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Background: Hepatocellular carcinoma (HCC) is a common malignancy in Asians with hepatitis B virus infection. HCC patients often present with poor liver function and large tumors resulting in rapid mortality. The impact of HCC surveillance and subsequent therapy on patient survival remain controversial.Aims: We sought to determine if surveillance for HCC in a community-based clinic improve survival and, if so, identify factors that contribute to the benefit of early tumor detection.Methods: From 1991 to 2008, alpha-fetoprotein and abdominal ultrasound examination were used as surveillance tests for HCC. The survival of HCC patients detected by surveillance was compared to patients who presented to the clinic with HCC (no surveillance). An adjusted lead-time bias interval was added to the survival time of patients who presented with HCC.Results: During this period, 26 patients with surveillance developed HCC while 52 patients presented with HCC. More surveillance patients had normal levels of alkaline phosphatase, alanine aminotransferase, and aspartate aminotransferase (p < 0.05-0.0001) and had tumors that were within Milan and University of California San Francisco (UCSF) criteria (p = 0.02-0.0001). The 1-, 3-, and 5-year survival rates were higher in surveillance patients and in those who received surgical or loco-regional therapies (p = 0.007-0.0001). On multivariate analysis, baseline independent factors predicting survival were single tumors (Hazard ratio [HR] 0.25, p = 0.0005), UCSF criteria (HR 0.29, p = 0.006), Child-Turcotte-Pugh class A (HR 0.45, p = 0.03), platelet counts per log(10) increase (HR 0.315, p = 0.04) and aspartate aminotransferase per log(10) increase (HR 5.7, p = 0.01).Conclusions: Surveillance for HCC identified patients with smaller tumor burdens and more adequate liver function who were able to receive more definitive therapies. HCC surveillance improves survival and should be included as standard of care for patients with hepatitis B. [ABSTRACT FROM AUTHOR]