Prevention, surveillance, and early detection of hepatocellular carcinoma – a Brazilian multidisciplinary consensus

COIMBRA, Felipe José Fernández; GODOY, André Luís de; FERNANDES, Paulo Henrique de Sousa; CASTRO NETO, Heládio Feitosa e; PINHEIRO, Rodrigo Nascimento; BOIN, Ilka de Fátima Santana Ferreira; ANDRAUS, Wellington; TUSTUMI, Francisco; AMARAL, Paulo Cezar Galvão do; BRANDÃO-MELLO, Carlos Eduardo; BRAUN, Alexcia Camila; BRAGHIROLI, Maria Ignez; BREDT, Luis César; CAPARROZ, Carla; CARRILHO, Flair José; CUNHA, Guilherme Moura; DINIZ, Alessandro Landskron; FORTE, Daniel Neves; GARCIA, José Huygens Parente; GENZINI, Tércio; CORREIA, Mauro Monteiro; OLIVEIRA, Cássio Virgílio Cavalcante de; KALIL, Antonio Nocchi; LIMA, Agnaldo Soares; MARTINS, Guilherme Lopes Pinheiro; ROCHA, Cristina Melo; MENEZES, Marcos Roberto de; MOTTA-LEAL-FILHO, Joaquim Maurício da; MURAD JÚNIOR, Munir; PEIXOTO, Renata D’Alpino; PINHEIRO, Rafael Soares Nunes; REZENDE, Marcelo Bruno de; RIBEIRO, Héber Salvador de Castro; MARTINS, Mario Rino; ROCHA FILHO, Duilio Reis da; ROSA, Arthur Accioly; SZUTAN, Luiz Arnaldo; TORRES, Orlando Jorge Martins; D’ALBUQUERQUE, Luiz Augusto Carneiro; MATTOS, Ângelo Alves de; COUTINHO, Anelisa Kruschewsky; HERMAN, Paulo; OLIVEIRA, Alexandre Ferreira

doi:10.1590/0102-672020260000018e1947

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REVIEW ARTICLE - POSITION PAPER • ABCD, arq. bras. cir. dig. 39 • 2026 • https://doi.org/10.1590/0102-672020260000018e1947 linkcopy

Prevention, surveillance, and early detection of hepatocellular carcinoma – a Brazilian multidisciplinary consensus

Prevenção, rastreamento e detecção precoce do carcinoma hepatocelular – um consenso multidisciplinar brasileiro

Authorship SCIMAGO INSTITUTIONS RANKINGS

Background: Hepatocellular carcinoma is a major cause of cancer-related mortality and represents a growing public health challenge.

Aims: To develop multidisciplinary evidence-based recommendations for the prevention and early detection of hepatocellular carcinoma.

Methods: This consensus was coordinated by the Brazilian Society of Surgical Oncology, with the participation of 13 additional national societies. A steering committee defined the key clinical questions addressing prevention, surveillance, and early detection strategies. Recommendation statements were informed by a comprehensive, non-systematic review of the literature conducted using PubMed, Scopus, and the Cochrane Library.

Results: Eighteen recommendations reached consensus, covering three main domains: 1. Primary prevention, including HBV vaccination, timely antiviral therapy for viral hepatitis, and lifestyle interventions for metabolic dysfunction. 2. Secondary prevention, outlining risk-based surveillance strategies for patients with advanced fibrosis or cirrhosis due to hepatitis B virus, hepatitis C virus, or metabolic dysfunction–associated steatotic liver disease. 3. Operational standards for surveillance, emphasizing ultrasound as the cornerstone of monitoring, the importance of structured reporting, management of small nodules, and the selective use of cross-sectional imaging.

Conclusions: These multidisciplinary recommendations provide practical, adaptable guidance for the prevention, surveillance, and early detection of hepatocellular carcinoma. This guidance document aims to reduce the burden of hepatocellular carcinoma and support better clinical outcomes across diverse healthcare settings.

