AFP (alpha-fetoprotein) is a protein made by the liver and yolk sac of an unborn baby; in the blood of healthy adults its level is low [4]. A high AFP may be a sign of liver cancer or of germ cell tumours, such as some cancers of the testis and ovary [1]. But hepatitis, cirrhosis and pregnancy can also raise it, and it is sometimes normal even when liver cancer is present [2, 3]. So a high AFP on its own does not mean liver cancer; the doctor reads it together with an ultrasound, CT or MRI scan of the liver [5].
Key points
- A high AFP does not always mean liver cancer: hepatitis, cirrhosis, pregnancy and germ cell tumours can also raise it [2, 3]. On the other hand, more than 4 in 10 patients with liver cancer have a normal AFP [5].
- People with cirrhosis or high-risk chronic hepatitis B should have a liver ultrasound every 6 months, usually together with AFP [5, 6]. In a large study of people with hepatitis B, this reduced deaths from liver cancer by more than a third [7].
- In a man with a lump in the testicle, AFP is measured before surgery together with two other tests, beta-hCG and LDH, and helps to show the type of tumour, its stage and how it responds during follow-up [8].
- After treatment, a fall in AFP is a good sign, and a new rise may be the first sign that the disease has come back [5, 8].
What is AFP in a blood test?
AFP is a protein made in the unborn baby by the yolk sac, the liver and the bowel. Its level in the baby peaks at around weeks 12 to 14 of pregnancy and then falls, so that one year after birth the AFP in the blood is usually below 15 nanograms per millilitre [4].
In adults, some tumours start making AFP again: liver cancer and germ cell tumours (a type of tumour found mostly in the testis and sometimes in the ovary) [1]. AFP is used to help diagnose these cancers and to follow how well treatment is working; in germ cell tumours it also helps to set the stage and predict how the disease will behave [1]. Read about tumour markers in general: What is a tumour marker?
What should AFP be? (normal level)
- From about the age of one, AFP in the blood is usually below 15 nanograms per millilitre [4]. Laboratory ranges differ slightly; compare your number with the range printed on your lab report.
- When people at high risk are monitored for liver cancer, an AFP of 20 or more is usually regarded as high, and a CT or MRI scan of the liver is needed [5]. A rise in AFP on two tests in a row, or a doubling, also matters [5].
- Some people always have a slightly raised AFP without any known reason; in some families this is inherited, and AFP usually stays between 15 and 30 [4, 8]. This can only be accepted once other causes have been ruled out [4].
What besides cancer can raise AFP?
| Cause | Explanation |
|---|---|
| Acute or chronic hepatitis, such as hepatitis B and C | Inflammation of the liver raises AFP [2, 3, 4] |
| Cirrhosis of the liver | AFP may also be raised in cirrhosis [2, 4] |
| Pregnancy | AFP rises naturally in pregnancy [3]; the result is interpreted by your obstetrician as part of antenatal care |
| Newborn babies and infants | AFP is naturally high in the first months of life and falls by about the age of one [4] |
| Inherited, persistent raised AFP | A slightly raised AFP without any illness; accepted only once other causes have been ruled out [4, 8] |
| Some rare inherited conditions | Such as ataxia-telangiectasia and hereditary tyrosinaemia [4] |
| Other cancers | Stomach, bile ducts (including bile duct cancer inside the liver), pancreas and lung [4, 5] |
A single high number is never enough to diagnose any illness; the doctor reads it together with your symptoms, liver blood tests and scans.
What does a high AFP mean? Do I have liver cancer?
Not necessarily. A high AFP may be a sign of liver cancer, but it also rises in hepatitis and cirrhosis [2]. AFP alone is not accurate enough to diagnose liver cancer and is no longer recommended for this [5]. Liver cancer is diagnosed with a dedicated CT or MRI scan of the liver with contrast, or with a biopsy [5].
If AFP is high, especially in someone with cirrhosis or hepatitis B, the doctor usually asks for a CT or MRI scan of the liver, even if the ultrasound is normal [5]. If AFP is very high but no lump is seen in the liver, the doctor may repeat the scan with a different method and also check the chest and pelvis [5]. In young men, a high AFP may come from a testicular tumour, so examining the testicles also matters [8]. Read about the symptoms: What are the symptoms of liver cancer?
Ultrasound and AFP every 6 months: who should be monitored?
