Use of hepatocellular carcinoma surveillance in patients with cirrhosis: a systematic review and meta-analysis
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BACKGROUND AND AIMS: Hepatocellular carcinoma (HCC) surveillance is associated with early tumor detection and improved survival; however, it is often underused in clinical practice. We aimed to characterize surveillance use among patients with cirrhosis and the efficacy of interventions to increase surveillance. APPROACH AND RESULTS: We performed a systematic literature review using the MEDLINE database from January 2010 through August 2018 to identify cohort studies evaluating HCC surveillance receipt or interventions to increase surveillance in patients with cirrhosis. A pooled estimate for surveillance receipt with 95% confidence intervals was calculated. Correlates of surveillance use were defined from each study and prespecified subgroup analyses. Twenty-nine studies, with a total of 118,799 patients, met inclusion criteria, with a pooled estimate for surveillance use of 24.0% (95% confidence interval, 18.4-30.1). In subgroup analyses, the highest surveillance receipt was reported in studies with patients enrolled from subspecialty gastroenterology/hepatology clinics and lowest in studies characterizing surveillance in population-based cohorts (73.7% versus 8.8%, P < 0.001). Commonly reported correlates of surveillance included higher receipt among patients followed by subspecialists and lower receipt among those with alcohol-associated or nonalcoholic steatohepatitis (NASH)-related cirrhosis. All eight studies (n = 5,229) evaluating interventions including patient/provider education, inreach (e.g., reminder and recall systems), and population health outreach strategies reported significant increases (range 9.4%-63.6%) in surveillance receipt. CONCLUSIONS: HCC surveillance remains underused in clinical practice, particularly among patients with alcohol-associated or NASH-related cirrhosis and those not followed in subspecialty gastroenterology clinics. Interventions such as provider education, inreach including reminder systems, and population health outreach efforts can significantly increase HCC surveillance.
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Cirrhosis in MASLD is under-recognised compared to other aetiologies, with less than one in four individuals with cirrhosis undergoing HCC surveillance.
“Cirrhosis in MASLD is under-recognised compared to other aetiologies, 248 with less than one in four individuals with cirrhosis undergoing HCC surveillance. 249”
From EASL-EASD-EASO Clinical Practice Guidelines on the management of metabolic dysfunction-associated steatotic liver disease (MASLD). (2024) · cites this paper as [249]
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Self-citationReveron‐Thornton, R. F., Teng, M. L. P., Lee, E. Y., Tran, A., Vajanaphanich, S., Tan, E. X., Nerurkar, S. N., Ng, R. X., Teh, R., Tripathy, D. P., et al. (2022) · Hepatology Communications · doi:10.1002/hep4.1923 · Cited by 97 · see citing works
Singal, A. G., Sanduzzi‐Zamparelli, M., Nahon, P., Ronot, M., Hoshida, Y., Rich, N. E., Reig, M., Vilgrain, V., Marrero, J. A., Llovet, J. M., et al. (2023) · Journal of Hepatology · doi:10.1016/j.jhep.2023.02.022 · Cited by 97 · see citing works
Self-citationA Phase 3 Biomarker Validation of GALAD for the Detection of Hepatocellular Carcinoma in Cirrhosis
Marsh, T. L., Parikh, N. D., Roberts, L. R., Schwartz, M., Nguyen, M. H., Befeler, A. S., Page-Lester, S., Tayob, N., Srivastava, S., Rinaudo, J. A., et al. (2024) · Gastroenterology · doi:10.1053/j.gastro.2024.09.008 · Cited by 92 · see citing works
Self-citationRich, N., Carr, C., Yopp, A., Marrero, J., & Singal, A. (2020) · Clinical Gastroenterology and Hepatology · doi:10.1016/j.cgh.2020.12.029 · Cited by 66 · see citing works
