Professional society guidelines recommend semiannual screening for
hepatocellular carcinoma (HCC) in patients with
cirrhosis; however, studies suggest underuse of screening in clinical practice. Our study's aim was to characterize reasons for HCC screening underuse among patients with
cirrhosis. We conducted a retrospective cohort study of patients with
cirrhosis diagnosed with HCC in two large health systems from 2011 to 2019. We classified screening receipt as consistent, inconsistent, or no screening in the year before HCC diagnosis. We categorized reasons for screening underuse as a potential failure at each of the following steps required for HCC screening: receipt of regular
outpatient care, recognition of
liver disease, recognition of
cirrhosis, screening orders in patients with
cirrhosis, and adherence to screening ultrasound appointments. Among 1,014 patients with
cirrhosis with HCC, only 377 (37.2%) had regular
outpatient care in the year before HCC presentation. Consistent screening was observed in 93 (24.7%) patients under regular
outpatient care, whereas 161 (42.7%) had inconsistent screening and 123 (32.6%) no screening. We found screening underuse related to failures at each step in the screening process, although nearly half (49.6%) were due to lack of screening orders in patients with known
cirrhosis. Conclusion: The most common reasons for HCC screening underuse in patients with
cirrhosis are lack of regular
outpatient care and lack of screening orders in those with known
cirrhosis, highlighting the need for interventions targeted at these steps to increase HCC screening use.