AGA update calls for better surveillance of hepatocellular carcinoma

A new update from the American Gastroenterological Association (AGA) urges stronger prevention efforts and better early-detection tools for hepatocellular carcinoma (HCC), the leading cause of cancer-related death in patients with cirrhosis, and the third most common cause of cancer-related death worldwide. 

Published in Gastroenterology, the update emphasizes that early detection is critical, as curative treatments are available when HCC is diagnosed at an early stage. Yet only 30–40% of cases are diagnosed early, reflecting both limitations in current surveillance tools and low uptake of these tools. Meanwhile, the epidemiology of liver disease is shifting: non‑viral liver diseases - metabolic dysfunction–associated steatotic liver disease (MASLD) and alcohol‑related liver disease (ALD) - are now the fastest‑growing drivers of HCC, expanding the number of patients who need screening. 

The update outlines eight best-practice advice statements to help clinicians with risk stratification and surveillance strategies for HCC. 

Key insights: 

• Prevention is key 
  Reducing HCC deaths starts with preventing cirrhosis. That includes vaccination and treatment of HCV and hepatitis B virus (HBV), treatment of ALD, management of MASLD, and early intervention for liver disease. 

• Ultrasound + AFP remain the standard - for now. 
  Semiannual ultrasound and alpha‑fetoprotein testing remain the top surveillance approach. Novel blood‑ and imaging‑based biomarkers show promise, and ongoing trials such as TRACER and PREMIUM will help determine how and when they can be integrated into practice. 

• More precise risk stratification is needed. 
  Current surveillance strategies are not equally effective for all patients. Better tools are needed to identify who requires more intensive monitoring - and who may safely undergo less frequent surveillance - to support precision screening and improve early detection. 

• Surveillance benefits are well‑established. 
  Regular HCC surveillance improves outcomes for patients with cirrhosis of any etiology and for selected patients with chronic HBV. However, real‑world use remains low, underscoring the need for more accessible and effective approaches. 

Looking ahead, new models - such as the PAGED‑B score incorporating HBV DNA viral load - and machine‑learning tools, such as the SMART‑HCC score, show potential to improve risk prediction. These approaches will require additional validation before widespread adoption.