Abstract
The burden for hepatocellular carcinoma (HCC) attributed to nonalcoholic fatty liver
disease (NAFLD) continues to grow in parallel with rising global trends in obesity.
The risk of HCC is elevated among patients with NAFLD-related cirrhosis to a level
that justifies surveillance based on cost-effectiveness argument. The quality of current
evidence for HCC surveillance in all patients with chronic liver disease is poor,
and even lower in those with NAFLD. For a lack of more precise risk-stratification
tools, current approaches to defining a target population in noncirrhotic NAFLD are
limited to noninvasive tests for liver fibrosis, as a proxy for liver-related morbidity
and mortality. Beyond etiology and severity of liver disease, traditional and metabolic
risk factors, such as diabetes mellitus, older age, male gender and tobacco smoking,
are not enough for HCC risk stratification for surveillance efficacy and effectiveness
in NAFLD. There is an association between molecular and genetic factors and HCC risk
in NAFLD, and risk models integrating both clinical and genetic factors will be key
to personalizing HCC risk. In this review, we discuss concerns regarding defining
a target population, surveillance test accuracy, surveillance underuse, and other
cost-effective considerations for HCC surveillance in individuals with NAFLD.
Keywords
liver cancer - cirrhosis - surveillance - guidelines - biomarkers - fatty liver
