Liver cancer surveillance: who is checked, how, and what follow-up results mean
There are no widely recommended liver cancer screening tests for people at average risk, but testing may be recommended for some people at higher risk. (ACS, 2025) For people with cirrhosis and some people with chronic hepatitis B, AASLD and NICE advise an ultrasound, usually with an AFP blood test, about every 6 months. (AASLD, 2023)(NICE NG50)
What surveillance looks for
Hepatocellular carcinoma (HCC) accounts for about 90% of primary liver cancers. (EASL, 2025) Liver cancer can be hard to find early because signs and symptoms often do not appear until its later stages, and small tumors are hard to feel because most of the liver is covered by the right rib cage. (ACS, 2025) A lot of people who develop liver cancer have long-standing cirrhosis (scar tissue from liver damage). (ACS, 2025) Among people with cirrhosis, the yearly risk of HCC is between 1% and 6%. (NCI PDQ, 2025)
Who is offered surveillance
AASLD says people at high risk of HCC should be entered into surveillance programs, provided they would be candidates for HCC treatment. Its at-risk groups: (AASLD, 2023)
| Group | What AASLD says |
|---|---|
| Cirrhosis (Child-Pugh A or B), any cause | HCC risk of 1.0% per year or more: sufficient risk for surveillance. This includes cirrhosis from hepatitis B, hepatitis C (viremic, or after a sustained virologic response), alcohol, nonalcoholic steatohepatitis and other causes. (AASLD, 2023) |
| Child-Pugh C cirrhosis | Only people who are candidates for liver transplantation. All people listed for transplantation should have surveillance every 6 months. (AASLD, 2023) |
| Chronic hepatitis B without cirrhosis | HCC risk of 0.2% per year or more: men from an endemic country older than 40, women from an endemic country older than 50, people from Africa at an earlier age (surveillance can start as early as the third decade of life, given a median age of 46 at HCC diagnosis), people with a family history of HCC, or a PAGE-B risk score above 10. (AASLD, 2023) |
| Not enough risk on current evidence | Hepatitis C with stage 3 fibrosis, and nonalcoholic fatty liver disease without cirrhosis (HCC risk below 0.2% per year). AASLD recommends against routine surveillance in these groups. (AASLD, 2023) |
- Endemic country: as defined in AASLD hepatitis B guidance. (AASLD, 2023)
- When surveillance is not advised: AASLD recommends against surveillance for people with life-limiting conditions that cannot be remedied by liver transplantation or other directed therapies. (AASLD, 2023)
- Other conditions: ACS lists cirrhosis from any cause, hereditary hemochromatosis and chronic hepatitis B (even without cirrhosis) as reasons some experts recommend screening. (ACS, 2025) MedlinePlus lists screening for liver cancer in people with certain types of hemochromatosis, and in people who have hepatitis B or C or cirrhosis. (MedlinePlus, liver cancer)
To find out whether you have hepatitis or liver scarring, see hepatitis B test results, hepatitis C test results and fatty liver screening and FIB-4.
The tests
- Ultrasound and AFP every 6 months: AASLD says surveillance should use ultrasound and AFP at semiannual (about every 6 months) intervals (statement 10). (AASLD, 2023) Abdominal ultrasound has been the cornerstone of surveillance for over 20 years. (AASLD, 2023)
- Ultrasound: sound waves are bounced off the liver, and the echoes form a picture called a sonogram. (NCI, patient)
- AFP (alpha-fetoprotein): a tumor marker for liver cancer measured in blood. Many people with early liver cancer have normal AFP levels, and high levels may be seen in some people with chronic liver disease who don't have liver cancer, in some other cancers and in some non-cancerous conditions. (ACS, 2025) Pregnancy and hepatitis can also raise AFP. (NCI, patient) AASLD says an AFP cutoff of 20 ng/ml is the most common threshold for surveillance, with a sensitivity of about 60% and a specificity of about 90%. (AASLD, 2023)
- CT or MRI: AASLD does not recommend routine CT or MRI, or tumor markers other than AFP, for surveillance. Contrast-enhanced MRI may be considered for some people in whom ultrasound works poorly (statement 11). (AASLD, 2023)
What follow-up results mean
AASLD bases the next step after a surveillance ultrasound on how well the liver was seen, whether a lesion was found, and the AFP level. (AASLD, 2023)
- US-1 (no liver lesion), good visualization (score A) and normal AFP: continue surveillance every 6 months. (AASLD, 2023)
- US-2 (a lesion smaller than 1 cm): repeat ultrasound and AFP in 3 to 6 months, given a low risk of HCC. If the lesion stays stable on two or more follow-up ultrasounds, the person can return to surveillance every 6 months. (AASLD, 2023)
- US-3 (a new or enlarging solid lesion of 1 cm or more), or a raised AFP whatever the ultrasound shows: high risk of HCC; diagnostic imaging with multiphase CT or contrast-enhanced MRI. (AASLD, 2023)
- Visualization score B or C (limited view): seen in about 20% of people, especially those with obesity and non-viral causes of cirrhosis; the best follow-up is unknown. (AASLD, 2023)
On CT or MRI, LI-RADS grades liver nodules from LR-1 (benign) to LR-5 (HCC). (AASLD, 2023)
- LR-3: about a 30% probability of HCC; AASLD advises repeat CT or MRI in 3 to 6 months. (AASLD, 2023)
- LR-4: about a 75% probability of HCC; AASLD advises team discussion of the next step, including repeat imaging within 3 months or immediate biopsy. (AASLD, 2023)
- LR-5: a 95% to 99% probability of HCC. (AASLD, 2023)
- LR-M: features suggesting cancer; 93% to 100% are malignant on tissue sampling, but only 29% to 44% are HCC, so biopsy should be performed. (AASLD, 2023)
Harms: AASLD says harms from false positives and indeterminate results occur in about 10% of people with cirrhosis under surveillance, and most are mild. (AASLD, 2023) A false-positive result can cause anxiety and is usually followed by more tests, such as a liver biopsy, which has rare but serious complications including hemorrhage and spread of cancer cells along the needle path. (NCI, patient) See also liver function test results.
