecavir) and curative direct-acting antivirals for HCV remain cornerstone strategies to reduce progression to cirrhosis and downstream cancer risk.
For patients already at risk, the guidance reaffirms that semiannual ultrasound combined with α‑fetoprotein (AFP) remains the preferred surveillance strategy. This combination improves early detection and survival compared with ultrasound alone, despite modest sensitivity limitations. Advanced imaging with CT or MRI is not recommended for routine surveillance due to cost, access, and potential harms.
The update narrows who should be screened: surveillance is recommended for all patients with cirrhosis (Child-Pugh A/B and selected C awaiting transplant) and certain patients with chronic HBV without cirrhosis, but not for most noncirrhotic patients with MASLD or post-SVR HCV due to low annual HCC incidence.
Investigational tools are a major focus. Blood-based biomarker panels such as GALAD and emerging liquid biopsy approaches show promise but are not ready for routine use and should not replace ultrasound plus AFP. Likewise, multicancer early detection tests are not recommended for HCC surveillance. Abbreviated MRI protocols may improve sensitivity and are under active study but remain investigational.
Risk stratification is evolving but not yet clinic-ready for most cirrhosis populations. Existing models lack sufficient validation, though PAGE-B and REAL-B scores can help stratify HCC risk in patients with chronic HBV without cirrhosis.
The authors underscore a persistent gap: fewer than one in four patients with cirrhosis undergo consistent surveillance. As they note, improving outcomes will require both better tools and broader implementation: “There is a critical need for improved biomarkers and more precise risk-stratification tools to improve the efficiency of HCC early detection.”
Clinicians should also weigh potential harms of surveillance—including false positives, anxiety, and costs—and engage in shared decision-making, especially for patients with limited life expectancy.
Overall, the update signals a future shift toward precision surveillance—but for now, prevention of cirrhosis and consistent use of ultrasound plus AFP remain the most effective strategies.
Source: Rich NE, et al. (2026, April 15). Gastroenterology. AGA Clinical Practice Update on Risk Stratification and Emerging Surveillance Strategies for Hepatocellular Carcinoma: Expert Review