Among those with chronic HCV infection without advanced fibrosis or cirrhosis, the incidence of HCC is decreased in patients with a SVR and probably also in relapsers when compared with nonresponders [
78]. Several studies and a meta-analysis have concluded that eradication of HCV with antiviral therapy reduces the risk of HCC in patients with chronic hepatitis C, independent of fibrosis stage [
79,
80]. However, a reduction in the risk of HCC does not necessarily indicate improvement in overall survival, and interferon is less effective in patients with cirrhosis. In addition, cirrhotic patients tend to be older, and liver-unrelated mortality may be significant and obscure any potential benefit of interferon therapy. A few studies have shown that, in patients with advanced fibrosis and/or cirrhosis who achieved a SVR, the age-adjusted hazard ratio for developing HCC and death is significantly reduced. The failure to achieve a SVR was associated with a higher risk of liver-related complications, HCC, and liver-related mortality compared with those who achieved a SVR [
81]. However, several studies have demonstrated no beneficial effect of interferon therapy on the prognosis of cirrhotic patients. A recent meta-analysis that included 30 studies comprising 31,528 patients from 17 countries reported a 4.6 % absolute reduction in developing HCC following a SVR [
82]. Furthermore, in patients with advanced liver disease, achieving a SVR reduced the overall risk of developing HCC from 17.8 to 4.2 %, with a reduction in incidence from 3.3 % per person-year to 1.05 % (CI 0.7–1.5 %) per person-year. Prospective data extracted from the HALT-C cohort also suggested that, following a SVR, the incidence of HCC decreased from 8.8 to 1.1 % over approximately 7 years of follow-up. A recently published meta-analysis demonstrated that antiviral treatment was associated with a reduced risk of HCC in patients who attained a SVR, compared with nonresponders; the best outcomes were observed in patients treated with ribavirin-based regimes [
83]. The attainment of a SVR also demonstrated prevention of the development of esophageal varices [
72,
84]. There have been case reports and long-term follow-up studies that have shown development of HCC in patients with advanced hepatic fibrosis after achievement of a SVR. These observations underscore the continued risk of HCC and the need for ongoing surveillance with imaging and alpha-fetoprotein (AFP) testing in patients with chronic hepatitis C and advanced hepatic fibrosis or cirrhosis, even after a SVR. A recent study tried to risk-stratify patients further by creating a scoring system based on age, platelets, AFP, and fibrosis score [
85]. Patients were identified as low, medium, or high risk depending on their score. In the low-risk group, 9 out of 657 patients developed HCC over 9 years, equating to a 0.17 % risk per annum, an incidence rate that is well below that where screening is deemed cost effective. If this score is validated, it may help identify which patients should be recommended for long-term HCC surveillance. Achievement of eradication of HCV was associated with a marked decrease of HCC [
28].