Understanding Liver Cancer Risk and Prevention: A Comprehensive Guide for Patients

Table of Contents

• Key Points
• Background: Why Liver Cancer Prevention Matters
• Understanding Cancer Prevention Strategies
• The Challenges of Liver Cancer Screening
• Clinical Risk Scores: Predicting Individual Risk
• Molecular Risk Scores: The Future of Risk Prediction
• Current and Emerging Screening Tools
• Personalized Screening: Matching Intensity to Risk
• Prevention in Hepatitis B
• Prevention in Hepatitis C
• Limitations and Challenges
• Recommendations for Patients
• Frequently Asked Questions
• Source Information

Key Points

• Liver cancer is the second most lethal cancer worldwide, and death rates are rising in Europe, North America, South America, and Africa.
• Fewer than 20% of at-risk patients receive recommended screening, far below the 34% threshold needed for screening to be cost-effective.
• Ultrasound sensitivity can be as low as 32%, and AFP levels can rise for reasons unrelated to cancer, limiting current screening tools.
• Antiviral treatment reduces liver cancer risk in hepatitis B and C, but risk is not eliminated, especially in patients with cirrhosis.
• Personalized risk-based screening, using clinical or molecular scores, was more cost-effective than uniform twice-yearly screening in a recent assessment.

Background: Why Liver Cancer Prevention Matters

Liver cancer, predominantly hepatocellular carcinoma (HCC, the most common type of primary liver cancer), is the second most lethal cancer worldwide. Unlike many other cancers that have seen declining death rates, liver cancer mortality continues to increase in Europe, North America, South America, and Africa. This contrasts sharply with East Asia, where liver cancer deaths have been decreasing.

The numbers tell a stark story. Cirrhosis (severe scarring of the liver) was estimated to cause over 1.2 million deaths in 2013, representing 2% of all deaths globally. This represents a 47% increase since 1990. Cirrhosis and liver cancer are the major life-limiting consequences of progressive liver diseases.

The main causes of chronic liver disease fall into two categories:

• Viral causes: Hepatitis B virus (HBV) and hepatitis C virus (HCV)
• Metabolic causes: Alcohol abuse and non-alcoholic fatty liver disease (NAFLD, now often called metabolic dysfunction-associated steatotic liver disease)

In the United States, liver cancer is the fastest-rising cause of cancer-related deaths. The death rate has increased across almost all counties over the past three decades. This increase is particularly notable in two groups: HCV-infected white men aged 55 to 64 years old, and Hispanics affected with NAFLD in the Texas region.

Computer models forecasting trends until 2030 predict that liver cancer rates will continue increasing in specific groups. These include people born between 1950 and 1959, Hispanic men, and black women.

Why is liver cancer so dangerous? The answer lies in how difficult it is to treat successfully. Even after surgical removal of the tumor or ablation (destroying the tumor with heat or other methods), 70% of patients experience the cancer returning within 5 years. Once tumors reach an advanced stage, currently available medical therapies provide only marginal survival benefit and are not cost-effective.

The genetic complexity of liver cancer tumors makes developing effective treatments even harder. Tumors contain highly complex and heterogeneous genetic abnormalities that hamper identification of effective treatment strategies, despite the growing number of molecular targeted anticancer agents available.

This reality leads to an important conclusion: preventing liver cancer from developing in at-risk patients makes more sense than trying to treat advanced-stage disease with limited health benefit. However, despite clear knowledge of what predisposes patients to liver disease progression toward cirrhosis and cancer, prevention remains extremely challenging. The 5-year survival rate for liver cancer remains below 15%.

Understanding Cancer Prevention Strategies

Cancer prevention encompasses a wide variety of medical interventions. Understanding the different levels of prevention helps patients and doctors plan the most appropriate approach.

Primary prevention focuses on preventing exposure to cancer-causing factors or eliminating them at an early stage. This can be achieved through vaccination, lifestyle modification, or environmental interventions tailored to specific causes.

