Nonalcoholic fatty liver disease (NAFLD) is characterised by the presence of hepatic steatosis without significant alcohol consumption or concomitant liver disease. Patients with NAFLD-related cirrhosis are at a high risk of developing liver complications, including hepatocellular carcinoma (HCC). However, up to one-third of HCCs associated with NAFLD develop in patients without cirrhosis.
Current guidelines recommend surveillance of HCC in high-risk patients, which is mainly restricted to those with cirrhosis. For patients with NAFLD but without cirrhosis, surveillance recommendations focus solely on those with chronic hepatitis B and C viruses, and those with advanced fibrosis.
As such, although they are significantly affected by HCC, there remains a lack of surveillance for patients with chronic liver disease in the absence of cirrhosis.
This review aims to present the current challenges and future directions of surveillance for HCC in patients with NAFLD.
There is a need to address concerns regarding the surveillance of HCC in NAFLD patients. These concerns include lack of HCC risk stratification, as well as surveillance test accuracy and adherence.
Patients with NAFLD-related cirrhosis have a high risk for developing HCC. This risk justifies surveillance of these patients based on the cost effectiveness argument. However, for patients with cirrhosis, no effective risk stratifiers are currently in place to guide HCC prevention and early diagnosis.
Similarly, no validated risk stratification tools for the development of HCC in patients with chronic liver disease but without cirrhosis currently exist. However, due to the large population attributable factor (PAF) for HCC from non-cirrhotic NAFLD, it may also be justified to monitor these patients.
Further, surveillance programs for high risk patients with cirrhotic NAFLD are rarely adhered to in clinical practice. Indeed, less than 20% of patients with cirrhosis undergo adherence to such programs. Guidelines for surveillance interval and recall must be clarified to improve program adherence and patient prognosis.