AGA Guidelines on HCC Surveillance: Gastroenterology | May 2026

Introduction

Hepatocellular carcinoma (HCC) remains a leading cause of cancer-related mortality in patients with cirrhosis. Despite advances in treatment, outcomes are largely determined by stage at diagnosis, making surveillance critical. Current strategies rely on ultrasound with AFP, but limitations in sensitivity and poor real-world uptake have created a need for better risk stratification and improved surveillance tools.

Why This Guideline Is Required

Traditional surveillance approaches are suboptimal due to:

Underuse in clinical practice

Limited sensitivity of ultrasound

Changing epidemiology (rise of MASLD and alcohol-related liver disease)

Lack of validated biomarkers and risk-based strategies

This guideline focuses on improving risk stratification, surveillance efficiency, and early detection.

20 Key Takeaways for Clinicians

1. Prevention of cirrhosis is the most effective HCC strategy

Treat viral hepatitis, alcohol use, and metabolic syndrome early.

2. Surveillance saves lives

Early detection improves access to curative therapies and survival.

3. Standard surveillance = Ultrasound + AFP every 6 months

Still the recommended global standard.

4. Semiannual surveillance is superior to annual surveillance. It detects earlier-stage tumours and improves outcomes.

5. Ultrasound has limitations

Reduced sensitivity in obesity, MASLD, and advanced liver disease.

6. AFP improves sensitivity when added to ultrasound

A combination is better than ultrasound alone.

7. Surveillance is underutilised

Less than 25% of eligible cirrhosis patients undergo regular screening.

8. Target population = All cirrhosis patients

Regardless of aetiology.

9. Select non-cirrhotic HBV patients need surveillance

Based on age, ethnicity, and risk scores.

10. No routine surveillance in non-cirrhotic MASLD or HCV

Unless better risk stratification tools are available.

11. Surveillance not useful in limited life expectancy

Especially non-transplant candidates with advanced disease.

12. Harms of surveillance must be considered

False positives, anxiety, cost, and unnecessary procedures.

13. Biomarkers like GALAD are promising but not ready

Do not replace ultrasound + AFP yet.

14. Liquid biopsy is the future—but still experimental

Requires validation in large prospective trials.

15. Multicancer detection panels should NOT be used

Not validated for HCC surveillance populations.

16. MRI has higher sensitivity, but is not routine

Cost, access, and practicality limit widespread use.

17. Abbreviated MRI is promising

May become a future alternative in selected patients.

18. Risk stratification is the future of surveillance

Not all cirrhosis patients have equal risk.

19. Current risk models are imperfect

Limited validation and modest predictive performance.

20. HBV risk scores (PAGE-B, REAL-B) are useful

Can guide surveillance decisions in non-cirrhotic HBV patients.

Practical Clinical Message

HCC surveillance is evolving from a uniform approach to a personalised strategy. While ultrasound + AFP remains the backbone, future progress will depend on risk-based surveillance, better biomarkers, and improved patient selection.

Conclusion

This guideline reinforces that current surveillance methods are effective but imperfect. The next phase in HCC care lies in precision surveillance, combining clinical risk, biomarkers, and imaging innovations to improve early detection while minimising harm.