Current protocols for HCV post-SVR monitoring may need updating to expand screening for liver cancer to those without cirrhosis. This article is dedicated to all non-cirrhotics who have been diagnosed with liver cancer following treatment for HCV.
HepCBC’s volunteer Webmaster, CD Mazoff, PhD (discourse analysis, McGill), is battling liver cancer (HCC). For several years, CD has faithfully published the online HepCBC Weekly Bull every Friday, showcasing Canada’s most important viral hepatitis news of the week. The last few weeks, the bulletin has not gone out because our webmaster has been diagnosed with Stage Four liver cancer (HCC), and is currently taking a palliative chemo-therapy regimen which regularly leaves him weak, nauseated, and in pain. Nevertheless, he has been trying to teach new volunteers how to do his job.
CD did not have cirrhosis, so was not subject to the post-SVR monitoring (hepatitis C after-cure) protocols recommended every 6 months for those who have cirrhosis. Such monitoring includes a liver ultrasound and blood tests for alfa-feto protein (AFP), ALT, AST, and other factors. If CD had been monitored the same as someone with cirrhosis, his HCC would likely have been caught much sooner, and he would probably have been eligible for one of the current HCC treatments which can extend patients’ lives for many years, or until they can get a transplant. CD, now age 69, had lived with hepatitis C several decades before he was cured in 2015 with the new Gilead direct-acting antiviral (DAA) Harvoni. However, liver tests had always shown he had no obvious liver scarring or fibrosis, so after he achieved SVR, he was told he was cured, that he should simply celebrate the good news, and that he needn’t worry about his liver any more. CD is not alone, as shown in the two articles referenced below which probe this issue.
We recommend the following actions to address the need for broadened post-SVR HCC monitoring:
- a retrospective study be made of HCC patients who have been cured of hepatitis C, including any pre- or post-treatment assessments of liver damage (degree and date[s]), treatment (regimen[s] and beginning/end date[s]), age and gender, estimated number of years patient was infected, and progress of the HCC over time (NOTE: this study would probably be based on the BC Centre for Disease Control’s BC Hepatitis Testers Cohort database);
- with the above data, a new, broader post-SVR monitoring protocol be developed which extends the HCC monitoring currently recommended for those with cirrhosis to non-cirrhotics, even to those showing no liver scarring; and
- responsibility for such a broader monitoring protocol be given by HCV treaters to patients’ family practitioners/GPs/NPs once SVR has been achieved, as making requisitions for these tests could be easily (and more economically) accomplished at this level of practice.
The following articles further support the three above actions:
(i.) January, 2019 article shows that 20% of hepato-cellular carcinoma (HCC) cases develop in non-cirrhotic livers, and the typically-late diagnoses mean the prognosis of these patients is poor:
“… HCC in non-cirrhotic patients is clinically silent in its early stages because of lack of symptoms and surveillance imaging; and higher hepatic reserve in this population…[T]here is a dire need for implementation of surveillance strategies in the patient population at risk, to decrease the disease burden at presentation and improve the prognosis of these patients…”
[World J Hepatol. 2019 Jan 27;11(1):1-18. doi: 10.4254/wjh.v11.i1.1. Desai A1, Sandhu S2, Lai JP3, Sandhu DS4]
(ii.) November, 2018 article recommends that post-SVR monitoring for HCC should be broadened to include hepatitis C patients with fibrosis level 3 as well as cirrhosis (level 4 and above).
[Dr. Norah A. Terrault, MD, MPH; November 2018]