Saturday, May 25, 2013

Hepatitis C: Am I At Risk For Liver Cancer?

Hepatitis C: Am I At Risk For Liver Cancer?

Offered on the blog today are a few studies that look at the risk for developing liver cancer in people who are - or who have been - infected with chronic hepatitis C.   The CDC reported hepatitis C is the leading cause of liver cancer which is the fastest rising cause of cancer-related death in the U.S. Without a doubt this disease can lead to serious health problems including liver damage, cirrhosis, liver cancer and liver failure.

In the United States the CDC has implemented screening strategies to identify people at high risk for hepatitis C. Included in the risk group are people born between 1945 and 1965 - age 47 to 67, who currently account for about 75% of the estimated 2.7 and 3.9 million people infected with the virus.

*Learn more about who is at risk and why here.

I often ask myself why people forgo HCV testing if they fall into this high risk population. Most people would agree, preventive strategies for cancer or liver damage are worth the time it takes for a routine blood test.

Additionally a large portion of people are unaware they are infected. These people are in need of clinical evaluation and counseling including prevention strategies; using alcohol, supplements, over-the-counter medications or prescription drugs can cause additional liver damage.

Alcohol And HCV

Older studies have confirmed in patients with hepatitis C heavy alcohol intake contributes to HCV-associated liver disease and can cause significantly more liver scarring or cirrhosis, a more recent study has shown even moderate alcohol increases the risk for liver-related mortality. Last month in the medical journal Alimentary Pharmacology & Therapeutics, researchers concluded; Although chronic hepatitis C is associated with increased risks for overall and liver-related mortality, these risks are even higher for patients consuming moderate and excessive amounts of alcohol. Here is a comment from the study's lead author Zobair Younossi; For instance, the risk of liver-related death among people with hepatitis C who averaged two or fewer drinks a day was 74 times that of similar people without hepatitis C. Check out the interview here.

Disease Progression

Medscape reported: Out of 100 people that contract the infection, 75–85 people will develop chronic infection, 60–70 people will develop chronic liver disease, five to 20 people will develop cirrhosis over the course of their chronic infection and one to five people will die of complications including hepatocellular carcinoma (HCC). The good news is that the overall percentage of people with HCV who develop cirrhosis or liver cancer is low, unless that person is you, then its at 100%.

Liver Cancer Without Cirrhosis?

In the June 2013 issue of American Journal of Roentgenology researchers investigated liver cancer in patients with chronic HCV - without advanced fibrosis or cirrhosis.

AJR Am J Roentgenol. 2013 Jun;200(6):W610-W616.

Hepatocellular Carcinoma in Chronic Hepatitis C in the Absence of Advanced Fibrosis or Cirrhosis.

Lewis S, Roayaie S, Ward SC, Shyknevsky I, Jibara G, Taouli B.

1 Department of Radiology/Body MRI and Translational and Molecular Imaging Institute, Ichan School of Medicine at Mount Sinai, One Gustave Levy Pl, Box 1234, New York, NY 10029.


OBJECTIVE. The objective of our study was to describe the cross-sectional imaging appearance of hepatocellular carcinoma (HCC) in patients with chronic hepatitis C virus (HCV) infection in the absence of advanced fibrosis and cirrhosis.

MATERIALS AND METHODS. This study is a retrospective review of our surgical database to identify patients with chronic HCV infection and HCC who underwent hepatectomy and who had undergone preoperative CT or MRI. Only patients with a Metavir fibrosis score of F0, F1, or F2 on pathology were included. Patients with hepatitis B virus coin-fection or other causes of chronic liver disease and patients with histopathologic evidence of advanced fibrosis or cirrhosis (Metavir scores F3 and F4) were excluded. Contrast-enhanced CT or MRI examinations performed within 2 months before surgery were reviewed for the number, size, and location of tumors; tumor enhancement characteristics; and presence of macrovascular invasion.

RESULTS. Two hundred forty-five resections of HCC in patients with HCV were performed in our institution from 1987 to 2012. Of this group, 26 patients (10.6%) had a Metavir fibrosis score of F0, F1, or F2; of those patients, 19 (18 men and one woman; 18 non-Asian patients and one Asian patient; mean age, 64 years) had imaging studies available for review. Twenty-one HCCs (mean size, 4.5 cm; range, 0.9-14.8 cm) were evaluated at imaging. Typical wash-in and washout characteristics were seen in 16 of 19 viable lesions (84.2%). The remaining two HCCs were completely necrotic after transarterial chemoembolization. Eighteen patients had a solitary tumor. Most tumors (15/21, 71.4%) developed in the right hepatic lobe.

