I read the recent publication on screening for hepatocellular carcinoma (HCC) in acute intermittent porphyria with great interest . Innala and Andersson  concluded that ‘Screening for HCC in carriers of AIP enables early diagnosis and a choice of potentially curative treatments with improved prognosis’ and also recommended ‘annual screening using liver imaging for AIP gene carriers >50 years of age’. There are some concerns regarding this long-term study. First, there are many other confounding causes of liver cancer such as alcohol and viral infection with hepatitis. The effect of these possible confounding factors should be clarified and controlled for. Second, it would be interesting to know the cost-effectiveness of the proposed screening. Population-scale screening might not be wise if the benefit is low compared with the cost.