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requirement, since these outcomes will not be observable for many years [143] ; survival rate change is indeed
a necessary indicator. Any benefits and risks should be compared and reviewed before adopting a certain
method of screening [57,117,144] . If the risks outweigh the benefits, it cannot be regarded as effective and is
therefore not recommended. The surveillance adherence rates should be increased and improved [40,145] , and
[37]
should be supported by patients, providers, and health care systems/governments . From the perspective of
public health, cost-effective evaluation should be considered, and the benefits and risks of screening should
be compared, as well [31,86,144,146] . Obviously, benefits of liver cancer screening, at least in terms of greater
benefits than harms from the surveillance, have been evident so far.

CONClUsION
The success of screening depends on having sufficient numbers of personnel to perform the screening
tests by using the technology appropriately or to achieve adequate coverage of the population, and on
the availability of facilities that can undertake subsequent diagnosis, treatment, and follow-up, as has
been addressed by the WHO [147] . The bulk of available evidence suggests that screening for liver cancer
is beneficial, certainly benefits outweigh harms. Inasmuch as symptomatic presentation of liver cancer
has an almost universally fatal outcome, screening for liver cancer is an appropriate method that could
be used to detect early stage liver cancer in China and other endemic countries/areas where liver cancer
burden is substantial. The combined use of AFP and US for liver cancer screening, in the view of its relative
cost-effective or applicability in community/population-based screening, are recommended while other
novel markers or techniques remain to be developed. High risk individuals with established risk factors
(etiological) and or characteristics (clinically identified) are the target populations; and opportunities for
screening at-risk persons is to be encouraged even in regions with financial and medical limitations. Only in
this way will it be possible to find more early and curable liver cancers.

DeClARATIONs
Acknowledgments
The authors would like to thank Prof. Thomas W. Kensler at Public Health Sciences Division, Fred
Hutchinson Cancer Research Center, Seattle, Washington for his useful comments and language editing.

Authors’ contributions
Design of the work, data analysis and interpretation: Chen JG
Data acquisition, material support: Chen JG, Zhang YH, Lu LL, Chen HZ
Provided administrative, technical support: Shen AG, Zhu YR
Wrote the manuscript: Chen JG, Shen AG

Availability of data and materials
Not applicable.

Financial support and sponsorship
This work was supported partially by the China Cancer Foundation Program, and by Chinese National Key
Projects (2012ZX10002009, 2018ZX10732202-001).

Conflicts of interest
All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.

Consent for publication
Not applicable.