Treating HBV Patients With Cirrhosis: The Need for Vigilant HCC Screening

 Source - Clinical Thoughts @ Clinical Care Options

Treating HBV Patients With Cirrhosis: The Need for Vigilant HCC Screening
Maria Buti, MD 
5/14/2014

When treating hepatitis B patients with liver cirrhosis, my first aim is to achieve complete viral suppression. Using one of the current recommended oral HBV drugs, tenofovir and entecavir, HBV DNA becomes undetectable in almost all my HBV patients with cirrhosis. As I review in a CME activity now available on this Web site, virologic suppression is associated with improvement in clinical endpoints, such as a reduction in or prevention of liver disease progression and hepatic decompensation, reduced incidence of hepatocellular carcinoma (HCC), and less frequent need for HBV-associated liver transplantation.

However, the risk of developing HCC still exists. There are several factors associated with a higher risk of HCC such as older age, male sex, thrombocytopenia, HBeAg positivity, high HBV DNA level, and, conferring the greatest risk, a history of decompensated cirrhosis. The only modifiable HCC risk factor in a patient who presents with cirrhosis is the HBV DNA level by means of long-term antiviral treatment with entecavir or tenofovir, provided the patient is adherent to the medication.

Continued Need for HCC Surveillance
Recent data show that the risk of HCC in patients with chronic HBV infection and liver cirrhosis remains elevated even in patients who have received at least 3-4 years of oral antiviral therapy. The data suggest that persistent virologic suppression does not reduce the risk of developing HCC during the first years of therapy presumably because cancer may already have started to develop in these patients. For these reasons, all patients with HBV-associated cirrhosis require lifelong HCC surveillance with an abdominal ultrasound and serum alpha-fetoprotein determinations every 6 months for early detection of HCC.

How I Counsel and Treat My Patients
I feel it is important to advise these patients to completely abstain from alcohol consumption, particularly patients with existing substantial liver injury. Heavy use of alcohol (> 40 g/day) has been associated with worsening liver disease and an increased risk of HCC. The exact amount of alcohol that can be safely consumed is unclear.

Currently, I am treating all my patients with HBV-associated cirrhosis with entecavir or tenofovir. Most of them are HBeAg negative and achieve undetectable HBV DNA after a short period of treatment. These patients need long-term treatment because I rarely see HBsAg clearance. To date, I have not seen any cases of HBV drug resistance with tenofovir and only a few cases with entecavir in treatment-naive patients. However, in lamivudine treatment–experienced patients, the risk of resistance with entecavir rescue therapy is high. Over the last years in my practice, I have not seen any patients with hepatic decompensation, but I do still discover cases of HCC during routine surveillance, reinforcing my current practice of continual surveillance.

Your Thoughts?
I’m interested to hear about your own experiences in treating your HBV cirrhotic patients with oral antivirals. Have you observed noteworthy improvements in liver histology in your patients with advanced fibrosis or cirrhosis? Are you ensuring that you continue HCC screening in any patient with a history of cirrhosis? 

Links:
Clinical Focus Module
•HBV Therapy and Liver Fibrosis
•Downloadable slideset
•HCC Risk in Cirrhotic HBV Patients

Topics: HBV - Treatment