Semiannual ultrasound with alpha-fetoprotein is what guidelines recommend for cirrhosis and selected chronic hepatitis B, and its weaknesses are well known: poor sensitivity for early-stage tumours, poor real-world adherence, and no randomised evidence that it reduces mortality in cirrhosis. This expert opinion assesses what might replace it and reaches a conclusion about targeting rather than technology.
Two categories are examined. Abbreviated MRI protocols aim to keep the accuracy of a full liver protocol while cutting scan time and cost: the dynamic contrast-enhanced version can make a definitive diagnosis without recall imaging, and the non-contrast version has shown better sensitivity and specificity than ultrasound in recent trials. Blood biomarker panels - protein-based tests such as GALAD and HES 2.0, and circulating tumour DNA assays such as Oncoguard and HelioLiver - may improve adherence, but face methodological problems and need prospective longitudinal evaluation against outcomes, not just against detection.
The argument that matters is the last one. Enhanced surveillance should be allocated by expected benefit rather than by cancer risk, and the two come apart: a patient with decompensated cirrhosis and competing mortality has a high risk of hepatocellular carcinoma and little to gain from finding it three months earlier, because they will not be a candidate for curative treatment either way.
So the usable change is in how the surveillance conversation is framed. Before ordering, ask what would happen if the scan found a 2 cm lesion - is this patient a candidate for resection, ablation or transplantation? Where the answer is no, surveillance is a burden rather than a benefit. That question costs nothing and is available in every clinic, including those where abbreviated MRI never will be.
- Before each surveillance scan, ask what curative option the patient would actually be offered
- Reserve enhanced surveillance for patients who could receive effective treatment on detection
- Do not adopt a biomarker panel on detection performance alone - ask for outcome data
- Non-contrast abbreviated MRI is the most promising alternative where MRI capacity exists
- Keep six-monthly ultrasound where nothing better is available; the alternative is no surveillance
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