Abstract: Hepatocellular carcinoma (HCC) remains a major global health burden, particularly in regions with high hepatitis B virus (HBV) prevalence such as Indonesia. Despite advancements in antiviral therapies, the prognosis of HCC is often poor due to delayed diagnosis. This study aims to evaluate the accuracy of the neutrophil-lymphocyte ratio (NLR) as a predictive marker for HCC incidence among chronic HBV patients at Haji Adam Malik General Hospital, Medan. A cross-sectional study was conducted involving 255 chronic HBV patients, of whom 74 (29.0%) were diagnosed with HCC. Clinical and laboratory data were analyzed using independent t-tests and ROC curve analysis. The NLR was significantly higher in the HCC group compared to the non-HCC group (7.16 vs. 3.25, p < 0.001). ROC analysis revealed an AUC of 0.785 for NLR, indicating good accuracy. At a cutoff value of 4.95, NLR demonstrated a sensitivity of 73.0% and a specificity of 72.4% in predicting HCC incidence. Furthermore, the NLR value ≥4.95 was associated with a notably higher proportion of HCC cases (51.92%) compared to NLR <4.95 (13.33%). The findings support the utility of NLR as a simple, non-invasive, and cost-effective tool for early risk stratification of HCC in chronic HBV patients. Elevated NLR reflects systemic inflammation, which plays a pivotal role in HCC pathogenesis via immune dysregulation, tumor promotion, and impaired antitumor surveillance. Given the promising predictive capacity of NLR, its incorporation into routine clinical assessments could improve early identification of high-risk individuals. However, further prospective and multicenter studies are needed to validate its applicability across broader patient populations.