Ruggeri has recently reviewed the cost-effectiveness of screening for hepatocellular carcinoma (HCC).1 However, evidence for effectiveness is still lacking, with only two randomized trials available, both from China, one of which is negative and the other positive but with several major flaws.2 Only observational studies are available from developed countries, and conclude that screening improves survival, despite raw data showing that screened patients die younger than nonscreened patients, (length time and lead time biases).3 The National Cancer Institute recommends that “based on fair evidence, screening would not result in a decrease in mortality from HCC … based on fair evidence, screening would result in rare but serious side effects”.4