Liver cancer surveillance: who to screen and how in AU general practice

What hepatocellular carcinoma is

Hepatocellular carcinoma (HCC) is primary cancer arising from hepatocytes — the main functional cells of the liver. It accounts for approximately 90% of primary liver cancers worldwide and is the fifth most common cancer globally. In Australia, HCC incidence and mortality are rising rapidly, driven by three intersecting epidemics: chronic hepatitis B (predominantly in Asian-born and African-born communities), the legacy hepatitis C cohort (many still at risk despite direct-acting antiviral cure), and the burgeoning metabolic dysfunction-associated steatotic liver disease (MASLD) epidemic linked to obesity and type 2 diabetes.

The most important fact about HCC from a general practice perspective is the survival gradient by stage. Overall five-year survival in Australia is under 20% — because most cases are diagnosed when the tumour is already advanced and unresectable. But patients diagnosed at BCLC very early or early stage have five-year survival exceeding 70% with curative therapy. The purpose of HCC surveillance is to catch the tumour before this window closes.

A. Core clinical — the AU general-practice framework

Pathophysiology in brief

Cirrhosis from any cause is the dominant predisposing condition for HCC. Chronic inflammation, fibrosis, and hepatocyte regeneration create an environment of genomic instability that favours malignant transformation over years to decades. This is why cirrhosis itself — not only the underlying aetiology — is the primary surveillance trigger.

Chronic hepatitis B is the important exception: HBV DNA can integrate into the host genome and drive hepatocellular carcinogenesis without cirrhosis, particularly in people of Asian and African ancestry who have been infected since childhood. This is why selected hepatitis B carriers without cirrhosis also qualify for surveillance.

MASLD (formerly NAFLD) is now the fastest-growing cause of HCC in developed countries. Approximately 20–30% of MASLD-associated HCC arises in non-cirrhotic livers, though risk is substantially higher once advanced fibrosis (F3–F4) or cirrhosis is established.

The median HCC tumour doubling time is 4–5 months, which directly informs the 6-monthly surveillance interval — the interval is calibrated to detect tumours before they exceed 2 cm, the threshold at which the full range of curative options remains available.

Australian epidemiology

Per the Gastroenterological Society of Australia (GESA) and MJA 2023 analysis:

• HCC is among the fastest-growing cancer mortality categories in Australia
• Chronic hepatitis B — approximately 230,000 Australians live with chronic HBV; the ASHM Hepatitis B Mapping Project documents substantially higher prevalence and lower diagnosis rates in African-born and Asian-born communities
• Chronic hepatitis C — post-DAA cohort still at risk if cirrhosis was established before cure
• MASLD — now the dominant driver of new HCC cases in Western populations
• Aboriginal and Torres Strait Islander communities — higher HCC incidence and mortality, compounded by barriers to surveillance uptake

Surveillance criteria

Per AASLD 2023 Practice Guidance and Cancer Council Australia HCC clinical guidelines, commence 6-monthly liver ultrasound plus serum AFP in:

All adults with cirrhosis (any cause)

Selected patients without cirrhosis:

• Chronic hepatitis B carriers: Asian men aged ≥40, Asian or African women aged ≥50
• Chronic hepatitis B with family history of HCC (first-degree relative)
• Chronic hepatitis B with high HBV DNA (>2,000 IU/mL) and/or elevated ALT
• Chronic hepatitis B with advanced fibrosis on elastography (F3–F4) even if not yet cirrhotic
• MASLD with established advanced fibrosis (F3–F4) — transient elastography or biopsy-confirmed

Surveillance modality

Liver ultrasound plus serum AFP every 6 months is the recommended modality. Combined sensitivity for early HCC is approximately 60–70%; AFP alone has sensitivity of only 40–60% and insufficient specificity. Ultrasound quality is limited by obesity, severe hepatic steatosis, or cirrhotic nodularity — in these circumstances, add contrast-enhanced CT or MRI as the surveillance modality or upgrade for inadequate ultrasound.

B. Surveillance — working through an abnormal result

Lesion ≥1 cm on surveillance ultrasound

Any new lesion ≥1 cm identified on surveillance ultrasound requires same-week hepatology referral for contrast-enhanced multiphasic CT or MRI with hepatobiliary contrast — do not arrange a repeat ultrasound in 3 months.

The diagnostic pattern in cirrhotic livers follows LI-RADS criteria: arterial-phase wash-in followed by portal-venous-phase wash-out is the hallmark of HCC neovascularisation. In a confirmed cirrhotic patient, a LI-RADS 5 lesion — classic wash-in/wash-out plus additional major features — is considered diagnostic of HCC without tissue biopsy.

