Background: Serum alpha fetoprotein (AFP), ultrasound, computerized tomography scanning, and magnetic resonance imaging are commonly used to screen for hepatocellular carcinoma (HCC) in patients with cirrhosis. Aim: To assess the accuracy of screening in advanced cirrhosis. Methods: The study group consisted of 239 patients with proven HCC in the explanted liver at the time of liver transplant. AFP and imaging were done at referral and serially until transplant. Results: Hepatocellular carcinoma was detected before liver transplant in 78% and discovered incidentally in 22%. The cause of cirrhosis was hepatitis C (HCV) (55%), hepatitis B (HBV) (17%), alcohol (9%), and other/unknown (19%). Although AFP was elevated 62%, the median level was 15 ng/mL. Only 26%, 15% and 13% were more than 100, 400 and 1000 ng/mL, respectively. By comparison, AFP was elevated in 20% without HCC, but exceeded 100 ng/mL in only 3%. The overall accuracy of AFP was poor regardless of the cutoff. Magnetic resonance imaging was more accurate than computerized tomography or ultrasound in detecting tumour, particularly when performed within 3 months of transplant. Conclusions: Magnetic resonance imaging is most sensitive for imaging HCC and best reflects actual tumour size. AFP is insensitive and adds little to screening strategies, but has prognostic value when extremely elevated.