Hepatocellular carcinoma (HCC) ranks the fourth most common cancer globally, with approximately 905,000 new cases and 830,000 deaths in 2020 [1]. It was evaluated that the surveillance participation rate in population aged 35 to 74 in China is 37.5–62.3% [2]. Despite the existence of national surveillance guidelines, implementing a comprehensive nationwide HCC surveillance program remains challenging due to China’s extremely large population and uneven development across regions, with about 466,000 new cases annually, accounting for almost half of the global HCC incidence [3]. While hepatitis B virus (HBV) infection remains the primary risk factor in China, other etiologies including hepatitis C, alcohol abuse, and nonalcoholic fatty liver disease are becoming increasingly prevalent.

Early detection of HCC through regular surveillance can significantly improve outcomes, as curative interventions are feasible in early-stage disease [4]. International guidelines recommend semi-annual abdominal ultrasound with or without alpha-fetoprotein (AFP) for high-risk patients [5,6]. A guideline from China also suggested that HCC surveillance including ultrasound and AFP should be performed every 6 months for patients at high-risk [7]. However, a metaanalysis revealed that only 37% of HCC cases are diagnosed via surveillance globally [8], with patient nonadherence emerging as a major barrier, largely due to lack of awareness and education.

To assess patients’ understanding of HCC surveillance, we conducted an 8-item questionnaire survey on 292 highrisk patients with chronic HBV infection (136 with cirrhosis and 156 without cirrhosis) at two Chinese outpatient clinics from July 2022 to June 2023. The complete questionnaire is available in Table 1. The results revealed significant misconceptions about HCC surveillance among these patients, highlighting both overestimation and underestimation of its value.

Most patients overestimated surveillance effectiveness, with 61.6% believing it could prevent HCC development. This misconception may lead to unrealistic expectations and potential disappointment. Additionally, 41.8% expected surveillance to reduce 5-year mortality by 60% or more, far exceeding the actual benefit demonstrated in clinical studies [4]. 76.0% failed to recognize that abdominal ultrasound has a high rate of missed diagnosis of HCC. These misconceptions about HCC surveillance are illustrated in Figure 1.

Conversely, underestimation of surveillance importance was also prevalent. Alarmingly, 60.6% thought surveillance was only necessary when symptomatic, despite early-stage HCC often being asymptomatic. This belief could lead to delayed diagnosis and missed opportunities for curative treatment. Moreover, 38.4% of high-risk patients believed they didn’t need regular surveillance at all, a concerning finding that underscores the urgent need for patient education.

Our study revealed a strong correlation between educational level and survey performance. Among patients with junior high school education or lower, 61.5% answered 3 or fewer questions correctly, compared to only 11.3% of those with a bachelor’s degree. This disparity highlights the need for tailored educational interventions, particularly for patients with lower educational levels. The detailed breakdown of correct answers by educational level is presented in Supplementary Figure 1.

The timing of surveillance also showed misconceptions, with 17.5% of patients believing that annual or less frequent surveillance would be adequate, contrary to the recommended 6-month interval. This could result in delayed diagnosis and poorer outcomes, as demonstrated by recent studies [9,10].

These findings have significant clinical implications. First, they highlight the urgent need for comprehensive education programs on HCC surveillance, tailored to different educational levels. Such programs should address both overestimation and underestimation of surveillance benefits, emphasizing its importance while setting realistic expectations. Second, healthcare providers should actively engage in long-term care and education for high-risk patients, rather than passively waiting for them to seek surveillance. This may require improvements in healthcare delivery systems, including reminder systems and patient navigation programs [11]. Third, the development of more accurate and accessible HCC surveillance tools is crucial. While ultrasound remains the primary surveillance tool, its limitations in certain patient populations necessitate research into alternative or complementary methods [10].

Our study has several limitations that warrant consideration. First, its two-center design in tertiary hospitals may limit generalizability to other healthcare settings or regions in China. Second, the questionnaire, while comprehensive, may not capture all aspects of patients’ understanding of HCC surveillance and we failed to ask the participants about their actual surveillance of HCC, due to the small number of doctors assisting in the study. The closed-ended questions might have led to response bias. Third, our cross-sectional design prevents us from assessing how patients’ knowledge changes over time or after educational interventions. Fourth, we didn’t explore the reasons behind patients’ misconceptions. Lastly, while we found a correlation between educational level and survey performance, other factors such as socioeconomic status, healthcare access, and previous medical experiences were not accounted for. Additionally, our study focused solely on patients with HBV infection, and the findings may not fully represent the perceptions of all HCC high-risk groups. Future multicenter, longitudinal studies with mixed-methods approaches could address these limitations and provide a more comprehensive understanding of HCC surveillance perceptions among high-risk populations.

In conclusion, our study reveals a critical gap in knowledge about HCC surveillance among high-risk patients with chronic HBV infection in China. Addressing this gap through targeted education, improved healthcare delivery, and enhanced surveillance strategies could significantly improve early detection rates and ultimately reduce HCCrelated mortality. Future research should focus on developing and evaluating effective educational interventions, optimizing surveillance protocols for diverse patient populations, and exploring novel surveillance technologies to overcome current limitations.