Self-citationHepatocellular carcinoma: Epidemiology, diagnosis and treatment
Mauro, E., de Castro, T., Zeitlhoefler, M., Sung, M. W., Villanueva, A., Mazzaferro, V., & Llovet, J. M. (2025) · JHEP Reports · doi:10.1016/j.jhepr.2025.101571 · Cited by 89 · see citing works
Singal, A. G., Patibandla, S., Obi, J., Fullington, H. M., Parikh, N. D., Yopp, A. C., & Marrero, J. A. (2020) · Clinical Gastroenterology and Hepatology · doi:10.1016/j.cgh.2020.09.014 · Cited by 83 · see citing works
Self-citationRational HCC screening approaches for patients with NAFLD
Singal, A. G., & El-Serag, H. B. (2022) · Journal of Hepatology · doi:10.1016/j.jhep.2021.08.028 · Cited by 80 · see citing works
Self-citationGuan, M., Zhang, S., Ding, Q., Li, N., Fu, T., Zhang, G., He, Q., Shen, F., Yang, T., & Zhu, H. (2023) · Journal of Clinical Medicine · doi:10.3390/jcm12030949 · Cited by 73 · see citing works
Patient Preferences for Hepatocellular Carcinoma Surveillance Parameters
Woolen, S. A., Singal, A. G., Davenport, M. S., Troost, J. P., Khalatbari, S. H., Mittal, S., Siddiqui, S., Fobar, A. J., Morris, J., Odewole, M., et al. (2021) · Clinical Gastroenterology and Hepatology · doi:10.1016/j.cgh.2021.02.024 · Cited by 70 · see citing works
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Multidisciplinary care for patients with HCC: a systematic review and meta-analysis
Dahan, K. S. E., Reczek, A., Daher, D., Rich, N. E., Yang, J. D., Hsiehchen, D., Zhu, H., Patel, M. S., Molano, M. D. P. B., Sanford, N. N., et al. (2023) · Hepatology Communications · doi:10.1097/hc9.0000000000000143 · Cited by 69 · see citing works
Self-citationHepatocellular Carcinoma Screening Process Failures in Patients with Cirrhosis
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Karim, M. A., Singal, A. G., Kum, H., Lee, Y., Park, S., Rich, N. E., Noureddin, M., & Yang, J. D. (2022) · Clinical Gastroenterology and Hepatology · doi:10.1016/j.cgh.2022.03.010 · Cited by 58 · see citing works
Self-citationUsing cell-free DNA for HCC surveillance and prognosis
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Hepatocellular carcinoma surveillance: current practice and future directions
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Self-citationSanchez, J. I., Jiao, J., Kwan, S., Veillon, L. J., Warmoes, M. O., Tan, L., Odewole, M., Rich, N. E., Wei, P., Lorenzi, P. L., et al. (2021) · Cancer Prevention Research · doi:10.1158/1940-6207.capr-20-0612 · Cited by 53 · see citing works
Self-citationOverdiagnosis of hepatocellular carcinoma: Prevented by guidelines?
Rich, N. E., & Singal, A. G. (2021) · Hepatology · doi:10.1002/hep.32284 · Cited by 49 · see citing works
Self-citationTan, D. J. H., Quek, S. X. Z., Yong, J. N., Suresh, A., Koh, K. X. M., Lim, W. H., Quek, J., Tang, A. S. P., Tan, C., Nah, B. K. Y., et al. (2022) · Clinical and Molecular Hepatology · doi:10.3350/cmh.2022.0136 · Cited by 54 · see citing works
Racial and Sex Disparities in Hepatocellular Carcinoma in the USA
Ajayi, F., Jan, J., Singal, A. G., & Rich, N. E. (2020) · Current Hepatology Reports · doi:10.1007/s11901-020-00554-6 · Cited by 48 · see citing works
Self-citationNovel Biomarkers for Early Detection of Hepatocellular Carcinoma
Attia, A. M., Zavareh, M. S. R., Hwang, S. Y., Kim, N., Adetyan, H., Yalda, T., Chen, P., Koltsova, E. K., & Yang, J. D. (2024) · Diagnostics · doi:10.3390/diagnostics14202278 · Cited by 45 · see citing works
Opportunities to address gaps in early detection and improve outcomes of liver cancer
McMahon, B., Cohen, C., Brown Jr, R. S., El-Serag, H., Ioannou, G. N., Lok, A. S., Roberts, L. R., Singal, A. G., & Block, T. (2023) · JNCI Cancer Spectrum · doi:10.1093/jncics/pkad034 · Cited by 44 · see citing works