MedlinePlus, when to contact a medical professional: "Contact your provider if you develop ongoing abdominal pain, especially if you have a history of liver disease." (MedlinePlus, liver cancer)
Where they differ:
- AASLD (US, 2023): ultrasound and AFP about every 6 months for the at-risk groups in the table, and against routine surveillance in hepatitis C with stage 3 fibrosis or fatty liver disease without cirrhosis. (AASLD, 2023)
- EASL (Europe, 2025): its updated guidelines include personalised surveillance based on individual risk assessment and the use of new tools. (EASL, 2025)
- NICE (UK), cirrhosis: ultrasound, with or without AFP, every 6 months for people with cirrhosis who do not have hepatitis B. (NICE NG50)
- NICE (UK), chronic hepatitis B: ultrasound and AFP every 6 months with significant fibrosis (METAVIR F2 or higher, or Ishak 3 or higher) or cirrhosis; without these, consider it if the person is older than 40, has a family history of HCC and HBV DNA of 20,000 IU/ml or more; do not offer it if HBV DNA is below 20,000 IU/ml and the person is younger than 40. (NICE CG165)
- NCI (US): there are no standard or routine screening tests for liver cancer. (NCI, patient) Its evidence summary says, based on fair evidence from randomized trials, that screening people at elevated risk does not reduce deaths from hepatocellular cancer. (NCI PDQ, 2025) AASLD cites a randomized trial in chronic hepatitis B and several cohort studies in cirrhosis showing lower HCC deaths with surveillance. (AASLD, 2023)
- ACS (US): no widely recommended screening for average risk; for cirrhosis, hereditary hemochromatosis or chronic hepatitis B, some experts recommend AFP and ultrasound every 6 months. (ACS, 2025)
- USPSTF (US): its topic list has screening for hepatitis B and hepatitis C infection, and no liver cancer screening topic. (USPSTF topics)
Your doctor decides what your result means for you.
This page does not give treatment advice. If you have an abnormal result, see after an abnormal screening result for questions to ask.
Questions people ask
Who needs liver cancer screening?
There are no widely recommended screening tests for people at average risk. Checks are offered to people at higher risk: the AASLD lists cirrhosis from any cause and some people with chronic hepatitis B without cirrhosis, depending on age, ancestry, family history and a risk score. (ACS, 2025) (AASLD, 2023)
How often is liver cancer surveillance done?
AASLD says surveillance should be done with ultrasound and AFP about every 6 months. NICE says ultrasound, with or without AFP, every 6 months for people with cirrhosis who do not have hepatitis B. (AASLD, 2023) (NICE NG50)
What does US-3 mean on a liver ultrasound?
In the AASLD guidance, US-3 is a new or enlarging solid liver lesion of 1 cm or more. People with US-3, or a raised AFP whatever the ultrasound shows, have a high risk of HCC and should have diagnostic imaging with multiphase CT or contrast-enhanced MRI. (AASLD, 2023)
What does LI-RADS 3 or LR-3 mean?
LI-RADS grades liver nodules on CT or MRI from LR-1 (benign) to LR-5 (HCC). AASLD says LR-3 observations have about a 30% probability of HCC and advises repeat CT or MRI in 3 to 6 months. (AASLD, 2023)
Is a normal AFP test reassuring?
Not on its own. Many people with early liver cancer have normal AFP levels, and high AFP can be seen in some people with chronic liver disease who do not have liver cancer. (ACS, 2025)