The tool designed to close that gap is surveillance, the repeated testing of asymptomatic people at risk of a disease so that it can be detected early. All major international professional bodies, including the European Association for the Study of the Liver, the American Association for the Study of Liver Disease and the Asian Pacific Association for the Study of the Liver, recommend that patients with cirrhosis and high-risk chronic hepatitis B undergo liver ultrasound with or without serum alpha-fetoprotein measurement every six months. The annual risk of developing hepatocellular carcinoma in chronic liver disease ranges from about 1 per cent in alcohol-related cirrhosis to 2 per cent in hepatitis B and 3 to 8 per cent in hepatitis C. But a comprehensive review published in The Lancet Regional Health – Europe reveals that the evidence underpinning this universal recommendation is far shakier than most clinicians and patients realise, and that the gap between what guidelines advise and what actually happens in clinics is enormous.

The mortality benefit of surveillance rests largely on a single randomised controlled trial conducted in China, which found that six-monthly ultrasound with or without alpha-fetoprotein reduced hepatitis B-related liver cancer mortality by 37 per cent. No subsequent randomised study has ever replicated the finding, and further trials are widely considered unfeasible or unethical. In one Australian feasibility study, 99.5 per cent of patients declined randomisation to a no-surveillance arm. In place of trial data, the field relies on cohort studies and modelling: a meta-analysis of 59 international studies involving 145,396 patients found that surveillance was associated with earlier-stage diagnosis, higher receipt of curative treatment and improved overall survival after adjustment for lead-time bias. Critics counter that a trial in largely non-cirrhotic hepatitis B carriers may not generalise to older, sicker cirrhotic populations facing competing causes of death, a concern underscored by Danish registry data showing that liver cancer contributes only modestly to mortality in alcohol-related cirrhosis.

The surveillance test itself is also under scrutiny. Ultrasound is operator-dependent, with a sensitivity of just 47 per cent for early disease, and performance deteriorates further in patients with obesity or advanced cirrhosis. Around 20 per cent of surveillance ultrasounds are judged inadequate to visualise the liver, a particularly troubling statistic as metabolic dysfunction-associated steatotic liver disease, or MASLD, surges across populations with rising adiposity. Computed tomography and magnetic resonance imaging can be substituted when visibility is poor, but no randomised evidence supports cross-sectional imaging for surveillance, and cost, radiation and cumulative gadolinium exposure limit enthusiasm. Meanwhile, the harms of surveillance, physical, financial and psychological, have never been systematically quantified at scale. One United States study found physical harms in 27 per cent of patients, and emerging work highlights anxiety, false positives and out-of-pocket costs as meaningful burdens whose weight likely varies with a patient’s baseline cancer risk.

Against this contested backdrop, actual uptake of surveillance is dismal. A recent meta-analysis of 49 studies covering more than 1.2 million patients found that while 54 per cent of eligible people received some surveillance, fewer than 10 per cent received the guideline-concordant biannual testing. Country-level figures expose the patchwork: biannual uptake is around 17 per cent in the United Kingdom, 8 per cent in France, 4 per cent in Norway and under 20 per cent in the United States, compared with roughly 80 per cent in Japan and 75 per cent in Taiwan. Barriers span three levels. Patients may lack awareness of their risk or face logistical and financial constraints; clinicians report limited knowledge, time pressure and scepticism about the guidelines; and health systems lack national programmes, registries and recall infrastructure to keep at-risk patients in the loop.

Europe’s institutional response has been strikingly ambivalent. Europe’s Beating Cancer Plan, launched in 2021 with 4 billion euros earmarked for cancer action, explicitly declines to support liver cancer surveillance, with the European Commission stating that screening elevated-risk people entails uncommon but serious harms and might not reduce mortality. The United States National Cancer Institute draws a similarly pessimistic conclusion from the same Chinese trial. Professional societies, meanwhile, continue to recommend surveillance, leaving patients and advocacy groups lobbying for care that many clinicians, awaiting formal national guidance, remain reluctant to organise. The authors of the review argue that this deadlock leaves cirrhotic and viral hepatitis patients in a state of flux, receiving variable care in a disease that disproportionately affects society’s most marginalised members.