Secondary prevention involves early detection and chemoprevention (using medications to prevent cancer) of liver cancer occurrence in patients already exposed to disease-causing agents.

Tertiary prevention occurs after radical liver cancer treatment and aims to reduce two types of recurrence:

• Disseminative recurrence: Cancer returning from spread of residual tumor cells
• De novo recurrence: New cancers developing in the remaining scarred or cirrhotic liver

The development of cancer chemoprevention has been challenging, with scarce progress over past decades. The mechanisms of how human cancers begin remain elusive. It is not feasible to verify mechanisms of cancer initiation in patients that are inferred from laboratory studies. This is because it is ethically and logistically difficult to monitor cancer-free individuals with molecular assessments for long durations until a cancer develops.

To overcome this challenge, researchers have proposed a "reverse-engineering" approach. In this method, clinically relevant targets are first identified in patient groups with completed long-term follow-up. These targets are then validated in experimental systems.

Another factor limiting chemoprevention development is that animal models may not resemble human disease. This can lead to false discovery of chemoprevention targets and biomarkers. More sophisticated modeling strategies may improve these approaches.

Relatively difficult access to liver tissue samples is another limiting factor. This contrasts with easier access to specimens from other tissues, such as skin, cervix, and gastrointestinal tract cancers, which have enabled more advanced chemoprevention development. Liquid biopsy (testing blood samples for cancer markers) may resolve the issue of sampling, although it is still uncertain whether informative biomolecules are present in the circulation.

A major difficulty is the design and conduct of chemoprevention clinical trials, which are generally very resource-intensive. Chemoprevention trials typically require large sample sizes and long observation periods for several reasons:

• Suboptimal potency of chemoprevention agents that must meet high safety requirements
• Insufficient enrichment of high-risk patient populations
• Lack of reliable surrogate endpoints for definitive long-term clinical outcomes

For instance, two large liver cancer chemoprevention trials enrolling patients with advanced fibrosis in Europe and the U.S. failed to demonstrate an effect of maintenance low-dose interferon on liver cancer incidence in the whole study population. However, in subgroup analyses of patients with more advanced disease (cirrhosis or portal hypertension, which is high blood pressure in the liver's blood vessels), liver cancer incidence was reduced. This supports the concept of identifying high-risk patients in chemoprevention trials to better capture treatment effects with smaller sample sizes compared to conventional "all-comer" enrollment.

Interestingly, in retrospective and prospective assessments of interferon and other agents in HCV-infected patients, a liver cancer preventive effect started to emerge approximately 2 years after enrollment. This observation may indicate that researchers need to account for the latent period required for subclinical neoplastic clones (early cancer cells) to become clinically recognizable. Researchers need to account for this latent period when designing liver cancer chemoprevention trials.

Regular twice-yearly liver cancer screening is recommended based on current guidelines, but its implementation in clinical practice is far from satisfactory. Furthermore, there is no established liver cancer chemoprevention therapy to date.

Various factors that contribute to chronic liver diseases may serve as chemoprevention targets. These include hepatitis virus infection, hepatic inflammation and fibrosis, and metabolic syndrome. However, the obstacles reviewed above hamper the discovery of such chemoprevention targets and biomarkers.

These challenges obscure the optimal timing and duration of chemopreventive interventions during the lengthy natural history of fibrotic liver disease progression toward liver cancer, which typically lasts for decades. Clinical validation of findings could easily extend beyond the scope and timeframe of typical research studies and clinical trials. This may be less appealing for pharmaceutical industry engagement, as companies may favor a faster return on investment.

The Challenges of Liver Cancer Screening

Screening is a vital component of cancer prevention. Current practice guidelines recommend regular liver cancer screening by twice-yearly ultrasound with or without alpha-fetoprotein (AFP, a blood marker) testing. This applies to clinically identifiable populations with liver cancer risk exceeding a certain threshold.