LI-RADS category	Interpretation	Action
LR-1	Definitely benign	Resume routine surveillance
LR-2	Probably benign	Repeat ultrasound in 3–6 months
LR-3	Intermediate probability	CT or MRI in 3–6 months; discuss with hepatology
LR-4	Probably HCC	Multidisciplinary team assessment; consider biopsy in non-cirrhotic
LR-5	Definitely HCC	HCC confirmed; proceed to staging and treatment planning
LR-M	Probably malignant (not HCC-specific)	Biopsy; non-HCC malignancy must be excluded

Lesion under 1 cm

Lesions under 1 cm on surveillance ultrasound should be repeated with ultrasound in 3 months (not 6 months). If the lesion grows to ≥1 cm or shows suspicious features, proceed to CT or MRI.

Rising AFP without discrete lesion

A progressive AFP rise without a visible lesion on ultrasound should prompt CT or MRI and urgent hepatology discussion — AFP elevation can precede radiologically detectable HCC by several months.

C. BCLC staging and treatment overview

Barcelona Clinic Liver Cancer (BCLC) staging

BCLC integrates tumour burden, liver function (Child-Pugh score), performance status, and presence of portal hypertension to guide treatment allocation:

BCLC stage	Definition	Preferred treatment
0 (Very early)	Single lesion ≤2 cm, Child-Pugh A, PS 0	Ablation (RFA/MWA) or resection
A (Early)	1 lesion ≤5 cm OR 2–3 lesions each ≤3 cm, Child A/B, PS 0	Resection / ablation / transplantation
B (Intermediate)	Multinodular, no vascular invasion, Child A/B, PS 0	Transarterial chemoembolisation (TACE)
C (Advanced)	Vascular invasion or extrahepatic spread, Child A/B, PS 1–2	Systemic therapy
D (Terminal)	Child-Pugh C or PS ≥3	Best supportive care

Systemic therapy for advanced HCC

Atezolizumab plus bevacizumab is first-line systemic therapy for advanced HCC per IMbrave150 (NEJM 2020), demonstrating superior overall survival compared with sorafenib (19.2 vs 13.4 months). Contraindications include oesophageal varices at bleeding risk (bevacizumab), active autoimmune disease, and recent major surgery.

Sorafenib remains a second-line or alternative option. Lenvatinib is non-inferior to sorafenib and offers an alternative first-line agent. Second-line agents include regorafenib, cabozantinib, and ramucirumab (AFP ≥400 ng/mL).

Liver transplantation — Milan criteria

Transplantation offers the best curative outcomes for patients with both HCC and underlying cirrhosis who meet the Milan criteria: a single lesion ≤5 cm, or two to three lesions each ≤3 cm, without macrovascular invasion or extrahepatic disease. Australian transplant programmes — at Austin Health (Melbourne), Royal Prince Alfred Hospital (Sydney), Princess Alexandra Hospital (Brisbane), and Sir Charles Gairdner Hospital (Perth) — manage transplant listing and waitlist care.

Prevention of HCC

• Hepatitis B vaccination — the most effective HCC-prevention intervention globally; included in the National Immunisation Programme birth-dose and infant schedule; catch-up for unvaccinated adults particularly in high-risk communities
• Hepatitis C direct-acting antiviral cure — reduces HCC incidence by 70–80%; PBS-unrestricted since 2016 (Australia was among the first countries to fund this universally)
• Alcohol cessation for alcohol-related liver disease
• MASLD risk-factor management — weight loss, glycaemic control, and aerobic exercise reduce hepatic fibrosis progression

D. Australian operations

GP HCC surveillance register

GPs should proactively identify patients with cirrhosis or qualifying hepatitis B/MASLD and enrol them in a recall system for 6-monthly ultrasound plus AFP. eTG supports this with practice-level implementation guidance. Document surveillance status in the patient record.

MBS items

• MBS 55036 — hepatic ultrasound (surveillance; may require hepatology specialist referral notation)
• MBS 65070 — serum AFP (with hepatocellular carcinoma clinical indication)
• MBS 56507/56807 — CT abdomen with and without contrast (staging/diagnosis)
• MBS 55054 — MRI abdomen (hepatobiliary contrast HCC diagnosis)

PBS

• Sorafenib — PBS Authority, advanced HCC, Child-Pugh A/B, ECOG 0–2
• Lenvatinib — PBS Authority, advanced HCC, Child-Pugh A, ECOG 0–1, not amenable to locoregional therapy
• Atezolizumab + bevacizumab — PBS Authority, advanced HCC Child-Pugh A, ECOG 0–1, no prior systemic therapy

Coordination with hepatology and oncology

HCC management requires a hepatology-led multidisciplinary team. GPs contribute by maintaining surveillance, ensuring follow-up between specialist appointments, monitoring for hepatic decompensation (ascites, encephalopathy, variceal bleeding), and coordinating advance care planning when disease progresses to terminal stages.

