BACKGROUND: Hepatocellular carcinoma (HCC) patients with advanced symptoms or liver failure are often ineligible for transplantation, leading only to symptom control. Additionally, various factors lead to other HCC stage patients remaining in natural history. OBJECTIVE: To describe the demographic of untreated HCC patients and to analyze survival-influencing factors. METHODS: single-center retrospective observational study examining HCC patients diagnosed from 2015 to 2021 who received symptom control as their primary treatment. Baseline characteristics and survival data were collected and analyzed. RESULTS: Of 685 HCC patients, 26% (n=181) remained in natural history, median age 71 years, 82% male patients, 93% with cirrhosis, 53% with previous decompensation. At a mean follow-up of 9.98 months, the mortality rate was 84%. While 49.8% of patients were BCLC-D stage, other reasons for remaining in natural history included frailty (25.4%) comorbidities (16%), and patient's treatment refusal (8%). Independent survival factors were BCLC stage, previous decompensation and diagnosis within the screening program, with 37% of untreated patients detected through surveillance. CONCLUSIONS: Liver function, BCLC stage and functional status influence survival in natural HCC history. A significant 37% diagnosed through screening indicates inclusion criteria refinement necessity to avoid overdiagnosis and optimize resources.