A series of cohort studies and model-based simulations indicate that liver cancer screening is cost-effective and associated with improved early tumor detection, curative treatment rates, and survival. These benefits occur when screening is available to more than 34% of patients at risk. However, the real-world utilization rate is below 20% due to multiple patient-related and provider-related factors.

Population-based interventions such as mailed outreach could improve the utilization rate to up to 50%. With currently available resources, the vast size of the target population is another obstacle. Cirrhosis is estimated to affect 1-2% of the global population and caused over 1.2 million deaths (2% of total deaths) in 2013, increased by 47% since 1990.

The magnitude of liver cancer risk for emerging populations is yet to be determined. These populations include patients with non-cirrhotic NAFLD and patients who have achieved HCV cure. Screening strategies for these populations have not been established.

These issues highlight the limitation of the current one-size-fits-all approach. This approach assumes uniform liver cancer risk across all patients with the same clinical condition (for example, HCV cirrhosis). This results in often harmful over-estimation or under-estimation of liver cancer risk for each patient. Thus, prediction of individual liver cancer risk is critical to implementing effective and feasible liver cancer screening.

Clinical Risk Scores: Predicting Individual Risk

Researchers have evaluated combinations of readily available clinical symptoms and laboratory variables to develop liver cancer risk-predictive scores. However, their performance is somewhat limited and they are yet to be adopted in clinical practice.

Semi-quantitative histological fibrosis stage (measuring scarring in liver tissue samples) has been associated with future liver cancer risk. However, sampling variability in liver biopsy hampers its robust determination. Quantification of collagen proportionate area (measuring the amount of scar tissue) may enable more reliable estimation of liver cancer risk.

Hemodynamic measurement of portal hypertension, called hepatic venous pressure gradient (HVPG), has been associated with liver cancer risk. Liver stiffness measurement (LSM) by ultrasound-based or magnetic resonance imaging (MRI)-based elastography has been associated with increased risk of liver cancer, mostly in viral hepatitis, including cured HCV infection. This measurement presumably captures fibrotic and inflammatory tissue contents.

Smoking has been associated with increased liver cancer risk in a meta-analysis of 38 cohort studies and 58 case-control studies, with a relative risk of 1.51. Smoking is incorporated in several liver cancer risk scores. The population attributable fraction (PAF) of smoking for liver cancer was 9% in the U.S. Passive smoking was also associated with liver cancer development, with an odds ratio of 4.86 at home and 2.44 at work.

The association of metabolic liver cancer risk factors is affected by smoking, with an interaction p-value of 0.004. Alcohol exposure may also enhance risk, as suggested by characteristic somatic DNA aberrations.

Molecular Risk Scores: The Future of Risk Prediction

Molecular biomarkers of liver cancer risk have been actively explored. Some of these biomarkers were combined with clinical prognostic factors to develop integrative liver cancer risk scores to complement clinical scoring systems and refine liver cancer risk prediction.

Several germline single nucleotide polymorphisms (SNPs, common genetic variations) have been identified as indicators of elevated liver cancer risk with odds ratios of around 1.5 in prospective and retrospective cohorts. These include:

• EGF: In HBV-infected or HCV-infected patients
• MPO, DEPDC5, and MICA: In HCV-infected patients
• Region in 1p36.22, STAT4, and HLA-DQ: In HBV-infected patients
• PNPLA3 and TM6SF2: In alcoholic liver disease and NAFLD patients

Shorter telomeres (protective caps on chromosomes) and germline mutations in the TERT gene were observed in NAFLD-related liver cancer patients. A SNP in the MBOAT7 gene was linked to liver cancer in non-cirrhotic NAFLD patients. A recent genome-wide association study identified a SNP in the TLL1 gene associated with liver cancer risk after HCV cure. A 7-gene SNP panel called the Cirrhosis Risk Score was associated with fibrosis progression in HCV-infected individuals.

