Introduction: Hepatocellular carcinoma (HCC) is a leading cause of cancer-related deaths. Current international guidelines recommend 6-monthly ultrasound surveillance in all patients with cirrhosis and those with hepatitis B virus-related risk factors to detect early-stage HCC. However, it is unknown whether the benefits of surveillance are comparable across patient groups and underlying disease-related factors. We aimed to evaluate patient- and disease-related factors associated with HCC stage at diagnosis and survival in an ethnically diverse UK population.
Methods: This was a multicentre retrospective observational study including patients with newly diagnosed HCC between 2007 and 2020 from six UK centres. Cox proportional-hazards regression and multivariate logistic regression models were used.
Results: Overall, 1,780 HCC patients comprising 20.9% with ArLD, 29.7% with NAFLD, and 31.0% with viral hepatitis were analysed. Surveillance was associated with improved survival in patients with viral hepatitis but not in patients with ArLD and NAFLD. Surveillance was also associated with early-stage disease (BCLC stage 0 or A) at presentation in viral hepatitis but not in patients with ArLD. Females with ArLD were 2.5-fold more likely to present with early-stage HCC than males. Patients with NAFLD were more likely to develop HCC in the absence of cirrhosis. Type 2 diabetes was not associated with mortality, but metformin use did show survival benefit. Patients of white ethnicity had improved survival and were less likely to present with late-stage HCC compared to other ethnicities.
Conclusions: HCC surveillance as currently delivered was less effective for detecting early-stage HCC in patients with non-viral and non-cirrhotic liver disease. Gender and ethnicity influences stage at presentation and outcomes. HCC surveillance strategies are needed to refine risk stratification particularly in patients with NAFLD or without cirrhosis.
Keywords: Hepatocellular carcinoma; Surveillance strategy.
Liver cancer is the third leading cause of cancer death in the world and chronic liver disease, including infection with hepatitis viruses, and cirrhosis is the main risk factor. Current international guidelines recommend surveillance with an ultrasound scan every 6 months for people with risk conditions so that any cancer can be detected at an early stage when it can potentially be cured. This study looked back at 1,780 patients from six UK hospitals who had a new diagnosis of liver cancer. The current surveillance effectively found cancers at early stage (stages 0 or A) in people whose liver disease was due to hepatitis B and C viruses but was less effective in people with alcohol-related liver disease and non-alcoholic fatty liver disease (NAFLD). The study also found that White patients were almost twice as likely to have early-stage cancer at the time of diagnosis compared to other ethnicities. Females were twice as likely to have early-stage cancer from alcohol-related liver disease at time of diagnosis compared to males. Some people, particularly those who have NAFLD, can develop liver cancer before they develop cirrhosis, and this group of patients are not included in current surveillance. This study highlights the need for surveillance strategies that are designed to find cancers at curable stages for all patients including those of all ethnicities, people with NAFLD, and those who do not have cirrhosis.
© 2025 The Author(s). Published by S. Karger AG, Basel.