Who should be tested for liver cancer and why is testing so important?

While bowel, breast and skin cancer screening are top of mind in general practice, surveillance for liver cancer may be less familiar. But liver cancer surveillance is vital for our at-risk patients, due to the poor prognosis associated with delayed diagnosis. Get the latest on who should be tested and how often, and how we can help our patients get tested.

How common is liver cancer in Australia?

In Australia, both the incidence and mortality rates of hepatocellular carcinoma (HCC) have been increasing over several decades, and the overall 5-year survival rate currently sits at about 23%.^1,2,3

The increasing rates of HCC in Australia are thought to reflect:^2,4

• revised diagnostic criteria;
• an increased at-risk population due to migration; and
• a rise in metabolic dysfunction-associated fatty liver disease due to rising obesity rates.

You can find out more about liver cancer epidemiology here.

Who’s at increased risk of liver cancer?

We know that patients at risk of hepatocellular carcinoma are those with:⁴

• liver cirrhosis;
• chronic hepatitis B or hepatitis C infection;
• alcohol-related liver disease (ARLD); and
• metabolic dysfunction-associated fatty liver disease (MAFLD).

People with cirrhosis make up 85% to 90% of those diagnosed with HCC.¹

HCC is also disproportionately high among Aboriginal and/or Torres Strait Islander people and migrants to Australia from countries where viral hepatitis is endemic.⁴

Why is liver cancer surveillance so important?

Low 5-year survival rates in people with liver cancer are related to many patients being diagnosed with late-stage disease.⁴ Surveillance of our at-risk patients aims to detect HCC early, when curative treatment is still possible.⁴

HCC surveillance programs aim to improve the rates of early detection and curative treatment of HCC, as well as overall survival in people with cirrhosis.⁴

Who should be tested and what tests are needed for people at risk of liver cancer?

Liver ultrasound is the current standard of care for HCC surveillance – in general, testing should be done every 6 months in people at high risk of liver cancer.⁴

A blood test looking for the tumour biomarker alpha-fetoprotein (AFP) can be used in addition to ultrasound to help improve detection rates.^2,4

HCC surveillance in people with cirrhosis

Surveillance should be offered to people with cirrhosis who are:

• willing to have an HCC diagnosis made and consider treatment if HCC is diagnosed;and
• suitable – well enough to receive HCC treatment and with a life expectancy greater than 6 months.⁴

HCC surveillance in people without cirrhosis

Surveillance is also recommended for some people with chronic hepatitis B (HBV) infection without cirrhosis. Factors such as age, ethnicity and family history also need to be considered in these patients.

According to Cancer Council Australia Guidelines, surveillance is generally recommended for the following people with chronic HPV infection without cirrhosis:^2,4

• Asian or Pacific background men aged 40 years or older
• Asian or Pacific background women aged 50 years or older
• Sub-Saharan African people aged 20 years or older
• Aboriginal and/or Torres Strait Islander people aged 50 years or older
• Aboriginal and/or Torres Strait Islander people with a family history of HCC
• Anyone aged 40 years or older with a family history of HCC

See the Cancer Council Guidelines for more detailed information on HCC surveillance.^1,4

Risk assessment for surveillance

Before surveillance is offered, it’s best to perform an individual risk assessment and discuss the risks and benefits with your patient. It’s important to ensure that they are willing to participate in ongoing surveillance.⁴

Patient factors that need to be considered include:⁴

• age;
• family history of HCC;
• individual risk factors;
• ethnocultural group/region of birth;
• comorbidities;
• functioning (ECOG performance status scale); and
• liver-related health status.

Future considerations for surveillance testing

Unfortunately, there are some barriers to surveillance uptake.² The effectiveness of HCC surveillance can also be impacted by the limitations of the current tests and under-recognition of patients at risk.²

In 2023, the Cancer Council and Daffodil Centre published a report called ‘ Roadmap to Liver Cancer Control in Australia’. This document outlines priority actions for targeted screening for advanced liver disease and HCC surveillance.⁵

One of the priority actions identified for primary care is improved systems for surveillance, including patient recall and abnormal-results notification systems.⁵

Future improvements in HCC surveillance may also be achieved with prediction models that identify patients at risk of HCC, and the use of serum biomarkers as an alternative to ultrasound-based HCC surveillance.²