Letter to the editor regarding: Lai, Jimmy Che-To, et al “Non-invasive risk-based surveillance of hepatocellular carcinoma in patients with metabolic dysfunction-associated steatotic liver disease”

We read with great interest the study by Lai, Yang, Lee et al, which used a large multicentre cohort to establish non-invasive test thresholds—Fibrosis-4 Index (FIB-4) ≥3²⁵ or liver stiffness measurement (LSM) ≥20 kPa (or LSM ≥15 kPa in the two-step algorithm)—to guide hepatocellular carcinoma (HCC) surveillance in patients with metabolic dysfunction-associated steatotic liver disease (MASLD).

The study represents an important step forward. However, we wish to raise two methodological concerns that, in our view, warrant discussion before these thresholds are adopted in clinical guidelines.

Concern 1: Differential surveillance intensity may inflate observed incidence gradients

HCC events in this cohort were ascertained through prospective follow-up, medical record review or validated registries. In routine clinical practice, however, patients with higher FIB-4 or LSM values are more likely to be referred to hepatologists and to receive more frequent abdominal imaging .1 If high-risk patients underwent more intensive surveillance than low-risk patients—a realistic scenario in a…