Keywords:
Liver; Carcinoma, Hepatocellular; Consensus; Guidelines as Topic; Early Detection of Cancer; Epidemiology

This is the first article in a four-part series of the Brazilian multidisciplinary consensus on hepatocellular carcinoma.

This consensus provides evidence-based recommendations on prevention, surveillance, and early detection.

It integrates the available scientific literature with national clinical expertise to support and guide clinical decision-making.

CENTRAL MESSAGE Prevention and early detection save lives in liver cancer. This Brazilian multidisciplinary consensus integrates the best scientific evidence and the expertise of specialists from across the country to more effectively guide the prevention, identification, and surveillance of hepatocellular carcinoma. By answering key clinical questions and offering practical, easy-to-use recommendations, this document helps physicians and healthcare teams provide better care to people at risk.

PERSPECTIVES This consensus provides practical guidance to improve the prevention and early detection of liver cancer in daily clinical care. The recommendations emphasize raising awareness of hepatocellular carcinoma, stimulating the development of broader surveillance programs, promoting earlier diagnosis, and improving outcomes for patients at risk for developing primary liver cancer.

Participating Medical Societies
Brazilian Society of Oncological Surgery*
Brazilian Society of Clinical Oncology
Brazilian College of Surgeons
Brazilian College of Hepato-Pancreato-Biliary Surgery
Brazilian College of Digestive Surgery
Brazilian Society of Interventional Radiology and Endovascular Surgery
Brazilian Society of Radiotherapy
Brazilian Association of Organ Transplantation
Brazilian College of Radiology and Diagnostic Imaging
Brazilian Society of Hepatology
Brazilian Society of Pathology
Brazilian Federation of Gastroenterology
National Academy of Palliative Care

Grade of recommendation	Quality of supporting evidence	Clarity of risk/benefit	Implications
Strong	High	Benefits clearly outweigh risks and burdens, or vice versa.	A strong recommendation applies to most patients in most circumstances without reservation. Clinicians should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present.
	Moderate	Benefits clearly outweigh risks and burdens, or vice versa.	A strong recommendation applies to most patients. Clinicians should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present.
	Low	Benefits appear to outweigh risks and burdens, or vice versa.	A strong recommendation applies to most patients. Some of the evidence base supporting the recommendation is, however, of low quality.
Weak	High	Benefits closely balanced with risks and burdens.	Weak recommendation, best action may differ depending on the circumstances, the patients, or their societal values.
	Moderate	Benefits closely balanced with risks and burdens. Some uncertainty in the estimates of benefits, risks, and burdens.	Weak recommendation, alternative approaches likely to be better for some patients under some circumstances.
	Low	Uncertainty in the estimates of benefits, risks, and burdens. Ben efits may be closely balanced with risks and burdens.	Very weak recommendation; other alternatives may be equally reasonable.