To find liver cancer early, guidelines recommend a liver ultrasound every 6 months; the American liver association's guideline asks for it together with AFP, and the European cancer guideline (Asian edition) with or without AFP [5, 6]. Adding AFP to the ultrasound finds more small cancers [5]. These groups should be monitored [5, 6]:
- anyone with cirrhosis of the liver, whatever the cause (hepatitis B or C, alcohol, fatty liver or other causes), if the state of their liver and general health would allow cancer treatment
- people with chronic hepatitis B without cirrhosis who are at high risk; for example, men over 40 and women over 50 from countries where hepatitis B is common, or people with a family history of liver cancer
In a study in China of about 19,000 people with hepatitis B or chronic hepatitis, in the group invited for an ultrasound and AFP every 6 months, deaths from liver cancer were more than a third lower [7]. Read more: Screening and early detection of liver cancer and Which screening tests do I need?
AFP and beta-hCG in testicular cancer and germ cell tumours
In a man with a lump in the testicle, three markers, AFP, beta-hCG and LDH, are measured before the testicle is removed [8]:
- AFP: testicular cancer has two main types, "seminoma" and "non-seminoma". AFP is raised in 4 to 6 in 10 men with a non-seminoma. Seminomas do not make AFP; so if AFP is high, the tumour contains non-seminoma parts and is treated as a non-seminoma, unless there is another convincing cause such as liver disease [8].
- Beta-hCG: this is the pregnancy hormone, and it is very low in healthy men [4]. It is raised in 4 to 6 in 10 men with a non-seminoma, in about 1 in 7 men with stage 1 seminoma and in about half of seminomas that have spread [8].
- LDH: may be raised in both types, but it also rises in many conditions that are not cancer [8].
After the testicle is removed, these markers should fall at a known speed: if all of the tumour has been removed, AFP returns to normal within about 3 to 4 weeks and beta-hCG within a few days [4]. If they stay high, disease has probably remained somewhere else in the body [4]. The marker levels after surgery set the stage and the prognosis group [8]. During follow-up, a clear rise in AFP or beta-hCG is often the first sign that the disease has come back, and treatment may be needed even when scans show nothing [8]. Read more: What are the symptoms of testicular cancer? and Testicular cancer
In women under 40 with a suspicious ovarian growth, AFP and beta-hCG are also measured together with CA-125, so that less common types of ovarian tumour are not missed [10]: What does a high CA-125 mean?
When should I call my doctor?
Show your AFP result to the doctor who ordered it; a single number is neither a reason to worry nor a reason to feel reassured. In these situations do not wait, and see a doctor soon:
- if you have cirrhosis or hepatitis B and your AFP has risen; a CT or MRI scan of the liver is usually needed [5]
- a lump or swelling in the upper abdomen that could be an enlarged liver [9]
- painless enlargement of a testicle, or a change in its shape or firmness [9]
- if you have had liver or testicular cancer and your AFP has risen during follow-up, contact your care team [5, 8]
In someone with cirrhosis, vomiting blood, black stools, confusion, or fever with a swollen abdomen needs urgent care: call your local emergency number.
Frequently asked questions
My AFP is slightly high but my liver ultrasound is normal; what should I do?
A slightly raised AFP may be seen in hepatitis and cirrhosis [2]. But if you are at risk of liver cancer, the American liver association's guideline says that a high AFP, even with a normal ultrasound, needs a CT or MRI scan of the liver [5]. If you do not have liver disease, the doctor checks your liver blood tests and tests for hepatitis; sometimes a slightly raised AFP is inherited [4].
My AFP is normal; does that mean I do not have liver cancer?
Does AFP rise in pregnancy?
Yes; AFP rises naturally in pregnancy [3]. If you had this test during pregnancy, discuss the result with your obstetrician or midwife as part of your antenatal care.
My baby's or child's AFP is high; should I worry?
AFP is naturally high in newborn babies and falls to the adult level (below 15 nanograms per millilitre) by about the age of one [4]. The doctor interprets the number according to the child's age.
In men, does a high AFP mean testicular cancer?
What is beta-hCG in men, and what does a high level mean?
Beta-hCG is a hormone made in pregnancy, and it is very low in healthy men; some testicular tumours make it [4, 8]. Sometimes a high result is false; for example, when the male hormone (testosterone) is low, a similar hormone from the pituitary gland can make the test read high [4, 8]. Discuss the result with your doctor.
My AFP has risen after treatment for liver cancer; what does it mean?
It may be a sign that the disease has come back, and a scan is needed [5]. After surgery for liver cancer, the American liver association's guideline recommends scans of the abdomen and chest together with AFP every 3 to 6 months [5]. Contact your care team. Read more: What is cancer recurrence and how is it followed up?
