The letter from Dr Zhang regarding our recent article1 raises interesting points that are worthy of discussion. Surveillance ultrasound examination is regarded as the cornerstone of hepatocellular carcinoma (HCC) surveillance, although increasing data suggest suboptimal effectiveness when implemented in clinical practice, including a low sensitivity for early tumor detection and suboptimal specificity leading to screening-related harms.2 Our study highlights the benefit of using the serum biomarker, alpha fetoprotein (AFP), in combination with ultrasound to increase sensitivity for early HCC detection.