The contrast with countries that have committed to national programmes is instructive. Japan, the first nation to implement organised liver cancer surveillance, built its system in the 1980s through close cooperation between the Japan Society of Hepatology, government ministries and frontline hospitals. Super-high-risk patients, such as those with viral cirrhosis, are scanned every three to four months with ultrasound plus three tumour markers, alpha-fetoprotein, AFP-L3 and PIVKA-II, with optional dynamic CT or Gd-EOB-MRI once or twice a year. Ultrasounds are frequently performed directly by hepatologists rather than radiologists, and an annual eradication campaign, nationwide hepatitis testing and electronic record alerts keep risk populations engaged. The results are unmatched: more than 80 per cent of high-risk individuals covered, 65 per cent of cancers diagnosed at early BCLC stage 0 or A, and a five-year survival of 43 per cent, more than double the European figure. Taiwan pairs a reimbursed surveillance programme with its hepatitis B vaccination success, while Egypt offers free lifelong four-monthly monitoring through 58 specialised units. Thailand has shown that risk scores and the GAAD biomarker panel can cut the surveillance-eligible population dramatically and cost-effectively.

Within Europe itself, national philosophies diverge sharply. Denmark restricts surveillance to viral hepatitis and PAGE-B high-risk patients, judging the evidence insufficient for alcohol-related or MASLD-related cirrhosis, where local registry data show an annual cancer incidence of just 0.7 per cent; it is now trialling surveillance for all cirrhosis patients in one region to generate better evidence. Spain operates a clinician-led, risk-stratified model with uptake approaching 80 per cent in specialised care, though only 47 per cent of national cases are detected through surveillance. The United Kingdom, despite running the world’s largest universal healthcare system, records some of the worst hepatobiliary cancer outcomes among wealthy nations, with under 20 per cent of patients receiving curative therapy and emergency presentation the most common route to diagnosis. A community pilot programme has referred 7,892 patients to hepatology, but no formal health-economic evaluation has yet been published, and the country still lacks a national cirrhosis registry.

The patient experience, often overlooked in policy debates, adds a further layer of urgency. A British Liver Trust survey of 135 people affected by primary liver cancer found surveillance frequently undermined by poor communication, inconsistent delivery and stigma. Patients reported not understanding what the scans were for, being forgotten by their liver teams, waiting more than six months for appointments and travelling over 20 miles for care. Many described feeling blamed for their disease, with assumptions about alcohol use shaping their engagement with services. The review’s authors argue that surveillance must be reframed as a patient-centred pathway, consistent, clearly communicated, stigma-aware and locally accessible, or it risks reinforcing the very inequalities it is meant to counter.

The path forward, the authors suggest, lies in three converging innovations. First, risk stratification: tools such as the aMAP score, FIB-4 index, the Toronto HCC risk index and elastography-based stiffness measures could concentrate resources on those most likely to benefit, an approach already trimming eligible populations in Thailand and Denmark. Second, novel biomarkers: the GALAD score has passed phase III validation, outperforming alpha-fetoprotein in detecting cancer up to 12 months before diagnosis, while methylated DNA panels such as mt-HBT and HelioLiver show comparable early-stage sensitivity, and patients consistently prefer blood tests to ultrasound. Third, abbreviated MRI, a faster, cheaper imaging protocol now being tested in multiple international trials, may serve populations poorly served by ultrasound, particularly those with MASLD. The authors’ key recommendations call for a large multinational risk-based trial, research into alternative modalities, free surveillance at the point of care, patient navigation programmes and coordinated advocacy by professional societies and patient groups toward the European Commission and National Cancer Institute. With MASLD projected to become the leading cause of liver cancer, often arising even without cirrhosis, the authors warn that Europe’s current deadlock is untenable: further observational studies will not convince sceptics, and only pragmatic, risk-based, well-funded programmes, on the model of Japan, Taiwan and Egypt, can translate four decades of partial evidence into falling mortality.

Subject of Research: Hepatocellular carcinoma surveillance practices, evidence and barriers in Europe and globally

Article Title: Hepatocellular carcinoma surveillance in Europe: challenges and lessons from global practice

Article References: Qurashi, M., Buti, M., Lai-Hung Wong, G., Qureshi, H., Kudo, M., Tanwandee, T., Chen, C.-J., Abdelaziz, A. O., AbdAllah, M., Howell, J., Hebditch, V., Singal, A. G., Jepsen, P., & Sharma, R. (2026). Hepatocellular carcinoma surveillance in Europe: challenges and lessons from global practice. The Lancet Regional Health – Europe, 70, Article 101852. https://doi.org/10.1016/j.lanepe.2026.101852

Image Credits: AI Generated

DOI: 10.1016/j.lanepe.2026.101852

Keywords: hepatocellular carcinoma, liver cancer, surveillance, cirrhosis, ultrasound, alpha-fetoprotein, MASLD, hepatitis B, GALAD biomarker, abbreviated MRI, risk stratification, Europe