Self-citationRadiological Diagnosis of Chronic Liver Disease and Hepatocellular Carcinoma: A Review
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Self-citationNon-alcoholic fatty liver disease-related hepatocellular carcinoma
Daher, D., Dahan, K. S. E., & Singal, A. G. (2023) · Journal of Liver Cancer · doi:10.17998/jlc.2022.12.30 · Cited by 43 · see citing works
Self-citationWe need stronger evidence for (or against) hepatocellular carcinoma surveillance
Jepsen, P., & West, J. (2021) · Journal of Hepatology · doi:10.1016/j.jhep.2020.12.029 · Cited by 42 · see citing works
Surveillance of patients with cirrhosis remains suboptimal in the United States
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Wagle, N. S., Park, S., Washburn, D. J., Ohsfeldt, R. L., Rich, N. E., Singal, A. G., & Kum, H. (2022) · Clinical Gastroenterology and Hepatology · doi:10.1016/j.cgh.2022.07.031 · Cited by 40 · see citing works
Self-citationKao, S. Z., Sangha, K., Fujiwara, N., Hoshida, Y., Parikh, N. D., & Singal, A. G. (2024) · EClinicalMedicine · doi:10.1016/j.eclinm.2024.102755 · Cited by 37 · see citing works
Self-citationKim, N. J., Rozenberg‐Ben‐Dror, K., Jacob, D. A., Rich, N. E., Singal, A. G., Aby, E. S., Yang, J. D., Nguyen, V., Pillai, A. A., Fuchs, M. A., et al. (2020) · Clinical Gastroenterology and Hepatology · doi:10.1016/j.cgh.2020.09.015 · Cited by 37 · see citing works
Self-citationHepatocellular Carcinoma Surveillance Patterns and Outcomes in Patients With Cirrhosis
Daher, D., Dahan, K. S. E., Cano, A., Gonzales, M. A., Ransom, C., Jaurez, E., Carranza, O., Quirk, L., Morgan, T. M., Gopal, P., et al. (2023) · Clinical Gastroenterology and Hepatology · doi:10.1016/j.cgh.2023.08.003 · Cited by 36 · see citing works
Self-citationYakovchenko, V., Lamorte, C., Chinman, M., Goodrich, D. E., Gibson, S. P., Park, A., Bajaj, J. S., McCurdy, H. M., Morgan, T. R. M., & Rogal, S. S. (2023) · Implementation Science · doi:10.1186/s13012-023-01307-x · Cited by 35 · see citing works
National Liver Cancer Screening Trial (TRACER) study protocol
Singal, A. G., Parikh, N. D., Kanwal, F., Marrero, J. A., Deodhar, S., Page-Lester, S., Lopez, C., Feng, Z., & Tayob, N. (2024) · Hepatology Communications · doi:10.1097/hc9.0000000000000565 · Cited by 31 · see citing works
Self-citationPublic health strategies for hepatocellular carcinoma: from risk factors to prevention and control
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Differences between hepatocellular carcinoma caused by alcohol and other aetiologies
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Hepatocellular carcinoma surveillance in patients with non-alcoholic fatty liver disease
Dahan, K. S. E., Daher, D., & Singal, A. G. (2022) · Clinical and Molecular Hepatology · doi:10.3350/cmh.2022.0247 · Cited by 30 · see citing works
Self-citationGuan, M., Ouyang, W., Liu, S., Sun, L., Chen, W.-Y., Tong, X., Zhu, H., & Yang, T. (2022) · Hepatobiliary & pancreatic diseases international · doi:10.1016/j.hbpd.2022.05.003 · Cited by 28 · see citing works
Huang, D. Q., Tran, A., Tan, E. X. X., Nerurkar, S. N., Teh, R., Teng, M. L. P., Yeo, E. J., Zou, B., Wong, H.-N., Esquivel, C. O., et al. (2022) · HepatoBiliary Surgery and Nutrition · doi:10.21037/hbsn-21-419 · Cited by 28 · see citing works
Addressing racial and ethnic disparities in US liver cancer care
Kim, N. J., Cravero, A., VoPham, T., Vutien, P., Carr, R. M., Issaka, R. B., Johnston, J. M., McMahon, B. J., Mera, J., & Ioannou, G. N. (2023) · Hepatology Communications · doi:10.1097/hc9.0000000000000190 · Cited by 26 · see citing works
Protein induced by vitamin K absence or antagonist II: Experience to date and future directions
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Early detection of hepatocellular carcinoma: roadmap for improvement
