Challenges and Controversies

There are discordant results between the Fib-4 and fibroscan, The Fib-4 test variables include Age, AST, ALT and Platelet count, so there could be some inaccuracies related co-morbid conditions that could cause abnormalities in these markers. With cut-off of <1.25 for minimal fibrosis NPV 90% for advanced fibrosis and a score of >3.25 has a PPV of 65% for advanced fibrosis. In between these cut-off is indeterminate and not as helpful. Fibroscan has been shown to have the best diagnostic accuracy of all the non-invasive measures and has been compared to the gold standard of liver biopsy and has concordance rate of 83% for stage 3 fibrosis and 95% for stage 4 fibrosis.
Since the risk of HCC is present with stage 3 fibrosis a discussion regarding the risks/burden of doing lifelong HCC surveillance with ultrasound and AFP should be had with the patient. An alternative would be to do a liver biopsy as a definitive test since gold standard and use those results to inform the conversation.
The use of AFP is not agreed upon in the literature, however based on personal experience, I have had AFP's that have been elevated before a liver lesion was found on routine US imaging, so I have continued to use it with low threshold to go to cross sectional imaging if elevated.

I do not recommend HCV surveillance in the individuals I see in my Viral Hepatitis clinic who have F3 fibrosis. I follow the AASLD Practice Guidance on prevention, diagnosis, and treatment of hepatocellular carcinoma published in 2023. According to this guidance there is insufficient risk of developing HCC in persons with F3 fibrosis to warrant HCC surveillance. This individual has a FibroScan that is consistent with F3 fibrosis so I feel comfortable that she does not need HCC surveillance at this time.