Most patients living with hepatitis B and C in Rwanda are missing crucial liver cancer screenings, leaving them at high risk of preventable deaths, a new study has found.

Hepatocellular carcinoma (HCC) is the most common type of liver cancer and usually develops in people with long-term hepatitis infections.

Regular check-ups using ultrasounds and a simple blood test called alpha-fetoprotein (AFP) can help detect it early and save lives.

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Dr Fidel Rubagumya, a consultant oncologist and director of research at the Rwanda Military Referral and Teaching Hospital, and others analysed medical records of 388 patients seen between January 2022 and December 2024.

They found that only 15.5 per cent of patients received the recommended ultrasounds, while 12.1 per cent had AFP testing, in line with national hepatitis guidelines.

"Over one-third of patients never had an ultrasound, and nearly half never received AFP testing,” the researchers said, highlighting gaps in liver cancer surveillance.

The gaps in liver cancer surveillance have life-or-death consequences. In sub-Saharan Africa, patients diagnosed with hepatocellular carcinoma survive for a median of less than three months, and nearly 93 per cent die within a year.

Regular screenings, including ultrasounds and AFP blood tests, can catch the disease early and improve survival, yet the study showed that most patients are diagnosed at advanced stages.

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The research also revealed that middle-aged adults, between 31 and 50—the group most at risk for liver cancer—were less likely to stick to recommended surveillance schedules.

"Paradoxically, patients from rural provinces demonstrated better adherence than those in Kigali,” the study report authors said.

The authors suggest this may be due to Rwanda’s decentralised health system.

"Rural patients may receive more consistent follow-up through health posts staffed by community health workers, while urban patients in Kigali face overcrowded clinics with fragmented care,” they argue.

The researchers stress the need for stronger policy measures. They recommend integrating liver cancer screening into routine hepatitis care.

"Embedding ultrasound and AFP testing into every hepatitis treatment visit is critical to catch liver cancer early.”

They also suggest expanding access by training primary care physicians and general internists in basic ultrasound use, deploying portable machines to high-burden districts, and leveraging digital health tools to send automated reminders for tests.

"Awareness campaigns through Umuganda meetings and radio programs could encourage patients to attend screenings and follow-up appointments,” the authors say.

Systemic issues may be contributing to low surveillance, including clinics focusing more on acute care than preventive services and a false sense of security from successful hepatitis treatment programs, researchers pointed out. "Clinic workflows often focus on viral suppression rather than cancer monitoring.”

They stress that Rwanda’s successful infant hepatitis B vaccination programme shows that prevention and early detection are achievable when there is political commitment.

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While 13 patients (3.4 per cent) were found to have liver lesions on ultrasound, the study notes that follow-up data was missing for nearly half of the cohort, meaning the actual number of potential HCC cases may be higher.

"This underscores the importance of consistent and complete surveillance,” researchers notes.

"Without integrating HCC surveillance into routine care, many high-risk hepatitis patients will continue to be diagnosed late, missing opportunities for life-saving interventions.”