AGA Updates HCC Risk Stratification and Surveillance : Gastroenterology | Jun 2026

Introduction:

Hepatocellular carcinoma (HCC) remains a leading cause of cancer-related mortality among patients with chronic liver disease and cirrhosis. Outcomes are substantially better when HCC is detected at an early stage, allowing access to potentially curative therapies. However, surveillance remains underutilized, and currently recommended tools have important limitations in sensitivity and implementation. As the epidemiology of liver disease shifts toward metabolic dysfunction–associated steatotic liver disease (MASLD) and alcohol-associated liver disease, there is growing interest in improving risk stratification and surveillance strategies.

Problem Statement:

Current HCC surveillance relies primarily on semiannual ultrasound with α-fetoprotein (AFP), but this approach fails to detect a significant proportion of early-stage tumors. At the same time, numerous emerging biomarkers, risk prediction models, and imaging approaches have been proposed, creating uncertainty regarding their role in routine clinical practice. Clear guidance is needed on how these evolving tools should be incorporated into patient care.

Summary:

In this AGA Clinical Practice Update, experts reaffirm that semiannual ultrasound combined with AFP remains the preferred surveillance strategy for patients at risk of HCC, particularly those with cirrhosis and selected patients with chronic hepatitis B infection. The document emphasizes that prevention of cirrhosis through viral hepatitis treatment, alcohol use disorder management, and metabolic risk factor control remains the most effective strategy for reducing HCC-related morbidity and mortality. While several promising blood-based and radiologic biomarkers, including GALAD, are undergoing clinical validation, current evidence is insufficient to support their routine use as replacements for guideline-recommended surveillance. Similarly, multicancer blood-based screening panels are not recommended for HCC surveillance at present. The update also highlights the growing need for individualized risk stratification as HCC increasingly arises in patients with nonviral liver disease, where annual cancer risk may differ substantially from traditional viral hepatitis populations. Although numerous HCC risk prediction models have been developed, few have demonstrated sufficient validation for widespread clinical use. An exception is chronic hepatitis B without cirrhosis, where PAGE-B and REAL-B scores may help identify patients at higher future risk. Overall, the guidance advocates for evidence-based surveillance while encouraging continued development and validation of novel biomarkers and precision risk-stratification tools to improve early HCC detection.