Diagnostic Accuracy of Surveillance Tests for Hepatocellular Carcinoma in Cirrhosis: a Systematic Review and Network Meta-Analysis

OBJECTIVE:For surveillance for hepatocellular carcinoma (HCC) to be effective, tests-including imaging, serological biomarkers (conventional and genomic) and algorithms combining multiple tests-must identify early-stage tumours. We aimed to identify, appraise and synthesise studies reporting the accuracy of all such tests in people with cirrhosis. DESIGN:Systematic review and network meta-analysis of diagnostic test accuracy (NMA-DTA) data. DATA SOURCES:MEDLINE and Embase (2005 to September 2025) and a published Cochrane review. ELIGIBILITY CRITERIA:English-language, post-2005, one-gate or two-gate studies quantifying diagnostic accuracy of tests to detect HCC in populations wholly comprising people with cirrhosis, excluding those with pre-existing signs and symptoms of HCC. DATA EXTRACTION AND SYNTHESIS:Data extracted by one reviewer, checked by a second and made available in an open-access database. We assessed risk of bias using QUADAS-2. We synthesised data using Bayesian NMA-DTA, accounting for tumour stage and incorporating continuous tests across all possible thresholds. RESULTS:We included 170 studies (62 643 participants). Of 115 index tests, 97 were amenable to NMA-DTA. Ultrasound appears no better than alpha-fetoprotein at detecting very-early-stage HCC (sensitivity 0.34 (95% CrI 0.21 to 0.55) vs 0.39 (95% CrI 0.28 to 0.47)), only becoming superior as stage advances. Least affected by stage are contrast-enhanced MRI (sensitivity 0.70 (95% CrI 0.50 to 0.84) very-early; 0.86 (95% CrI 0.73 to 0.94) early; 0.90 (95% CrI 0.67 to 0.98) advanced) and CT (0.68 (95% CrI 0.26 to 0.93) very-early; 0.77 (95% CrI 0.29 to 0.95) early; 0.92 (95% CrI 0.49 to 0.99) advanced). No genomic biomarkers show convincing improvements over combinations of conventional blood-markers. Most studies are at high risk of bias, but conclusions are robust when restricting to studies with favourable methodological characteristics. CONCLUSIONS:Using advanced synthesis methods, we found that tests have low sensitivity for detecting early-stage HCC. Given rising prevalence of cirrhosis and HCC, we need better tests and a stronger evidence-base to inform optimal surveillance strategies. PROSPERO REGISTRATION NUMBER:CRD42022357163.