Alcohol-related hepatocellular carcinoma: surveillance and primary prevention

Gianni Testino

doi:10.17998/jlc.2025.09.16

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Correspondence Alcohol-related hepatocellular carcinoma: surveillance and primary prevention: Gianni Testino^1,2,3; Journal of Liver Cancer 2026;26(1):176-177.
DOI: https://doi.org/10.17998/jlc.2025.09.16
Published online: March 5, 2026

¹Unit of Addiction and Hepatology/Alcohological Regional Centre, IRCCS Policlinico San Martino Hospital, ASL3 Liguria, Genova, Italy

²Centro Studi Mutual-self-help, Community Programs and Caregiver Training, ASL3 Liguria, Genova, Italy

³Department for Healthy Lifestyles and Community Programs, ASL3-ATS Liguria, Genova, Italy

Corresponding author: Gianni Testino, Unit of Addiction and Hepatology/Alcohological Regional Centre, IRCCS Policlinico San Martino Hospital, SC Patologia delle Dipendenze ed Epatologia/ Centro Alcologico Regionale, ASL3 c/o Padiglione, 10 Largo Rosanna Benzi, 16132 Genova, Italy E-mail: gianni.testino@asl3.liguria.it

• Received: August 4, 2025 • Revised: September 1, 2025 • Accepted: September 16, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Dear Editor,

The epidemiology of hepatocellular carcinoma (HCC) has changed considerably over the past few decades, with non-viral causes of chronic diseases such as metabolic dysfunction-associated steatotic liver disease (MASLD) and alcohol-related liver disease (ALD) becoming increasingly prevalent worldwide.¹The review article by Lee reports the necessity to strengthen public health strategies for HCC,²a proposal with which I fully agree.

The paper highlighted the following important aspects: diagnostic delay, adherence to surveillance, health education, and prevention. These issues are particularly evident in cases of metabolic and alcoholic liver disease (MetALD) and ALD.

Diagnostic delay in alcohol use disorder (AUD) has long been recognized. Early identification of harmful or hazardous drinking should be increased, as it facilitates early diagnosis of alcohol-related pathologies such as ALD. Studies estimate an average diagnostic delay of approximately 40 months.³Stigma and social frailty are among the main contributing factors. Public stigma, as well as stigma within healthcare settings, remain pervasive. In addition, self-stigma should be recognized, as it lowers self-esteem and promotes the isolation of patients with AUD.⁴All of this worsens the overall burden of ALD. The observations made in this review are verified in real clinical practice.

It is important to develop an ethical discussion and emphasize that, for various neurophysiopathological reasons, AUD is not a self-inflicted disease. Society also stigmatizes individuals who do not consume alcoholic beverages. Social frailty, which is often present in patients with AUD, creates several problems, including lack of a support network, financial difficulties, and limited access to transportation for healthcare services. Other risk factors include low motivation, depression, anxiety, and poor disease awareness. As a result, patients do not always adhere to HCC surveillance programs. In the absence of symptoms or abnormal laboratory findings, patients may not understand the need for regular screening and follow-up.

Therefore, it is important to raise awareness regarding liver health and to promote comprehensive, high-quality public health initiatives. These efforts are essential to make citizens understand that liver health is crucial to overall quality of life.³Including informal caregivers, when present, in groups for psychological support and health education can also be beneficial.³

Surveillance adherence is often lacking due to the absence of a strong culture of liver health, and only 20-50% of patients with cirrhosis are evaluated by a hepatologist. Prevention is thus of crucial importance.

It is now well known that cancer increasingly affects individuals under the age of 50, and this is partly related to the exposure to voluntary risk factors during early life and young adulthood. The incidence of primary liver cancer has increased in young adults. These HCCs are caused by unhealthy lifestyle habits (MASLD and/or alcohol consumption). Alcohol consumption (particularly binge drinking) during adolescence leads to liver steatosis and MASLD. These problems are growing worldwide, indicating that prevention programs have not led to significant improvements. Productivity and markets have an upper hand in this regard. Effective public health education programs are still lacking. Health education should be enhanced for this population. Empowerment is essential to oppose environmental pressures.

To achieve the best results, prevention programs should be implemented during the pre-adolescent period. This is necessary to extend the disease-free life expectancy of future generations. Unhealthy lifestyle during adolescence can cause premature metabolic diseases and cancer. In an era of remarkable technological and pharmacological advances, an urgent challenge has emerged: primary prevention. This highlights the need to structurally incorporate the teaching of healthy lifestyles into school curriculum. Without such a vision, average disease-free life expectancy will continue to decline.⁵

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Conflicts of Interest

The author has no conflicts of interest to disclose.

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No funding to declare.

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Not applicable.

Author Contributions

Conceptualization: GT

Writing - original draft: GT

Writing - review & editing: GT

References

1. Gujarathi R, Klein JA, Liao CY, Pillai A. The changing demographics and epidemiology of hepatocellular carcinoma. Clin Liver Dis 2025;29:1−15.Article PubMed
2. Lee MH. Public health strategies for hepatocellular carcinoma: from risk factors to prevention and control. J Liver Cancer 2025;25:204−216.Article PubMed PMC PDF
3. Balbinot P, Pellicano R, Testino G. Burden of caregiving of alcohol related liver disease patients: a possible role of training and caregiver groups frequency. Proposal of a method, preliminary results. Minerva Gastroenterol (Torino) 2023;69:486−493.Article PubMed
4. Schomerus G, Leonhard A, Manthey J, Morris J, Neufeld M, Kilian C, et al. The stigma of alcohol-related liver disease and its impact on healthcare. J Hepatol 2022;77:516−524.Article PubMed
5. Balbinot P, Fagoonee S, Pellicano R, Testino G. Lifestyle factors among adolescent. Minerva Pediatr 2018;70:642−643.Article PubMed

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Alcohol-related hepatocellular carcinoma: surveillance and primary prevention

J Liver Cancer. 2026;26(1):176-177. Published online March 5, 2026

DOI: https://doi.org/10.17998/jlc.2025.09.16

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