Recommendation		Evidence level	Recommendation grade
1	Universal HBV vaccination — preferably initiated at birth — should be implemented as a primary prevention strategy to reduce the incidence of HBV-related HCC.	High	Strong
2	Antiviral treatment with nucleotide analogs should be initiated in patients with chronic HBV who have high serum HBV DNA levels (>10⁴ copies/mL or >2,000 IU/mL), elevated alanine aminotransferase, HBeAg positivity, and/or cirrhosis, as long-term viral suppression reduces the risk of HCC and disease progression. There is no recommendation for routine antiviral treatment in patients in the immune-tolerant phase solely to prevent HCC.	Moderate	Weak
3	Early treatment of chronic HCV infection with DAA is recommended to prevent the progres sion to advanced fibrosis or cirrhosis and reduce the risk of HCC. The benefit is most evident in patients who achieve sustained virologic response.	High	Strong
4	DAA therapy improves the quality of life and helps prevent hepatic decompensation in patients with cirrhosis. However, the impact of DAAs on reducing the risk of HCC recur rence remains incompletely elucidated, as does the appropriate timing for initiating antiviral treatment. Antiviral therapy may be offered to patients with HCC who have previously been treated with curative intent, given the uncertain impact on recurrence risk, while recogniz ing the clear benefits of viral eradication in maintaining liver function. While current evidence does not conclusively demonstrate a reduction in recurrence risk, delaying antiviral therapy solely due to concerns about recurrence is not supported.	Moderate	Weak
5	Patients with HCV-related HCC treated with curative intent should undergo indefinite surveillance with dynamic contrast-enhanced imaging (either multiphasic abdominal MRI or triphasic CT) every 3 to 6 months, given the persistent risk of recurrence related to underly ing liver disease and the field effect of hepatocarcinogenesis.	Moderate	Weak
6	Postoperative antiviral therapy is recommended for all patients with HBV-related HCC un dergoing curative-intent treatment, including liver resection or transplantation, regardless of baseline viral load.	High	Strong
7	Although no randomized controlled trials have confirmed a direct benefit of glycemic control in preventing HCC, diabetes management is strongly recommended in patients with fatty liver disease, especially when additional risk factors for cirrhosis are present.	Low	Strong
8	For overweight or obese patients with nonalcoholic fatty liver disease, lifestyle interventions, such as dietary changes and regular physical activity, are recommended to promote weight loss, improve metabolic parameters, and potentially reduce the risk of HCC.	High	Strong
9	To reduce the risk of HCC, it is recommended to avoid excessive alcohol consumption. Ex cessive alcohol use is associated with hepatic steatosis, fibrosis progression, and HCC.	High	Strong
10	Coffee consumption should be encouraged in patients with chronic liver disease as an ac cessible and potentially protective strategy against HCC. Metformin use is recommended in diabetic patients with chronic liver disease for its glycemic benefits and potential reduction in HCC risk. Despite promising observational data, statins should not be routinely used solely for HCC prevention until higher-quality evidence confirms their benefit in this setting.	Moderate	Weak
11	HCC surveillance is recommended for all patients with advanced fibrosis (F3) or cirrhosis (F4), regardless of etiology. In chronic HBV, surveillance is also indicated in F0–F2 patients with high-risk features (e.g., older age, male sex, high HBV DNA, family history, or Asian/Af rican ancestry). In selected F0–F2 cases with overlapping risks, individualized surveillance may be considered.	High	Strong
12	HCC surveillance is recommended for patients with MASLD who have biopsy-proven or non-invasively diagnosed advanced fibrosis (F3) or cirrhosis (F4).	High	Strong
13	Abdominal ultrasound is the first-line imaging modality for HCC surveillance.	Moderate	Strong
14	Serum alpha-fetoprotein should not be used as a standalone method for HCC surveillance. However, its combination with abdominal ultrasound may increase sensitivity for early tumor detection and can be considered, particularly in high-risk patients.	Moderate	Weak
15	HCC surveillance should be performed every 6 months.	Moderate	Strong
16	Ultrasound reports used for HCC surveillance in high-risk patients should be structured and standardized according to LI-RADS US®, explicitly documenting any acoustic limitations that may impair liver visualization and lesion detection. The report must clearly state the presence or absence of focal hepatic lesions and describe nodules with indeterminate morphology, specifying whether they are smaller or larger than 1 cm. In high-risk patients, ultrasound alone should not be used to establish a definitive diagnosis of hepatic hemangioma, and ad ditional imaging evaluation is required. Color and spectral Doppler assessment of hepatic and portal vascular structures should be routinely included to evaluate portal hypertension and to identify possible tumor-related or hematologic thrombosis.	Low	Strong
17	In patients with nodules smaller than 1 cm detected on ultrasound, follow-up should be performed at 3–4-month intervals for the first 2 years. If the nodule size remains stable after this period, follow-up can be resumed every 6 months.	Low	Strong
18	In patients with cirrhosis, MRI or CT may be considered as a surveillance modality for HCC when ultrasound has technical limitations that compromise its diagnostic performance.	Low	Strong

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