Redefining HCC Surveillance in India: A call for innovative and inclusive strategies

Hepatocellular carcinoma (HCC) is one of the top ten leading causes of cancer-related death in India, with recent reports suggesting a rising incidence. Chronic HBV infection is still the commonest cause of HCC in India but the recent surge of MASLD and better control of viral hepatitis is already changing the epidemiology. Most HCC in India are diagnosed at an advanced stage where cure is impossible, and prognosis is poor. These factors force us to rethink strategies for surveillance and diagnosis of early stage HCC in India. Current guidelines including from INASL, suggest six-monthly surveillance using abdominal ultrasound (USG) with or without Alpha Fetoprotein (AFP) testing. This strategy has several limitations, especially in patients with MASLD. Also, HCC surveillance is neither well-organized nor universally practiced in India. The current screening approach, therefore needs a radical change. The Japanese guidelines provide a template for a successful model for increasing the diagnosis of early HCC. Tumor markers like PIVKA II, and newer algorithms like the GALAD and the GAAD scores could refine the surveillance strategies in the coming years, as shown by emerging data from Thailand and China. Moving away from hospital-based imaging towards community-based use of blood markers and digital technology may be a potential solution to help reach at-risk populations. Healthcare economics and logistics will play a big part in implementation of a radical new strategy, and a nationwide chronic liver disease and HCC registry is needed to evaluate current practices, define populations at risk, and identify the best beneficiaries of surveillance in a resource-constrained setting like India. We also concurrently need to identify, upgrade or develop statewide centers of excellence to provide state-of-the-art integrated multidisciplinary care to patients who get diagnosed through surveillance pathways to actually improve patient outcomes.