Liver Cancer Screening

There is no routine liver cancer screening recommended for everyone. Instead, regular liver cancer surveillance is recommended for certain people who have a higher risk of developing hepatocellular carcinoma (HCC), the most common type of primary liver cancer. This is different from many other cancer screening programs because surveillance is targeted toward people with specific liver diseases or other risk factors.

For people at high risk, regular surveillance can help identify liver cancer at an earlier stage, when more treatment options may be available.

Who should be screened for liver cancer?

Liver cancer surveillance is generally recommended for people whose risk of developing hepatocellular carcinoma is high enough that regular testing is likely to provide a benefit. This includes many people with cirrhosis, regardless of what caused the liver damage. Cirrhosis can develop from conditions such as:

• Chronic hepatitis B or C

• Alcohol-related liver disease

• Metabolic dysfunction-associated steatotic liver disease (MASLD)

• Hemochromatosis

• Autoimmune liver diseases

• Certain inherited or metabolic conditions

Some people with chronic hepatitis B may also need liver cancer surveillance even if they have not developed cirrhosis. The decision can depend on factors such as age, family history, geographic ancestry, and other individual risk factors.

Not everyone with liver disease needs liver cancer surveillance. Your healthcare provider can determine whether your individual risk is high enough to recommend regular testing.

What tests are used for liver cancer surveillance?

The primary test used for liver cancer surveillance is an abdominal ultrasound. Ultrasound uses sound waves to create images of the liver and can identify masses or other abnormalities that may require additional evaluation. Many guidelines recommend liver ultrasound every six months for people at increased risk of hepatocellular carcinoma. In some cases, a blood test for alpha-fetoprotein (AFP) is performed along with ultrasound.

What is an AFP blood test?

Alpha-fetoprotein (AFP) is a protein that can be measured in the blood. AFP levels are elevated in some people with hepatocellular carcinoma. However, AFP is not a perfect tumor marker. Some people with liver cancer have normal AFP levels, while AFP can also become elevated for reasons other than cancer, including certain liver diseases. For this reason, AFP is generally not used by itself to screen for liver cancer. It may be combined with ultrasound as part of a surveillance program.

Why is screening usually done every six months?

Hepatocellular carcinoma can grow relatively quickly. For people at increased risk, surveillance approximately every six months provides a balance between detecting new cancers early and avoiding unnecessary testing. More frequent screening has generally not been shown to provide enough additional benefit to make it standard for most high-risk patients. Your healthcare provider may adjust the schedule depending on your individual situation or previous test results.

Are CT scans or MRIs used for routine screening?

CT and MRI can create more detailed images of the liver than ultrasound, but they are not usually the first test used for routine surveillance in most people. These tests may be recommended when:

• An ultrasound identifies a suspicious liver lesion

• The liver cannot be adequately evaluated with ultrasound

• A person's individual circumstances make ultrasound less reliable

• Additional information is needed to characterize a liver abnormality

MRI may also be used as an alternative surveillance strategy for selected high-risk patients. CT scans involve radiation exposure, while some MRI and CT examinations require contrast material. Your healthcare provider will determine which imaging test is most appropriate.

What happens if an ultrasound finds a liver nodule?

Finding a liver nodule does not automatically mean you have liver cancer. Small benign liver lesions are common. What happens next depends partly on the size and appearance of the nodule. Your healthcare provider may recommend:

• Repeat ultrasound after a shorter period of time

• Contrast-enhanced MRI

• Multiphase CT imaging

• Additional blood tests

• Evaluation by a liver specialist

Certain liver cancers can sometimes be diagnosed based on characteristic imaging findings without requiring a biopsy. In other situations, a biopsy may be necessary.

Is liver cancer screening recommended for people with fatty liver disease?

Fatty liver disease is increasingly common and can increase liver cancer risk, particularly when it progresses to advanced fibrosis or cirrhosis. However, routine liver cancer surveillance is not recommended for everyone with fatty liver disease. People with MASLD who have developed cirrhosis generally qualify for surveillance. Recommendations for people with advanced liver fibrosis but no cirrhosis may depend on individual risk and clinical guidelines.

If you have fatty liver disease, ask your healthcare provider whether you have fibrosis or cirrhosis and whether liver cancer surveillance is appropriate.

Does successful hepatitis C treatment mean screening can stop?

Not necessarily. Modern antiviral treatments can cure most hepatitis C infections and substantially reduce the risk of liver cancer. However, people who already developed cirrhosis before their hepatitis C was cured can remain at increased risk of hepatocellular carcinoma. For this reason, people with cirrhosis generally need to continue liver cancer surveillance even after successful hepatitis C treatment.

Do people with hepatitis B need screening?

Some people with chronic hepatitis B have an increased risk of liver cancer even without cirrhosis. Surveillance recommendations depend on individual risk factors. These may include:

• Age

• Sex

• Family history of liver cancer

• Geographic ancestry

• Duration and activity of hepatitis B infection

• Presence of cirrhosis

• Other clinical risk factors

• If you have chronic hepatitis B, your healthcare provider or liver specialist can determine whether you should have regular liver cancer surveillance.

• Know the symptoms of liver cancer

Screening and surveillance are intended for people who do not have symptoms. If you develop symptoms that could indicate a liver problem, you should talk with a healthcare provider rather than waiting for your next surveillance test. Possible symptoms of liver cancer include:

• Pain or discomfort in the upper right side of the abdomen

• A lump or feeling of fullness under the ribs on the right side

• Abdominal swelling

• Unexplained weight loss

• Loss of appetite

• Feeling full after eating a small amount

• Nausea or vomiting

• Fatigue or weakness

• Yellowing of the skin or eyes, called jaundice

• Dark urine

• Pale or chalk-colored stools

• Unexplained worsening of existing liver disease

These symptoms can have many causes other than cancer, but persistent or unexplained symptoms should be evaluated.

Staying on schedule with liver cancer surveillance

For people at increased risk, liver cancer surveillance is not a one-time test. It works best when it is performed consistently at the recommended intervals.

If you have cirrhosis, chronic hepatitis B, or another condition that increases your risk of hepatocellular carcinoma, ask your healthcare provider whether you should receive liver ultrasound with or without AFP testing approximately every six months.

If a surveillance test identifies something unusual, additional imaging can help determine whether the finding is benign or requires further evaluation. Staying on schedule gives your healthcare team the best opportunity to identify liver cancer at an earlier and potentially more treatable stage.