Melendez-Torres, J., & Singal, A. G. (2022) · Expert Review of Anticancer Therapy · doi:10.1080/14737140.2022.2074404 · Cited by 25 · see citing works
Self-citationRogal, S. S., Yakovchenko, V., Gonzalez, R. I., Park, A., Beste, L. A., Rozenberg‐Ben‐Dror, K., Bajaj, J. S., Scott, D., McCurdy, H. M., Comstock, E., et al. (2021) · Cancers · doi:10.3390/cancers13092251 · Cited by 25 · see citing works
Phase 3 Validation of PAaM for Hepatocellular Carcinoma Risk Stratification in Cirrhosis
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Self-citationHolistic management of hepatocellular carcinoma: The hepatologist's comprehensive playbook
Jaffe, A., Taddei, T. H., Giannini, E. G., Ilagan‐Ying, Y. C., Colombo, M., & Strazzabosco, M. (2022) · Liver International · doi:10.1111/liv.15432 · Cited by 23 · see citing works
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Hepatocellular carcinoma surveillance in Australia: current and future perspectives
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Advancing Surveillance Strategies for Hepatocellular Carcinoma: A New Era of Efficacy and Precision
Singal, A. G., Ng, M., & Kulkarni, A. L. (2024) · Journal of Clinical and Experimental Hepatology · doi:10.1016/j.jceh.2024.101448 · Cited by 21 · see citing works
Self-citationGovalan, R., Luu, M., Lauzon, M., Kosari, K., Ahn, J. C., Rich, N. E., Nissen, N. N., Roberts, L. R., Singal, A. G., & Yang, J. D. (2021) · Hepatology Communications · doi:10.1002/hep4.1795 · Cited by 21 · see citing works
Self-citationVaz, J., Strömberg, U., Midlöv, P., Eriksson, B., Buchebner, D., & Hagström, H. (2022) · Journal of Internal Medicine · doi:10.1111/joim.13570 · Cited by 21 · see citing works
Should we undertake surveillance for HCC in patients with MAFLD?
Norero, B., & Dufour, J. (2023) · Therapeutic Advances in Endocrinology and Metabolism · doi:10.1177/20420188231160389 · Cited by 21 · see citing works
Proportion of Time Covered by Hepatocellular Carcinoma Surveillance in Patients With Cirrhosis
Daher, D., Dahan, K. S. E., Yekkaluri, S., Gopal, P., Rich, N. E., Parikh, N. D., Murphy, C. C., & Singal, A. G. (2023) · The American Journal of Gastroenterology · doi:10.14309/ajg.0000000000002596 · Cited by 21 · see citing works
Self-citationPrevalence of the Absence of Cirrhosis in Subjects with NAFLD-Associated Hepatocellular Carcinoma
Castellana, M., Donghia, R., Lampignano, L., Castellana, F., Zupo, R., Sardone, R., Pergola, G. D., & Giannelli, G. (2021) · Journal of Clinical Medicine · doi:10.3390/jcm10204638 · Cited by 21 · see citing works
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Self-citationJarrah, M., Arvind, A., Gopal, P., Deodhar, S., Yang, J. D., Parikh, N. D., & Singal, A. G. (2025) · Liver Cancer · doi:10.1159/000547895 · Cited by 20 · see citing works
Self-citationClinical and Molecular Prediction of Hepatocellular Carcinoma Risk
Kubota, N., Fujiwara, N., & Hoshida, Y. (2020) · Journal of Clinical Medicine · doi:10.3390/jcm9123843 · Cited by 19 · see citing works
Current and new strategies for hepatocellular carcinoma surveillance
Polpichai, N., Maneenil, C., Danpanichkul, P., Rattananukrom, C., Choudhury, A. K., Wong, Y. J., Sripongpun, P., Liangpunsakul, S., & Kaewdech, A. (2025) · Gastroenterology report · doi:10.1093/gastro/goaf045 · Cited by 18 · see citing works
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Meta‐Analysis: Utilisation of Hepatocellular Carcinoma Surveillance
Tang, N. S. Y., Gunalan, S. Z., Ong, C. E. Y., Koh, B., Tham, E. K. J., Lim, R. Y., Tan, D. J. H., Syn, N. L. X., Ng, C. H., Muthiah, M. D., et al. (2025) · Alimentary Pharmacology & Therapeutics · doi:10.1111/apt.70403 · Cited by 17 · see citing works
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Self-citationScreening for Hepatocellular Carcinoma in Patients with Hepatitis B
