Understanding Missed HCC Screening in Patients With Cirrhosis: Barriers to Care

Surveillance for hepatocellular carcinoma (HCC) in patients with cirrhosis is a cornerstone of liver care, yet real-world adherence to screening remains a persistent challenge. In this segment of Liver Lineup: Updates & Unfiltered Insights, hosts Kim Brown, MD, and Nancy Reau, MD, examine new data on how wide the gap remains between guideline recommendations and clinical practice as well as why that gap exists.

Check out the full episode on advances in liver transplantation and hepatocellular carcinoma here.

Brown introduced a prospective, 3-year cohort study of adults with cirrhosis that evaluated adherence to HCC surveillance, along with patient-reported reasons for nonadherence. She explained that the investigators excluded individuals with pre-existing liver lesions or incomplete data and defined full adherence as receiving both ultrasound imaging and alpha-fetoprotein (AFP) testing every 6 months. Brown highlighted how low adherence truly was: fewer than 10% of patients met criteria for full adherence, while even partial adherence, defined as ultrasound alone, remained below 50%.

She emphasized that the reasons for nonadherence were multifactorial, the most striking being that more than a quarter of patients reported that surveillance had not been recommended by their treating physician. Brown described this as particularly disappointing given the well-established association between routine surveillance and earlier tumor detection. She suggested that this gap may be especially relevant in patients with metabolic disease, where clinicians may not consistently recognize cirrhosis-related cancer risk.

Reau expanded on these findings by highlighting practical challenges that arise in everyday clinical care. She noted that the study did not specify how many patients received AFP testing alone, an important omission given how surveillance is often implemented in practice.

Drawing from her own experience, Reau described how patients may resist blood draws, imaging studies, or both. She also pointed to frustrations around ultrasound quality, including inadequate visualization and the frequent need for follow-up imaging, which can lead to patient fatigue and disengagement.

Reau further emphasized that evolving guidelines have added complexity, particularly surrounding AFP, which has long been a point of debate. She pointed out that not all clinicians may be fully aware of updated recommendations re-incorporating it into routine surveillance, complicating how adherence is defined and measured.

Brown closed the discussion by returning to the issue of access and feasibility. While lack of physician recommendation was the leading barrier, resource limitations and geographic access were also significant. She underscored growing interest in blood-based screening strategies, noting that emerging data presented at The Liver Meeting may offer more practical, scalable approaches to HCC surveillance in the future, especially for patients who struggle to access imaging.

Editors’ note: Relevant Disclosures for Reau include AbbVie, Gilead, Salix, Arbutus, and VIR. Relevant disclosures for Brown include Mallinckrodt Pharmaceuticals, Gilead, Salix, Intercept, Ipsen, and Madrigal.

References

1. Shukla A, Padole V, Vaidya A. NON-ADHERENCE TO SURVEILLANCE PROTOCOL OF HEPATOCELLULAR CANCER IN PATIENTS WITH LIVER CIRRHOSIS: PREVALENCE AND REASONS. Presented at the American Association for the Study of Liver Diseases (AASLD) The Liver Meeting 2025. Washington, DC. November 7-11, 2025.