Editorial: Advancing HCC Surveillance in Hepatitis B With Biomarker‐Based Strategy

Hepatocellular carcinoma (HCC) remains a leading cause of cancer-related mortality globally, with chronic hepatitis B (CHB) being the primary etiological driver, particularly in Asia [1]. Early detection through surveillance is critical for improving outcomes in high-risk patients [2]. Current guidelines recommend semi-annual ultrasound, with or without alpha-fetoprotein (AFP) for HCC surveillance. However, this approach is limited by suboptimal sensitivity (~65%), operator dependency, and significant underutilization [3]. Recent advances in biomarker panels, such as the GALAD (Gender, Age, AFP-L3, AFP, Des-γ-carboxyprothrombin) and ASAP (Age, Sex, AFP, PIVKA-II), offer hope for improving early detection sensitivity [4]. These blood-based tests may address the logistic challenges of imaging-based surveillance, providing a more sensitive and standardised method for early HCC detection. However, their widespread adoption has been slow due to the absence of head-to-head randomised controlled trials and comprehensive cost-effectiveness analyses. In this issue of Alimentary Pharmacology and Therapeutics, Saeoui et al. address this crucial knowledge gap by providing an economic evaluation of biomarker-based HCC surveillance strategies in a Southeast Asian population with CHB [5]. The authors demonstrate that semi-annual ASAP testing is cost-effective, with an incremental cost-effectiveness ratio (ICER) of 76,447 THB (~$2207 USD) per quality-adjusted life-year (QALY) gained, compared to no surveillance. The superior cost-effectiveness of ASAP over ultrasound plus AFP surveillance (ICER: 108,294 THB per QALY) is particularly significant given the practical challenges faced by imaging-based programs. Several strengths of this study deserve emphasis. First, it offers a comprehensive economic evaluation that compares major biomarker panels against the standard of care within a single model. The analysis uses local cost data and validated inputs, with sensitivity analyses confirming the robustness of the results. Ultrasound surveillance faces systemic barriers, including a shortage of trained radiologists and equipment limitations in many remote regions [6]. Biomarker-based approaches could address these systemic barriers while improving clinical outcomes. The diagnostic threshold of GALAD and ASAP in detecting early HCC has been specifically validated in the Thai population [7]. While the model focused on CHB patients, the findings may extend to the growing population with MASH-cirrhosis, where ultrasound-based surveillance has suboptimal performance and remained underutilised. Several important considerations merit discussion. The study employed universal screening for all at-risk CHB patients, without considering baseline HCC risk. Given the variability of HCC risk among CHB patients [8], exploring precision surveillance could provide valuable insights. Transition from universal to precision surveillance may also pose challenges in clinical workflow and physician familiarity. Additionally, the success of biomarker-based programs depends on healthcare provider acceptance and patient compliance, which were not fully captured in economic models. Lastly, the absence of a head-to-head randomised trial comparing biomarker with ultrasound plus AFP in the CHB population introduces uncertainty regarding real-world performance. In conclusion, Saeoui et al.'s work provides economic evidence supporting biomarker-based HCC surveillance in CHB patients. The findings are particularly relevant for Asian countries, where CHB prevalence remains high, and healthcare resources are constrained. While further studies are needed to refine these conclusions and address remaining challenges, the current study offers a timely and valuable perspective on the future of HCC surveillance. Yu Jun Wong: conceptualization, methodology, supervision, funding acquisition, investigation, writing – original draft, writing – review and editing. This article is linked to Saeoui et al. papers. To view these articles, visit https://doi.org/10.1111/apt.70386 and https://doi.org/10.1111/apt.70422. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.