Liver tissue-derived transcriptome signatures (patterns of gene activity) have been associated with liver cancer risk. For example, a 32-gene signature in fibrotic liver has been validated as a pan-etiology liver cancer risk indicator. This indicator applies to patients with chronic hepatitis B or C, alcohol abuse, and non-alcoholic steatohepatitis (NASH, a more severe form of NAFLD).

Abundance of serum or plasma proteins such as insulin-like growth factor 1 (IGF1) and osteopontin (OPN/SPP1) has also been associated with liver cancer risk in cirrhosis. The N-glycosylation pattern of total serum protein (called GlycoHCCRiskScore) has identified a subset of compensated cirrhosis patients at liver cancer risk.

Body fluid-based biomarkers (from blood or urine) will enable less-invasive and more flexible prognostic prediction. This is important given the decrease of liver biopsies in clinical practice. However, tissue acquisition will help ensure their relevance to liver disease at least during the process of establishing such assays.

Scientifically rigorous biomarker validation following predefined phases of biomarker development will help ensure clinical validity of the biomarkers. These biomarkers are promising candidates for clinical translation, although assay development and implementation, regulatory approval, and reimbursement are challenging obstacles.

Current and Emerging Screening Tools

Abdominal ultrasound and serum AFP have been widely used as the main liver cancer screening modalities. The suggested minimal sensitivity for a liver cancer screening test to be cost-effective is 42%, assuming a screening access rate of 34%.

The sensitivity of ultrasound and AFP for detection of early-stage liver cancer tumors exceeds the threshold at approximately 60%. However, this is still considered suboptimal. Operator dependency and patient-related factors such as obesity are the major sources of variation in ultrasound sensitivity, which can be as low as 32%.

Serum AFP levels can non-specifically rise due to chronic hepatitis-related liver regeneration. This raises concern about its clinical utility as a screening modality. New serum and plasma biomarkers have been explored as possible replacements for AFP. Some of them are awaiting larger clinical validation for further development and deployment.

Integrative scores combining serum biomarkers with clinical variables have been proposed to improve diagnostic performance. In addition, identification of specific clinical contexts (for example, HCV cirrhosis with normal serum alanine aminotransferase [ALT] level) has been suggested as a strategy to achieve improved performance of AFP.

Computed tomography (CT) and MRI may serve as alternatives to ultrasound with better performance. These imaging methods are free from inter-operator variability. Indeed, CT and MRI can double the lesion-based sensitivity for small liver cancer tumors, reaching up to 86%. However, the high costs and irradiation (for CT) preclude their use as practical widespread options for liver cancer screening.

An abbreviated contrast-enhanced MRI (AMRI) has been developed as an option specifically designed for regular liver cancer screening. This approach costs half as much as a full MRI while maintaining a high sensitivity of 81% and specificity of 96%.

Personalized Screening: Matching Intensity to Risk

The heterogeneous individual liver cancer risk among patients captured by clinical or molecular scores will enable rational allocation of limited liver cancer screening resources. This approach directs resources to high-risk patients who most need the intervention. It also avoids ineffective and wasteful distribution of demanding screening efforts to low-risk individuals.

The currently recommended liver cancer screening interval of 6 months was determined based on estimated tumor volume doubling time. Uniformly longer or shorter intervals did not improve liver cancer detection. However, high-risk subjects likely develop liver cancer at a high frequency and in a multicentric manner (multiple locations). Given this, altering liver cancer screening intensity according to estimated individual liver cancer risk may enable more efficient early tumor detection.

Such a personalized risk-based cancer screening strategy has been successfully implemented in other tumor types, such as colorectal and breast cancers. In addition, education programs targeting high-risk communities with specific liver cancer risks based on etiology may efficiently improve uptake of high-risk individuals to liver cancer screening. An example is African-born immigrants in New York City with a high prevalence of HBV infection.

