HCC risk stratification scores: insights from large multi-center national cohort study

Current guidelines advocate biannual HCC surveillance for chronic hepatitis C patients who achieved sustained virological response (SVR) following direct acting antivirals (DAAs), posing a heavy burden on healthcare systems. This study aimed to identify the most accurate and clinically useful risk stratification tool among patients who achieved SVR following DAAs in a large, multicenter national cohort. A retrospective study across 52 NCCVH centers in Egypt included 8,419 CHC patients with cirrhosis (F4) or advanced fibrosis (F3) who achieved SVR after DAAs and had complete follow-up data. Baseline data were used to calculate HCC risk scores (GES, aMAP, THRI, ALBI, FIB-4). Prognostic performance was assessed using Kaplan–Meier analysis, AUC, Harrell’s C-index, and Brier score with calibration plots. Decision curve analysis and Net Reclassification Improvement were applied to evaluate clinical utility and incremental prognostic value. All evaluated HCC risk scores showed adequate performance, with significant separation of incidence curves (log-rank p ≤ 0.05). GES demonstrated the highest AUC (0.632), followed by THRI (0.600) and aMAP (0.591), with C-indices around 0.63.Kaplan–Meier analysis confirmed significant survival differences between risk groups. GES had superior calibration (Brier score 0.197, slope 0.90). Decision Curve Analysis favored GES, offering the greatest net clinical benefit, especially at thresholds 0.1–0.3. NRI analysis showed aMAP worsened classification (NRI = − 0.16), while THRI offered minimal improvement over GES (NRI = + 0.05). Implementation of the GES score in Egypt’s national HCC surveillance program, enabling individualized surveillance and reducing healthcare burden in accordance with current EASL recommendations.