For patients with established HCC, the Cancer Council Australia HCC clinical guidelines provide the Australian expert consensus framework.

Notifiable diseases and death

HAV, HBV, HCV, and HEV are notifiable in all Australian states and territories — notify the relevant public health unit for new diagnoses. Death from HCC is reportable to the coroner if the death is unexpected or the cause cannot be clearly attributed.

E. Special populations

Asian-born Australians with chronic hepatitis B

Approximately 230,000 Australians are living with chronic hepatitis B, the majority born in Asia or sub-Saharan Africa and infected perinatally or in early childhood. This group has substantially higher cumulative HCC risk. Many are not yet diagnosed or are not engaged with regular surveillance. The ASHM Hepatitis B Mapping Project documents the gap between HBV prevalence and surveillance engagement in these communities.

GPs in areas with large Asian-born populations should actively screen for HBsAg in unvaccinated individuals from high-incidence countries — particularly China, Vietnam, Korea, and Cambodia — and enrol those positive for CHB surveillance per the criteria above.

Aboriginal and Torres Strait Islander communities

Aboriginal and Torres Strait Islander Australians have higher HCC incidence and mortality than non-Indigenous Australians, driven by higher rates of CHB, alcohol-related liver disease, and barriers to healthcare access and surveillance uptake. The Australian Liver Cancer Action Plan identifies culturally appropriate engagement and community-controlled health service partnerships as key to closing this gap.

Haemochromatosis-related cirrhosis

HFE-associated hereditary haemochromatosis, common in Northern European-ancestry Australians, can progress to cirrhosis and HCC even after iron depletion. Once cirrhosis is established from haemochromatosis, the HCC risk is similar to other cirrhotic aetiologies and surveillance applies on the same 6-monthly schedule. Regular venesection does not eliminate HCC risk in cirrhotic haemochromatosis.

MASLD without established cirrhosis

GPs should assess MASLD fibrosis stage using non-invasive markers — FIB-4 score, NFS (NAFLD Fibrosis Score), and transient elastography (FibroScan) — rather than waiting for clinical cirrhosis to develop. FIB-4 ≥2.67 or transient elastography ≥12 kPa indicates advanced fibrosis warranting hepatology referral and HCC surveillance consideration. Obesity and type 2 diabetes substantially amplify the HCC risk in MASLD.

When to escalate

• New liver lesion ≥1 cm on surveillance ultrasound → same-week hepatology referral for contrast CT or MRI
• Progressive AFP rise (even without discrete lesion) → urgent hepatology referral; CT or MRI before the next surveillance cycle
• LI-RADS 4 or 5 lesion on CT/MRI → immediate hepatocellular carcinoma multidisciplinary team discussion
• Signs of hepatic decompensation (jaundice, new ascites, encephalopathy, variceal bleed) in a patient under HCC surveillance → emergency assessment; may indicate HCC progression or cirrhosis decompensation
• Patient with qualifying hepatitis B or MASLD not yet enrolled in surveillance → arrange baseline ultrasound and AFP; refer to hepatology if not already engaged
• Post-liver-transplant follow-up — all transplant recipients are managed by their transplant centre; GP coordinates general practice follow-up and reports new symptoms

What this article is and is not

This article provides a general-practice-level surveillance and referral framework for hepatocellular carcinoma in Australia, drawing on AASLD 2023 Practice Guidance, GESA and MJA 2023, Cancer Council Australia HCC guidelines, eTG, and IMbrave150. It does not replace specialist hepatology, oncology, or transplant medicine advice. Treatment decisions — systemic therapy, locoregional therapy, transplant listing — are made at multidisciplinary team meetings. Nothing in this article constitutes clinical advice for any individual patient.

For Australian consumer-friendly information: HealthDirect — Liver cancer, Liver Foundation Australia.

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Sources cited

1. AASLD 2023 Practice Guidance — HCC prevention, diagnosis, and treatment
2. GESA — HCC surveillance in Australia: current and future perspectives. MJA 2023
3. Cancer Council Australia — Hepatocellular Carcinoma Clinical Guidelines
4. ASHM — Hepatitis B Mapping Project Australia
5. eTG complete — Hepatocellular carcinoma surveillance
6. RACGP — Liver disease in general practice
7. IMbrave150 — Finn RS et al. Atezolizumab plus bevacizumab vs sorafenib in advanced HCC. N Engl J Med 2020;382:1894
8. Liver Foundation Australia — Australian Liver Cancer Action Plan
9. ACR LI-RADS v2018 — Liver Imaging Reporting and Data System
10. HealthDirect — Liver cancer