Challenges and adherence to hepatocellular carcinoma surveillance in patients with advanced chronic liver disease

INTRODUCTION AND OBJECTIVES: Hepatocellular carcinoma (HCC) is a major global health issue in patients with advanced chronic liver disease (ACLD). Although guidelines recommend biannual ultrasound surveillance for eligible ACLD patients, adherence remains suboptimal. This study aims to evaluate surveillance adherence, identify barriers to non-adherence, quantify the diagnostic yield of surveillance, and assess its impact on early-stage HCC detection. PATIENTS AND METHODS: This retrospective observational cohort study included adult ACLD patients followed at a tertiary hospital liver unit in Portugal during 2022. Patients with an ECOG ≥3, Child-Pugh class C ineligible for transplant, prior liver cancer, metastatic liver disease, or under investigation of a previously identified liver nodule were excluded. Surveillance adherence was defined as completion of two imaging tests within 150-210 days. Adherence rates, non-adherence reasons, and HCC incidence during one year of surveillance were analyzed. RESULTS: Among 621 patients, 54.8% were adherent to surveillance. Non-adherence was attributed to hospital-related (41.6%), patient-related (29.9%), and hepatologist-related (28.5%) factors. Lack of social support significantly increased the odds of non-adherence. Hepatologist adherence to surveillance protocols was 87.1%. Liver nodules were detected on ultrasound in 77 cases (12.4%), of whom 16 were HCC. Most HCC cases (62.5%) were confirmed by computed tomography, although the remainder required additional tests. While adherent patients had higher odds of earlier-stage diagnosis, it was not statistically significant. CONCLUSIONS: This study provides real-world evidence of the multifactorial barriers to HCC surveillance adherence. The findings support targeted interventions, risk-based surveillance strategies and follow-up in liver units to improve surveillance performance.