The net benefit of liver cancer screening is determined as a function of multiple factors:

• Screening interval
• Performance of screening modalities
• Liver cancer incidence in the target population
• Screening access rate

These factors have been evaluated by model-based cost-effectiveness analysis. A recent comprehensive assessment of individual risk-based tailored liver cancer screening strategies revealed superior cost-effectiveness of personalized screening compared to the currently recommended uniform twice-yearly screening of all patients.

For instance, exclusive screening of high-risk subjects using AMRI is a robustly cost-effective strategy. More frequent screening, four times per year, is cost-effective when annual liver cancer incidence is greater than 3%. Although these results need to be clinically verified, testing of such strategies is now technically feasible. This testing is feasible with the liver cancer risk tests and new screening modalities already available in the clinical setting.

Prevention in Hepatitis B

Chronic HBV infection has been the dominant cause of liver cancer in Southeast Asia and sub-Saharan Africa, although the incidence of HBV-induced liver cancer is declining. Co-infection with hepatitis delta virus, food contamination with aflatoxin B1, microcystins, and metabolic risk factors facilitate fibrosis or liver cancer development.

HBV DNA integration into the host genome is a unique feature that may lead to direct activation of oncogenic signals and carcinogenesis without requiring a fibrotic tissue microenvironment. Serum HBV DNA levels are associated with increased liver cancer risk. Certain HBV strains are also associated with increased liver cancer risk. Examples include genotype C in Asian populations and genotype F in Alaskan populations. Mutations in the HBV genome are also associated with increased liver cancer risk. Examples include the pre-Core and basal core promoter regions.

Universal HBV vaccination is effective as a primary liver cancer prevention measure by reducing neonatal HBV vertical transmission (from mother to baby). In a 20-year follow-up of a national vaccination program, the annual liver cancer incidence was significantly lower among vaccinated children aged 6-19 years compared with unvaccinated cohorts. The relative risk was 0.31.

Antiviral therapies have been evaluated as secondary prevention. In a meta-analysis of 12 clinical trials involving 2,082 patients, interferon-based regimens decreased cirrhosis and liver cancer development, with relative risks of 0.65 and 0.59, respectively.

Suppression of HBV replication by nucleot(s)ide analogs (NAs, antiviral medications) reduced liver cancer incidence from 7.4% to 3.9% (hazard ratio 0.49) in a prospective trial enrolling 651 Taiwanese patients. In a retrospective survey of 2,795 Japanese patients, liver cancer incidence was reduced from 13.3% to 1.1%.

Retrospective studies conducted mainly in Asia reported liver cancer risk reduction with newer generation first-line NAs, entecavir and tenofovir. The reduction was approximately 30% in cirrhotic patients and 80% in non-cirrhotic patients, although evidence in Western patients is still limited. A cohort study of 330 Taiwanese patients suggested that interferon may better prevent liver cancer development than NAs.

In the setting of tertiary prevention (adjuvant therapy after curative resection or ablation of primary liver cancer tumors), a meta-analysis of 13 trials with 6,350 patients reported a finding. Use of NAs is associated with lower recurrence-free survival, with a hazard ratio of 0.66. This was confirmed in a more recent clinical trial with a hazard ratio of 0.65.

Of note, the liver cancer incidence after achieving virologic response with HBV DNA level consistently below 2,000 IU/mL to NAs was significantly higher. This incidence was higher than the liver cancer incidence in inactive chronic hepatitis B. This indicates residual cancer risk not eliminated by current antiviral therapies. Even a low-level viremia (below 2,000 IU/mL) during entecavir treatment increases liver cancer risk, with a hazard ratio of 1.98. This risk is especially elevated in patients with cirrhosis, with a hazard ratio of 2.20, compared to patients with undetectable HBV DNA.