Sachar, Y., Brahmania, M., Dhanasekaran, R., & Congly, S. E. (2021) · Viruses · doi:10.3390/v13071318 · Cited by 16 · see citing works
Clinical Outcomes of Patients With Suspicious (LI-RADS 4) Liver Observations
Onyirioha, K., Joshi, S., Burkholder, D. A., Yekkaluri, S., Parikh, N. D., Singal, A. G., Wolf, E., Yokoo, T., Browning, T. G., Mendiratta‐Lala, M., et al. (2022) · Clinical Gastroenterology and Hepatology · doi:10.1016/j.cgh.2022.03.038 · Cited by 16 · see citing works
Self-citationNguyen, M. H., Roberts, L. R., Engel-Nitz, N. M., Bancroft, T., Ozbay, A. B., & Singal, A. G. (2022) · Current Medical Research and Opinion · doi:10.1080/03007995.2022.2124070 · Cited by 16 · see citing works
Self-citationBenhammou, J. N., Qiao, B., Ko, A., Sinnett‐Smith, J. W., Pisegna, J. R., & Rozengurt, E. (2023) · American Journal of Physiology-Gastrointestinal and Liver Physiology · doi:10.1152/ajpgi.00089.2023 · Cited by 16 · see citing works
Singal, A. G., Chen, Y., Sridhar, S., Mittal, V., Fullington, H. M., Shaik, M., Waljee, A. K., & Tiro, J. A. (2021) · Clinical Gastroenterology and Hepatology · doi:10.1016/j.cgh.2021.02.038 · Cited by 16 · see citing works
Self-citationAnalytical validation of a novel multi-target blood-based test to detect hepatocellular carcinoma
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Outcomes of National Survey of the Practice of Hepatocellular Carcinoma Surveillance
Scott, R. A., Cross, T., Clarke, C. G. D., Khan, S. A., Ryder, S. D., Franklin, J. M., & Aravinthan, A. D. (2023) · Journal of Hepatocellular Carcinoma · doi:10.2147/jhc.s403702 · Cited by 14 · see citing works
Clinician-Level Knowledge and Barriers to Hepatocellular Carcinoma Surveillance
Wong, R. J., Jones, P. D., Niu, B., Therapondos, G., Thamer, M., Kshirsagar, O. S., Zhang, Y., Pinheiro, P. S., Kyalwazi, B., Fass, R., et al. (2024) · JAMA Network Open · doi:10.1001/jamanetworkopen.2024.11076 · Cited by 14 · see citing works
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Self-citationHepatocellular Carcinoma Screening: From Current Standard of Care to Future Directions
Mohnasky, M., Gad, S., Moon, A. M., Barritt, A. S., Charalel, R. A., Eckblad, C., Caddell, A., Xing, M., & Kokabi, N. (2025) · Journal of the American College of Radiology · doi:10.1016/j.jacr.2024.10.014 · Cited by 14 · see citing works
- Authors
- Wolf, E., Rich, N. E., Marrero, J. A., Parikh, N. D., & Singal, A. G.
- Affiliations
- The University of Texas Southwestern Medical Center (US)
- University of Michigan (US)
- Corresponding author
- Singal, Amit G.
- Venue
- Hepatology
- Published
- 2020-11-20
- Volume
- 73
- Issue
- 2
- Pages
- 713-725
- ISSN
- 0270-9139 (ISSN-L)
- 1527-3350
- PMC
- PMC7648722
- OpenAlex
- W3021721319
- Cited by
- 333
- References
- 56
- Citations by year
- 2026: 47 · 2025: 69 · 2024: 66 · 2023: 57 · 2022: 48 · 2021: 33 · 2020: 13
- FWCI
- 5.03
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Hepatology (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Deep Blue (University of Michigan) (submittedVersion)
- Funders
- National Institutes of Health
- National Cancer Institute (U01CA230694, U01CA230669)
- Topics
- Health Sciences › Medicine › Hepatology › Hepatocellular Carcinoma Treatment and Prognosis
- Health Sciences › Medicine › Oncology › Global Cancer Incidence and Screening
- Health Sciences › Medicine › Epidemiology › Hepatitis B Virus Studies
- Keywords
- HCC surveillance, liver cirrhosis, alcoholic cirrhosis, nonalcoholic steatohepatitis, provider education, early cancer detection
- MeSH terms
- Carcinoma, Hepatocellular, Humans, Liver Cirrhosis, Liver Neoplasms, Mass Screening, Patient Acceptance of Health Care, Practice Patterns, Physicians', Guideline Adherence, Early Detection of Cancer
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