Should Patients with Hepatitis C Virus Cirrhosis Undergo Hepatocellular Carcinoma Surveillance Indefinitely?

Patients with chronic hepatitis C virus (HCV) infection are at risk to progress to cirrhosis, at which stage the development of hepatocellular carcinoma (HCC) may shorten their life expectancy. Diagnosing HCC in an early stage is pivotal to allow potentially curative locoregional therapy or liver transplantation, which are associated with the best patient outcomes. Therefore, biannual abdominal ultrasound, with or without alpha fetoprotein, has been frequently recommended as HCC surveillance strategy in patients with HCV-related cirrhosis. While MRI may be more appropriate for HCC detection in an increasing number of patients, the field is currently assessing the advantages and cost-efficacy of general MRI imaging over abdominal ultrasound. Updated assessment of the performance of HCC surveillance is also needed because of the development of effective direct-acting antivirals, which result in a sustained virological response (SVR) in almost all HCV-infected patients. This includes patients who already developed advanced disease. While SVR is considered to result in a 3- to four-fold lower risk of HCC, patients with cirrhosis who cured their HCV infection are not free-warded from this malignant complication. Their annual HCC rate has actually ranged from 1–4% and was rather stable over time. This residual HCC risk appears above the threshold for HCC surveillance to be cost-effective in the setting of SVR. Therefore, in absence of validated risk models with high accuracy to identify patients with a negligible risk of HCC after SVR, long-term surveillance remains indicated in all who developed HCV-related cirrhosis.