Hepatocellular Carcinoma in Egypt in the Post <scp>HCV</scp> Elimination Era: Changing Aetiology, Surveillance, and Management Pathways

Egypt carries one of the highest contemporary burdens of hepatocellular carcinoma (HCC) worldwide, shaped by a distinctive historical prevalence of hepatitis C virus (HCV) following parenteral anti-schistosomal therapy campaigns and now entering a new post-elimination era. Recent national estimates indicate 27 946 new liver cancer cases in 2022 (18.6% of the total cancer cases) and 26 971 deaths (28.3% of total cancer deaths), with a striking male predominance of approximately 4:1 and incidence and mortality rates of 22.0 and 19.9 per 100 000 in men versus 5.8 and 5.8 per 100 000 in women. Egypt's rapid scale-up of direct acting antivirals culminated in the "100 Million Health" initiative, which screened 65 million and treated more than 4 million with cure rates exceeding 98%, substantially reducing the chronic HCV reservoir. However, HCC risk persists after sustained virologic response in patients with advanced fibrosis or cirrhosis, and the national aetiologic profile is shifting toward metabolic dysfunction associated steatotic liver disease (MASLD), alongside ongoing contributions from hepatitis B virus and other locally relevant risk factors. In response, Egyptian recommendations adopt a pragmatic, risk assessed approach that intensifies surveillance for very high risk groups, using ultrasonography with alpha fetoprotein every 4 months in settings where HCC incidence and health system constraints justify closer follow up, with selective use of AFP L3, PIVKA II, and composite scores where available. Treatment pathways are increasingly structured across Ministry of Health and university based services, prioritising curative options for early stage disease, transarterial chemoembolization for intermediate stage disease, and modern systemic therapy for advanced disease. Despite these advances, major gaps remain in surveillance coverage, timely access to high quality imaging and biomarkers, and equitable delivery of locoregional and systemic treatments. This review synthesises Egypt's evolving post HCV HCC landscape and outlines priorities to translate virologic elimination into measurable reductions in HCC mortality.