HEPATOCELLULAR CARCINOMA surveillance must become more organised and consistent across Europe to improve early diagnosis, according to a new expert review.
Hepatocellular carcinoma (HCC), the most common form of primary liver cancer, is frequently diagnosed at an advanced stage, when curative treatment options are limited. Researchers examined current surveillance practices and lessons from programmes implemented around the world.
Current guidance recommends liver ultrasound every 6 months, with or without measurement of serum alpha-fetoprotein (AFP), for patients at high risk of HCC. This principally includes people with cirrhosis and selected patients with chronic hepatitis B.
However, the authors reported that surveillance across Europe remains fragmented. Eligible patients may not be identified, invited, or recalled consistently, while responsibility can be divided between primary care, hepatology, and radiology services.
Patient attendance may also be affected by limited understanding of surveillance, transport difficulties, socioeconomic disadvantage, and competing health problems. These barriers can result in missed examinations and delayed cancer detection.
Although ultrasound is widely available, non-invasive, and relatively inexpensive, its effectiveness varies. Obesity, nodular cirrhosis, and metabolic liver disease can make small tumours more difficult to identify, while operator experience and examination quality can also affect performance.
The researchers therefore called for minimum quality standards, appropriate training, and routine auditing of surveillance services. Patients whose ultrasound examinations provide inadequate visualisation may require alternative imaging approaches, although the cost and capacity implications must be considered.
Emerging strategies, including abbreviated MRI, novel blood-based biomarkers, and personalised risk models, could eventually improve surveillance. Nevertheless, the authors stressed that further validation is required before these approaches can replace established ultrasound-based pathways.
The review highlighted the value of structured programmes incorporating patient registers, automated invitations and reminders, defined referral pathways, and rapid follow-up of abnormal results. Surveillance uptake, scan quality, stage at diagnosis, treatment, and patient outcomes should also be monitored.
Lessons from programmes outside Europe indicate that coordinated systems may improve participation and enable more cancers to be detected at a treatable stage. However, approaches must be adapted to differences in national healthcare infrastructure, disease patterns, and available resources.
The authors also acknowledged limitations in the evidence supporting HCC surveillance. Much of the reported survival benefit comes from observational research, which can be affected by lead-time and selection biases. Randomised evidence for a mortality benefit remains limited and is derived largely from patients with hepatitis B.
Despite these uncertainties, the researchers concluded that Europe should prioritise organised, equitable, and quality-assured surveillance. Improving the reliable delivery of existing testing may offer a more immediate benefit than waiting for new surveillance technologies.
Reference
Qurashi M et al. Hepatocellular carcinoma surveillance in Europe: challenges and lessons from global practice. Lancet Reg Health Eur. 2026. DOI:10.1016/j.lanepe.2026.101852.
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