CONCLUSION. HCC can develop in patients with chronic HCV without advanced fibrosis or cirrhosis, most frequently in older non-Asian men, and usually appears as a large solitary tumor with a typical wash-in-washout enhancement pattern.

Liver Cancer With Cirrhosis After Successful HCV Therapy

Last month in Clinical Infectious Diseases, researchers concluded: The risk for HCC, liver decompensation, and death in patients with liver cirrhosis related to HCV was markedly reduced after SVR, but a long-term risk of developing HCC remains for up to 8 years.

This month the in-depth clinical information website, featured the study:

HCC risk persists 8 years after HCV eradication

May 9, 2013

The long-term risk for hepatocellular carcinoma among patients with hepatitis C remains up to 8 years after sustained virological response to antiviral therapy, researchers reported in Clinical Infectious Diseases.

The number of patients with cancer was too low to draw any firm conclusion, but it was nevertheless somewhat surprising that the risk remained for such a prolonged time period,” Soo Aleman, MD, PhD, of the departments of gastroenterology and hepatology and infectious diseases at Karolinska Institutet in Stockholm, told Infectious Disease News.

“We need to know how long this risk persists and which subgroups of patients are at the highest risk after achieving sustained virological response (SVR). Future studies are needed to answer these questions.”

Aleman and colleagues conducted a prospective study that included patients who had HCV-related cirrhosis.

Among the 351 patients, 110 reached SVR, 193 did not and 48 were untreated. The study was initiated in 2001 and the patients were followed for a mean of 5.3 years.

Six patients who achieved SVR developed hepatocellular carcinoma (HCC), for an incidence of 1 per 100 person-years. Two patients were diagnosed within a year after achieving SVR at 0.5 and 7.7 months, and the remaining four were diagnosed at 2.4, 7.4, 7.4 and 7.6 years.

All of the patients were tested for HCV RNA at HCC diagnosis, and all were negative.

Among patients who did not achieve SVR or who were untreated, the risk for HCC was higher. The risk for any liver-related complication, liver-related death or overall death was lower among patients who achieved SVR. These differences were similar after controlling for alcohol use, age, sex and diabetes.

“Patients who have liver cirrhosis prior to the eradication of HCV should continue to undergo surveillance with ultrasound regularly for early detection of hepatocellular carcinoma,” Aleman said.

Soo Aleman, MD, PhD, can be reached at Department of Gastroenterology and Hepatology, and Infectious Diseases, Karolinska University Hospital at Karolinska Institute, 171 76 Stockholm, Sweden; email:

Disclosure: Aleman reports financial relationships with Gilead, Janssen, MSD and Roche.

Screening For Liver Cancer

According to WHO  in 25 % of liver cancer patients, the underlying cause is hepatitis C. Long-term management of chronic hepatitis C infection for patients with cirrhosis include routine screening for liver cancer. These tests might mean an ultrasound twice a year, and twice-yearly measurements of  alpha-fetoprotein (AFP) levels in the blood, which is a liver-cancer marker.

Get Tested

If any of the risk factors mentioned in this article pertain to you, I urge you to please consider the CDC's recommendation and get tested once for hepatitis C. If the test is positive additional testing is needed.

According to the CDC Telebriefing on Hepatitis C testing held this month;

Today's data show that even among young people who get tested positive, only about half had follow-up tests to see if they were still infected. That's what you need to get appropriate care and treatment. Right now there are better Hepatitis C treatments available than ever and there are more treatments coming in the coming year. So confirming that someone is more infected is more important than ever. Not everyone with Hepatitis C will need treatment, but everyone with Hepatitis C should be linked to care so that they can monitor how their liver is doing, determine when and if treatment is warranted, avoid things like excess alcohol which can damage their liver, and avoid medications that could also damage their liver as well as getting vaccinated against hepatitis b to protect their liver. Liver disease is something which is causing an increasing number of deaths, and many of those deaths could be prevented with the current treatments and with preventive actions that people can take if, but only if, they know that they're infected. Today CDC is also issuing updated guidance for doctors and other health care providers about how to test for Hepatitis C and how to provide follow-up.

Need To Talk To Someone ?

Help is available, recently "Project Inform" announced the launch of a new national helpline, 877-HELP-4-HEP (877-435-7443), run by and for people affected by hepatitis C.

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