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

Most people with cirrhosis don’t know they’re at high risk for liver cancer-until it’s too late. Hepatocellular carcinoma (HCC) is the most common type of liver cancer, and over 80% of cases happen in people who already have cirrhosis. The good news? If caught early, HCC can often be cured. The bad news? Most cases are found too late because surveillance isn’t happening as it should.

Why Surveillance Matters for People with Cirrhosis

If you have cirrhosis, your liver is scarred. That scarring doesn’t just slow down liver function-it creates the perfect environment for cancer to grow. HCC doesn’t show symptoms in its early stages. By the time someone feels pain, loses weight, or turns yellow, the tumor is often too large to remove. That’s why screening isn’t optional-it’s life-saving.

Studies show that people who get regular surveillance live longer. Without it, only 10-20% survive five years after diagnosis. With it, that number jumps to 50-70%. One major study found that regular screening added about three months to life expectancy for people with a 1.5% annual risk of HCC. That might not sound like much, but when you’re talking about cancer, those months matter.

What Does HCC Surveillance Actually Look Like?

The standard screening test is a liver ultrasound every six months. It’s simple, non-invasive, and doesn’t use radiation. A technician moves a probe over your abdomen to look for lumps or abnormal areas. If something suspicious shows up, you’ll need a more detailed scan-usually an MRI or contrast-enhanced CT.

Some guidelines also suggest checking a blood marker called alpha-fetoprotein (AFP). But AFP isn’t perfect. It can be high for reasons other than cancer, like active hepatitis. And many early HCC tumors don’t raise AFP at all. So while some doctors still order it, most experts now say ultrasound alone is enough. If AFP is above 20 ng/mL, that’s a red flag-but it doesn’t replace imaging.

The timing matters too. HCC tumors grow about 1-2 cm every six months in cirrhotic livers. That’s why screening every six months is the sweet spot. Screen too early, and you waste resources. Screen too late, and you miss the window for cure.

Who Should Be Screened? Not Everyone with Cirrhosis

For years, the rule was simple: if you have cirrhosis, you get screened. But that’s changing. New research shows not all cirrhosis is the same. Your risk depends on what caused it, how advanced it is, and your overall health.

The European Association for the Study of the Liver (EASL) now recommends risk-based screening. They divide cirrhosis patients into three groups:

• High risk (over 2.5% annual risk): Ultrasound every six months, or possibly MRI.
• Medium risk (1.5-2.5% annual risk): Standard six-month ultrasound.
• Low risk (under 1.5% annual risk): Screening may not be needed.

For example, someone with cirrhosis from hepatitis B has a much higher risk than someone whose cirrhosis came from alcohol use and has been sober for five years. Someone with Child-Turcotte-Pugh (CTP) Class C cirrhosis-meaning their liver is failing-isn’t usually screened unless they’re on a transplant list. Their life expectancy is too short for surveillance to help.

In the U.S., the American Association for the Study of Liver Diseases (AASLD) still recommends screening everyone with CTP Class A or B cirrhosis. But they’re expected to update their guidelines in late 2024, and risk-based approaches are likely to become standard.

What Happens If Something Is Found?

If your ultrasound shows a mass larger than 1 cm, you don’t wait. You go straight to a multiphase MRI or CT scan. These scans use contrast dye to see how the tumor takes up blood-something HCC does differently than benign lumps.

Radiologists use a system called LI-RADS (Liver Imaging Reporting and Data System) to classify what they see. It’s like a traffic light: LR-1 is definitely benign, LR-5 is definitely HCC, and LR-3 or LR-4 means it’s probably cancer but needs more testing.

If the diagnosis is confirmed, treatment depends on how far the cancer has spread and how well your liver still works. The Barcelona Clinic Liver Cancer (BCLC) staging system is used worldwide to guide choices.