AFP thresholds and key evidence (for doctors)
For physicians
HCC surveillance (AASLD 2023). Target population: Child-Pugh A–B cirrhosis of any aetiology (and Child-Pugh C on the transplant list); non-cirrhotic chronic HBV in men over 40 or women over 50 from endemic countries, people from Africa at an earlier age, a family history of HCC or a PAGE-B score above 10. Ultrasound plus AFP every 6 months. Sensitivity of ultrasound alone for early-stage HCC is 53% (95% CI 35 to 70) with a specificity of 91%, and the sensitivity of ultrasound plus AFP is 63% (48 to 75). A cut-off of 20 ng/mL is the most common threshold (sensitivity about 60%, specificity about 90%), and the optimal cut-off may be lower in non-viral cirrhosis. "Increasing AFP": doubling, a rise on two consecutive tests, or 20 ng/mL or more. Elevated AFP regardless of the ultrasound result → multiphase CT or contrast-enhanced MRI; significantly elevated AFP (e.g. 200 or 400 ng/mL or more) without a mass on imaging → repeat with an alternative modality, chest and pelvic imaging and, if needed, PET-CT. AFP is no longer recommended for HCC diagnosis: more than 40% of HCCs have a normal AFP, and AFP is also raised in intrahepatic cholangiocarcinoma, gastric cancer and germ cell tumours. After resection: cross-sectional imaging of the abdomen and chest plus AFP every 3 to 6 months. In the USA, an AFP of 1000 ng/mL or more must fall below 500 ng/mL with locoregional therapy for transplant exception points; ramucirumab only with AFP of 400 ng/mL or more [5].
ESMO (Pan-Asian adaptation 2026). Surveillance in all patients with cirrhosis of any aetiology, if liver function and comorbidities allow tumour treatment [II, A]; in chronic HBV with a moderate or high risk score (e.g. PAGE-B) at the start of nucleoside analogue therapy [II, A]; abdominal ultrasound (or multiphase cross-sectional imaging if available) every 6 months, with or without AFP [II, A]; staging includes AFP [III, A] [6]. Shanghai trial (18,816 people aged 35 to 59 with HBV or chronic hepatitis): AFP and ultrasound every 6 months reduced HCC mortality from 131.5 to 83.2 per 100,000 (mortality rate ratio 0.63; 95% CI 0.41 to 0.98), with 58.2% adherence [7]. With AFP alone in high-risk populations, a sensitivity of 39% to 97%, specificity of 76% to 95% and PPV of 9% to 32% have been reported [3].
Germ cell tumours. AFP is raised in 40% to 60% of non-seminomas; seminomas do not produce AFP, so a raised AFP with pure seminoma pathology means a mixed tumour (NSGCT) unless there is a more persuasive explanation such as liver disease. Beta-hCG is raised in about 14% of stage I seminomas before orchiectomy, about half of metastatic seminomas and 40% to 60% of non-seminomas. False-positive beta-hCG results from cross-reactivity with LH and normalises after an intramuscular testosterone injection; AFP is chronically mildly elevated in some people for unclear reasons and can be substantially elevated by liver disease. Significant and unambiguously rising AFP or beta-hCG signals relapse in most cases and is an indication for treatment even without radiological evidence [8]. Half-life of AFP 5 to 7 days (normalisation 20 to 28 days after effective therapy) and of beta-hCG 24 to 36 hours (normalisation 4 to 6 days after orchiectomy in stage I); measure markers before orchiectomy and then weekly until normal; NSGCT with persistently elevated AFP or hCG after orchiectomy is presumed metastatic even without a mass on imaging; hereditary AFP elevation is usually 15 to 30 ng/mL [4]. For the S categories and the IGCCCG classification, see Diagnosis and staging of testicular cancer. NICE CG122: in women under 40 with suspected ovarian cancer, measure AFP and beta-hCG as well as CA-125 [10].
Scientific evidence
Scientific evidence
3 itemsAASLD Practice Guidance on prevention, diagnosis, and treatment of hepatocellular carcinoma
European Association of Urology Guidelines on Testicular Cancer: 2023 Update
Predicting Outcomes in Men With Metastatic Nonseminomatous Germ Cell Tumors (NSGCT): Results From the IGCCCG Update Consortium
Related cancer types
References
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Numbers in the text, such as [1], refer to these sources. Sources with a “Study card” button are summarised in the site’s evidence library.
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