Treatment with direct-acting antivirals (DAAs) has substantially improved the prognosis of patients with hepatitis C virus (HCV) infection. Although HCV elimination prevents liver disease progression, patients with advanced liver disease remains at risk of developing liver-related complications, mainly hepatocellular carcinoma (HCC).1, 2, 3 For this reason, European Association for the Study of the Liver (EASL) Clinical Guidelines still recommend lifelong HCC surveillance in patients with advanced liver fibrosis (F3) and cirrhosis (F4).4 Several studies have shown that the risk of developing HCC in patients with advanced disease is not homogeneous, being greater in those with cirrhosis than in those with advanced liver fibrosis,2, 3 and as a result, American Association for the Study of Liver Diseases (AASLD) recommends HCC surveillance only in patients with cirrhosis.5 In addition, the pretreatment stage of liver disease is nowadays generally established by using non-invasive methods, based mainly on liver stiffness measurement (LSM), and this may cause some patients to be misclassified. Moreover, the potential regression of liver fibrosis after sustained virological response (SVR) and its correlation with LSM values,6 as well as its relationship with the HCC risk over time are still unknown.

Therefore, it is relevant to define patients who remain at risk of developing HCC after SVR in whom surveillance is clearly indicated, and those with a very low HCC risk, who could be discharged from follow-up. Although this topic has already been investigated recently, we planned this study with the aim of assessing the value of non-invasive parameters, both at starting treatment (ST) and at SVR, in patients with advanced and compensated hepatitis C to predict the occurrence of HCC in order to identify subsets of patients with a very low risk for whom follow-up would not be cost-effective.