Surveillance for patients at risk of hepatocellular carcinoma: how to improve its cost-effectiveness and expand the role of multidisciplinary tumor board?

Surveillance for hepatocellular carcinoma (HCC) improves early tumor detection, increases access to curative therapies, and reduces mortality by about 40%. Early diagnosis through surveillance is essential and should be extended to as many at-risk patients as possible to maximize the benefits of multidisciplinary tumor board evaluations. Current guidelines recommend semi-annual abdominal ultrasonography (US), with/without serum alpha-fetoprotein measurement, for patients with cirrhosis and certain subgroups of individuals with pre-cirrhotic chronic liver disease. However, the populations eligible for surveillance include subsets with varying degrees of HCC risk, which may change over time in some individuals. As risk level is a key determinant of cost-effectiveness, the rigid, “one-size-fits-all” strategy appears inadequate. Moreover, certain non-cirrhotic patients - particularly those with advanced liver fibrosis - are currently excluded from surveillance but may benefit from risk stratification to identify those for whom surveillance would be cost-effective. Surveillance strategies must also consider potential harms, and the limitations of US as a screening test. In response, alternative approaches such as biomarkers-based tests and abbreviated magnetic resonance imaging are under investigation. This article reviews the literature advocating for a transition from the current “one-size-fits-all” approach to programs tailored to individual oncological risk (risk-stratified surveillance) or those that also consider the main factors (sex, etiology, phenotype) that influence screening test performance (precision surveillance). Additionally, it presents a seminal proposal for a risk-stratified algorithm designed to optimize cost-effectiveness and the risk-benefit balance by integrating variable screening intervals and modality selection.