Background and aims The effectiveness of surveillance for hepatocellular carcinoma (HCC) in the USA is largely unknown. The objective of this study was to evaluate the effectiveness of HCC surveillance in a national Veterans Administration (VA) practice setting, using the national VA hepatitis C virus (HCV) Clinical Case Registry.

Method The cohort consisted of 1480 HCV-infected patients who developed HCC during 1998–2007. The timing and intensity of receiving α-fetoprotein (AFP) and abdominal ultrasound (US) for HCC surveillance were evaluated. Overall mortality risk was examined using Cox proportional hazards regression models adjusting for demographics, clinical features and receipt of HCC-specific treatment.

Results The mean survival was 1.8 years following the HCC diagnosis date. Surveillance AFP or US were recorded in 77.8% of patients within 2 years prior to HCC diagnosis. Annual surveillance with both AFP and US was observed in only 2% of patients. The presence of either AFP or US surveillance during both 0–6 month and 7–24 month periods before HCC diagnosis was associated with a lower mortality risk (HR 0.71, 95% CI 0.62 to 0.82) compared with no surveillance. Receipt of two or more surveillance tests in the 0–6 months (HR 0.76 95% CI 0.66 to 0.88) and to a lesser extent in the 7–12 months (HR 0.81 95% CI 0.1 to 0.99) prior to HCC diagnosis was also associated with reduced mortality risk.

Conclusions Most patients with HCV-related cirrhosis do not receive regular imaging-based surveillance. The effectiveness of HCC surveillance tests in current clinical practice is rather modest in reducing HCC-related mortality.