Hepatocellular Carcinoma Surveillance and Treatment in Cirrhosis: What You Need to Know

Over 900,000 people worldwide are diagnosed with liver cancer each year, and more than 8 in 10 of those cases happen in people who already have cirrhosis. That’s not a coincidence. Cirrhosis - scarring of the liver from long-term damage - is the single biggest risk factor for hepatocellular carcinoma (HCC), the most common type of primary liver cancer. The good news? When caught early, HCC is often treatable. The bad news? Most people don’t get screened, and by the time symptoms show up, it’s often too late.

Why Surveillance Matters More Than You Think

If you have cirrhosis, regular screening isn’t optional - it’s life-saving. Studies show that people who get checked every six months are up to 70% more likely to survive five years after diagnosis than those who don’t. Why? Because HCC grows fast. In a cirrhotic liver, tumors can go from invisible to the size of a golf ball in under six months. That’s why guidelines from the American Association for the Study of Liver Diseases (AASLD) and the European Association for the Study of the Liver (EASL) both say: every adult with cirrhosis should get an ultrasound every six months.

Ultrasound is cheap, safe, and widely available. It doesn’t use radiation. It doesn’t require contrast dye. And it’s good enough to spot tumors bigger than 1 cm - the size at which curative treatments still work. But ultrasound alone isn’t perfect. That’s why some guidelines also suggest checking a blood marker called alpha-fetoprotein (AFP). If AFP is above 20 ng/mL, it’s a red flag. Not every elevated AFP means cancer - it can rise with inflammation or active hepatitis - but it’s a signal to dig deeper.

When an ultrasound shows something suspicious, the next step is always a contrast-enhanced CT or MRI scan. These scans show how blood flows through the liver, which helps doctors tell the difference between a harmless nodule and a tumor. The Liver Imaging Reporting and Data System (LI-RADS), updated in 2022, gives radiologists a standard way to describe what they see. A LI-RADS 5 result means the lesion is almost certainly HCC. That’s when treatment needs to start immediately.

Who Should Be Screened - And Who Doesn’t Need It

Not every person with cirrhosis is at the same risk. That’s where things get more nuanced. The old rule - screen everyone - is changing. New research shows that some people have such low risk that screening might do more harm than good, with unnecessary scans, anxiety, and costs.

The EASL’s 2023 Policy Statement introduced a risk-based model. It divides cirrhotic patients into three groups:

• High-risk (over 2.5% annual risk): These are people with hepatitis B, active hepatitis C (even after cure), heavy alcohol use, or advanced scarring. They get ultrasound every six months - and some may soon get MRI instead.
• Medium-risk (1.5-2.5% annual risk): Includes most people with NAFLD (non-alcoholic fatty liver disease) after viral clearance or moderate alcohol use. They stick with standard ultrasound every six months.
• Low-risk (under 1.5% annual risk): People with stable, mild cirrhosis from causes like autoimmune hepatitis that’s well-controlled. They might not need routine screening, but should still be monitored by their doctor.

Meanwhile, the AASLD still recommends screening everyone with Child-Turcotte-Pugh (CTP) Class A or B cirrhosis - even if they’re older or have other health problems. But they explicitly say not to screen those with CTP Class C cirrhosis unless they’re on a transplant list. Why? Because their life expectancy is often less than two years, and HCC treatment won’t help much if the liver is failing.

There’s a big gap in the U.S. The U.S. Preventive Services Task Force hasn’t issued any official guidance. That leaves primary care doctors confused. In VA hospitals, only about 30-50% of eligible patients get screened. In community clinics? Sometimes less than 20%. That’s not because doctors don’t know - it’s because systems aren’t built to remind them.

How Treatment Depends on Stage and Liver Health

If HCC is found early - and only about 30% of cases are - there are real chances for cure. Treatment options depend on three things: tumor size and number, liver function, and whether the cancer has spread.

Stage 0 or A (very early): Tumors are small (under 2 cm), single, and the liver still works well. Options include:

• Radiofrequency ablation (RFA): A needle is inserted through the skin, guided by ultrasound, and heated to burn the tumor. Success rates are over 85% for tumors under 2 cm.
• Microwave ablation: Similar to RFA but uses microwaves. Faster, works better near big blood vessels.
• Surgical resection: Removing the tumor. Only possible if the liver is healthy enough to regenerate. Usually reserved for younger patients with minimal scarring.