Prevention in Hepatitis C

Globally, 71 million individuals are affected with viremic HCV infection, representing a prevalence of 1%. The incidence and mortality of HCV-related liver cancer keep rising in specific subpopulations, such as the 1945-1965 birth cohort (baby boomers) and veterans in the U.S.

HCV clearance by antiviral therapies with a sustained virologic response (SVR, meaning the virus is no longer detectable) significantly reduces liver cancer incidence. However, interferon-based regimens had no impact on the incidence at a population level. This was due to low treatment uptake (1-3% annually) and a modest SVR rate of 50% in a regional study in Australia.

Despite the improved SVR rate with direct-acting antivirals (DAAs), liver cancer incidence is predicted to further increase until 2035. This will occur unless the treatment uptake rate is increased more than five-fold by 2018. HCV elimination is hampered by the high DAA costs and lack of comprehensive HCV screening linked to treatment programs.

Undiagnosed HCV infection is estimated to represent 50% or more of the whole infected pool. In addition, high-risk populations such as inmates and injection drug users contribute to the 3-4 million new infections each year. These populations serve as a reservoir that maintains the pool of HCV-infected subjects.

Limitations and Challenges

This review identifies several important limitations in the current approach to liver cancer prevention and screening.

Screening implementation gap: Despite clear guidelines recommending regular liver cancer screening, fewer than 20% of at-risk patients actually receive screening. This is far below the 34% threshold needed for screening to be cost-effective.

Suboptimal screening tools: Current screening methods (ultrasound and AFP) have significant limitations. Ultrasound sensitivity can be as low as 32% depending on the operator and patient factors such as obesity. AFP levels can rise for reasons unrelated to cancer, raising concerns about its reliability.

Uncertain risk in emerging populations: The magnitude of liver cancer risk for patients with non-cirrhotic NAFLD and patients who have achieved HCV cure is not yet determined. Screening strategies for these populations have not been established.

Challenges in chemoprevention research: Developing effective chemoprevention therapies has proven extremely difficult. Clinical trials require large sample sizes and long observation periods. Animal models may not accurately reflect human disease. Access to liver tissue samples is limited.

Residual risk despite treatment: Even after successful antiviral treatment, patients with cirrhosis remain at risk for liver cancer. Low-level viremia during treatment increases liver cancer risk, especially in patients with cirrhosis.

Barriers to HCV elimination: High costs of direct-acting antivirals and lack of comprehensive screening programs hamper efforts to eliminate HCV. Undiagnosed infections represent 50% or more of the infected population.

Recommendations for Patients

Based on this comprehensive review, patients with chronic liver disease should be aware of the following key points:

1. Understand your risk: Chronic infection with hepatitis B or C, alcohol abuse, and non-alcoholic fatty liver disease all increase your risk of liver cancer. The risk is highest if you have developed cirrhosis.
2. Ask about screening: Current guidelines recommend liver cancer screening every 6 months using ultrasound, with or without AFP blood testing. If you are not receiving regular screening, discuss this with your healthcare provider.
3. Discuss antiviral treatment: If you have hepatitis B or C, antiviral treatment can significantly reduce your risk of developing liver cancer. However, even successful treatment does not eliminate the risk entirely, especially if you have cirrhosis.
4. Consider lifestyle factors: Smoking increases liver cancer risk. If you smoke, quitting can help reduce your risk. Limiting alcohol consumption is also important.
5. Stay informed about new developments: Researchers are developing new risk prediction tools and screening methods that may allow for more personalized approaches to liver cancer prevention and detection.
6. Participate in research when possible: Clinical trials are needed to develop better prevention and screening strategies. Ask your healthcare provider if there are relevant studies you might join.

The future of liver cancer prevention lies in precision medicine. This means using individual risk prediction to tailor screening and prevention strategies to each patient's specific situation. While this approach is still being developed, it offers hope for substantially improving the currently dismal prognosis of liver cancer.

Frequently Asked Questions

What causes liver cancer?