Treatment Options: From Cure to Control

If HCC is caught early (BCLC stage 0 or A), you have a real shot at cure:

• Surgical removal: Removing the tumor is possible if it’s small and your liver is still functioning well.
• Liver transplant: The best option for many. You get a new liver and the cancer is gone. But you need to meet strict criteria-usually one tumor under 5 cm or up to three tumors under 3 cm each.
• Radiofrequency ablation (RFA): A needle is inserted into the tumor through the skin. Heat destroys the cancer cells. It’s used for tumors under 3 cm.

For slightly more advanced cases (BCLC stage B), the go-to treatment is transarterial chemoembolization (TACE). Doctors inject chemotherapy directly into the artery feeding the tumor, then block the artery to trap the drug inside. It slows growth and can shrink tumors.

If the cancer has spread beyond the liver or your liver is too damaged for surgery, options are limited but improving:

• Targeted drugs: Sorafenib and lenvatinib are oral pills that block signals cancer cells use to grow. They can extend life by several months.
• Immunotherapy: Drugs like nivolumab and pembrolizumab help your immune system recognize and attack cancer. They’re now used in combination with other drugs for advanced HCC.
• Clinical trials: New treatments are being tested all the time. If you’re eligible, it’s worth asking about.

Why Is Surveillance So Poorly Done?

Even though guidelines are clear, only 30-50% of cirrhotic patients in the U.S. get screened regularly. Why?

• Doctors don’t know: Many primary care providers aren’t trained to recognize who needs screening. Cirrhosis is often managed by specialists, but follow-up care falls to general doctors.
• No reminders: In 67% of clinics, there’s no electronic alert in the medical record when a patient with cirrhosis is due for a scan.
• Patient barriers: People miss appointments due to transportation, work, or fear. One study found 25-40% of patients skip their screening.
• Cost and access: Ultrasound isn’t free. In the U.S., the average cost per year is $287 for ultrasound alone. For patients on Medicaid, it’s harder to get scheduled.
• Racial disparities: White patients are 50% more likely to get screened than Black patients. Insurance status makes a big difference too.

What’s Changing in 2025 and Beyond?

The field is moving fast. New tools are emerging:

• AI-assisted ultrasound: Tools like Medtronic’s LiverAssist help technicians spot tiny tumors that the human eye might miss. They improve detection by up to 22%.
• Better blood tests: The GALAD score combines age, gender, AFP, AFP-L3, and DCP. It detects early HCC with 85% accuracy-better than AFP alone.
• Abbreviated MRI: A 5-7 minute liver MRI now costs $350-400. It’s being studied as a replacement for ultrasound in high-risk patients.
• Risk scores: The aMAP score (based on age, gender, albumin, bilirubin, platelets) can predict risk with 81% accuracy. It’s already being used in some European clinics.

A major trial called SURVIVE is tracking 10,000 cirrhotic patients to compare standard screening with risk-based screening. Results are due by late 2025. If they show better outcomes with risk-based approaches, guidelines will change fast.

What You Can Do

If you have cirrhosis:

• Ask your doctor: “Am I at risk for liver cancer? Should I be screened?”
• Make sure your ultrasound is scheduled every six months. Set a phone reminder.
• If you’re told you don’t need screening, ask why. Get the risk calculation-if your annual risk is over 1.5%, you should be screened.
• Know your liver function. Ask for your Child-Pugh score. If you’re Class C, ask if transplant is an option.
• Don’t wait for symptoms. By then, it’s often too late.

If you’re a caregiver or family member: Help track appointments. Call the clinic if a scan is missed. Bring someone with you to appointments to ask questions.

Final Thoughts

Hepatocellular carcinoma doesn’t have to be a death sentence. But it won’t be caught by accident. It needs a system-regular scans, clear protocols, and patients who know their risk. Right now, that system is broken for too many people.

The science is solid. The tools are here. What’s missing is consistent action. If you have cirrhosis, don’t assume someone else is watching out for you. Be your own advocate. Ask for the scan. Push for the follow-up. Because in this case, early detection isn’t just helpful-it’s the difference between life and death.