Stage B (intermediate): Multiple tumors, or one larger tumor, but no spread outside the liver. The go-to treatment is transarterial chemoembolization (TACE). A catheter is threaded into the liver artery, and chemo drugs plus tiny beads are delivered directly to the tumor. This cuts off its blood supply and poisons it at the source. It’s not a cure, but it can shrink tumors and extend life by years.

Stage C (advanced): Cancer has spread to blood vessels or lymph nodes. Surgery and ablation won’t help. The main treatment is targeted drugs like sorafenib or lenvatinib. These block signals that help tumors grow. Immunotherapy combinations - like atezolizumab plus bevacizumab - are now first-line for many patients because they’ve shown better survival than older drugs. Median survival is 15-20 months, but some patients live much longer.

Stage D (end-stage): The liver is failing, and the cancer is widespread. At this point, treatment focuses on comfort. Liver transplant is the only potential cure, but only if the tumor is small enough and the patient is healthy enough to survive surgery. The Milan criteria - one tumor under 5 cm, or up to three tumors each under 3 cm - are still the standard for transplant eligibility.

The Real Barriers: Why People Miss Screenings

Guidelines are clear. But in practice, most people with cirrhosis never get screened. Why?

• Doctors don’t trigger reminders. In 67% of clinics, there’s no electronic alert when a patient is diagnosed with cirrhosis. No reminder = no screening.
• Patient no-shows are high. Between 25% and 40% of people miss their ultrasound appointments. Some are scared. Others don’t understand why they need it if they feel fine.
• Access is unequal. Black patients are less than half as likely to get screened as white patients. Medicaid patients are screened at half the rate of those with private insurance.
• Cost and logistics. Ultrasound costs about $287 a year per patient. Add AFP testing, and it jumps to $412. For uninsured patients, that’s a lot. And not every clinic has a radiologist trained to read liver ultrasounds.

Successful programs fix these problems. One VA study used patient navigators - trained staff who call patients, schedule appointments, and explain why screening matters. No-show rates dropped from 32% to 14%. Another hospital added automated alerts to their electronic records. Time from cirrhosis diagnosis to first ultrasound dropped from 142 days to 67.

What’s Coming Next

The future of HCC screening is smarter, not just more frequent. New tools are on the horizon:

• AI-assisted ultrasound: Tools like Medtronic’s LiverAssist (FDA-cleared in 2022) help technicians spot tiny tumors that humans might miss. They boost detection by 18-22%.
• Blood biomarkers: The GALAD score - which looks at gender, age, AFP, AFP-L3, and DCP - can detect early HCC with 85% accuracy. It’s not ready for prime time yet, but NIH-funded trials are testing it alongside imaging.
• Abbreviated MRI: A full liver MRI takes 30 minutes and costs $800+. New 5-7 minute protocols cut costs to $350-400. For high-risk patients, MRI may soon replace ultrasound.
• The aMAP score: A simple formula using age, gender, albumin, bilirubin, and platelets can predict risk with 81% accuracy. It’s being tested in Europe and Asia.

By 2027, experts predict that 30-40% of high-risk patients will get MRI instead of ultrasound. The AASLD is expected to update its guidelines in late 2024, and those updates will almost certainly push for risk-based screening.

What You Should Do Right Now

If you have cirrhosis:

• Ask your doctor if you’re on a surveillance schedule. If not, ask why.
• Make sure your ultrasound is done every six months - no exceptions.
• Know your liver function score (Child-Pugh class). If you’re Class C, talk to your doctor about whether screening still makes sense.
• If you’re told you need a CT or MRI, don’t delay. Early detection saves lives.
• Bring someone with you to appointments. It’s hard to remember everything when you’re stressed.

If you’re a caregiver or family member: Help remind your loved one. Call to book the next scan. Drive them if they can’t. Write down questions before the visit. You’re not just helping - you’re extending their life.

Hepatocellular carcinoma doesn’t have to be a death sentence. But it won’t be caught unless someone is looking for it. The tools are here. The guidelines are clear. The only thing missing is action.

Next Steps if You’re at Risk

If you have cirrhosis from hepatitis B, hepatitis C, alcohol, or fatty liver disease:

• Request a copy of your latest liver ultrasound report.
• Ask if your doctor uses a formal HCC surveillance protocol.
• Set a recurring calendar reminder for your next scan - six months from now.
• If you’re unsure about your risk level, ask for your Child-Pugh score and MELD score.
• Consider asking about the GALAD score or aMAP score if your clinic offers advanced testing.

Don’t wait for symptoms. By the time you feel sick, it’s often too late. Screening is the only thing standing between you and a late-stage diagnosis. It’s simple. It’s proven. And it’s your best shot at living longer.