Liver cancer, mostly hepatocellular carcinoma, is linked to chronic liver diseases. Viral causes include hepatitis B and C. Metabolic causes include alcohol abuse and non-alcoholic fatty liver disease. These conditions create a high-risk environment for cancer. Risk is highest if cirrhosis, or severe liver scarring, has developed. In the United States, liver cancer is the fastest-rising cause of cancer-related deaths.

How often should I be screened for liver cancer?

Current guidelines recommend screening every 6 months using ultrasound, with or without a blood test called alpha-fetoprotein. This applies to people with known liver cancer risk above a certain threshold. However, fewer than 20% of at-risk patients actually receive screening. If you are not being screened regularly, discuss this with your healthcare provider.

What does it mean if my alpha-fetoprotein (AFP) level is high?

AFP is a blood marker used in liver cancer screening, but it has limitations. Levels can rise for reasons unrelated to cancer, such as liver regeneration from chronic hepatitis. This raises concern about its reliability as a screening test. AFP is often used together with ultrasound. Your doctor can interpret your result in the context of your overall liver health.

Can hepatitis B or C treatment reduce my risk of liver cancer?

Yes. Antiviral treatment for hepatitis B or C can significantly reduce liver cancer risk. For hepatitis B, nucleot(s)ide analogs reduced incidence from 7.4% to 3.9% in a prospective trial of 651 Taiwanese patients. For hepatitis C, clearing the virus with antiviral therapy lowers risk. However, even successful treatment does not eliminate the risk entirely, especially if you have cirrhosis.

What are the limitations of ultrasound for liver cancer screening?

Ultrasound sensitivity can be as low as 32%, depending on the operator and patient factors such as obesity. The suggested minimum sensitivity for a cost-effective screening test is 42%, assuming a screening access rate of 34%. Ultrasound and AFP together detect early-stage tumors at about 60% sensitivity, which is still considered suboptimal. CT and MRI can double sensitivity for small tumors but are costly.

What is personalized screening for liver cancer?

Personalized screening means matching screening intensity to your individual risk, rather than using the same approach for everyone. Risk can be estimated using clinical or molecular scores. A recent assessment found personalized screening was more cost-effective than uniform twice-yearly screening for all patients. For example, screening only high-risk subjects with abbreviated MRI was cost-effective. This approach is still being developed and needs clinical verification.

I have cirrhosis from hepatitis C and my doctor recommends liver cancer screening every 6 months — when should I get a second opinion on my liver cancer risk and screening plan?

A second opinion can help when you have cirrhosis from hepatitis B or C, alcohol abuse, or non-alcoholic fatty liver disease, since these raise liver cancer risk and risk is highest with cirrhosis. Guidelines recommend screening every 6 months with ultrasound, with or without AFP testing, yet fewer than 20% of at-risk patients receive it. A second opinion may clarify your individual risk, whether screening intensity should change, and whether antiviral treatment or lifestyle changes apply. Diagnostic Detectives Network provides independent expert second opinions.

Source Information

Original Article Title: Risk factors and prevention of hepatocellular carcinoma in the era of precision medicine

DOI: 10.1016/j.jhep.2017.09.016

Authors: Naoto Fujiwara, Scott L. Friedman, Nicolas Goossens, and Yujin Hoshida

Author Affiliations: Division of Liver Diseases, Department of Medicine, Tisch Cancer Institute, Graduate School of Biomedical Sciences, Icahn School of Medicine at Mount Sinai, USA; Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Japan; Division of Gastroenterology and Hepatology, Geneva University Hospital, Geneva, Switzerland

Publication: Journal of Hepatology, March 2018, Volume 68, Issue 3, Pages 526-549

DOI: 10.1016/j.jhep.2017.09.016

This patient-friendly article is based on peer-reviewed research. The original article was supported by the National Institutes of Health (NIH) and is available through PubMed Central. This translation is intended for educational purposes and should not replace consultation with qualified healthcare providers.