Thursday, June 21, 2018

Patient Friendly - NCCN new guideline for liver, gallbladder, and bile duct cancers

The National Comprehensive Cancer Network (NCCN), a not-for-profit alliance of 25 of the world's leading cancer centers devoted to patient care, research, and education, is dedicated to improving the quality, effectiveness, and efficiency of cancer care so that patients can live better lives. The intent of the NCCN Guidelines is to assist in the decision-making process of individuals involved in cancer care-including physicians, nurses, pharmacists, payers, patients, and their families-with the ultimate goal of advancing patient care in the fight against cancer.

The National Comprehensive Cancer Network (NCCN) has released a new guideline for liver, gallbladder, and bile duct cancers to assist patients in understanding their treatment decisions.

The new edition of the NCCN Guidelines for Patients reformats the evidence-based treatment recommendations from the NCCN Clinical Practice Guidelines and creates a patient-friendly version.

These step-by-step guides to the latest advances in cancer care, feature:
Questions to ask your doctors
Patient-friendly illustrations
Glossaries of terms and acronyms

"An essential element of patient empowerment is accessible, actionable, high-quality information," said Donna R Cryer, JD, President & CEO, Global Liver Institute, in a press release (June 19, 2018). The Institute provided sponsorship for the new guidelines for patients. "The Global Liver Institute is proud to work with NCCN to provide this information to support liver and bile duct cancer patients and their families in the hope that together we can make the cancer journey easier and more successful."

Incidence and deaths related to liver cancer are increasing globally, which correlates with rising rates of hepatitis B and hepatitis C infections, the latter of which is often a precursor to liver cancer. Additionally, metabolic disorders are associated with an increased risk of liver cancer. There are many treatment options for patients with hepatobiliary cancer to consider, including liver transplantation, surgery, radiation, ablation or embolization, and drug therapy.

"When people are diagnosed with liver cancer, they hope their doctor will be able to present them with a definitive best course of action, but there are often multiple treatments from which to choose,” explained Al B Benson III, MD, Robert H Lurie Comprehensive Cancer Center, Northwestern University. Dr Benson is the chair of the NCCN guidelines panel for hepatobiliary cancers. “The best choice for any given individual has to take into account their disease status, symptoms, lab results, and, of course, personal preferences.”

Sofosbuvir/velpatasvir and Resistance-associated Substitutions in HCV genotype 3

SOF/VEL and Resistance-associated Substitutions in HCV GT3
Alimentary Pharmacology & Therapeutics, June 21, 2018
J. von Felden; J. Vermehren; P. Ingiliz; S. Mauss; T. Lutz; K. G. Simon; H. W. Busch; A. Baumgarten; K. Schewe; D. Hueppe; C. Boesecke; J. K. Rockstroh; M. Daeumer; N. Luebke; J. Timm; J. Schulze zur Wiesch; C. Sarrazin; S. Christensen

Does the presence of resistance-associated substitutions impact the efficacy of therapy with sofosbuvir/velpatasvir with or without ribavirin in patients with HCV genotype 3?
Medscape - Full Text

Abstract and Introduction
Abstract
Background Twelve weeks of the pangenotypic direct–acting antiviral (DAA) combination sofosbuvir/velpatasvir (SOF/VEL) was highly efficient in patients with hepatitis C virus (HCV) genotype 3 (GT3) infection in the ASTRAL–3 approval study. However, presence of resistance–associated substitutions (RASs) in the HCV nonstructural protein 5A (NS5A) was associated with lower treatment response.

Aim To assess the efficacy and safety of SOF/VEL ± ribavirin (RBV) and the impact of NS5A RASs and RBV use on treatment outcome in HCV GT3 infection in a real–world setting.

View Full Article...…..

Free registration may be required.

Cost of illness of hepatocellular carcinoma in Japan: A time trend and future projections

Cost of illness of hepatocellular carcinoma in Japan: A time trend and future projections 
Kunichika Matsumoto, Yinghui Wu, Takefumi Kitazawa, Shigeru Fujita, Kanako Seto, Tomonori Hasegawa

Published: June 19, 2018

HCC using the cost of illness (COI) of HCC has been decreasing since 1996. Treatment of patients infected with hepatitis C virus using newly introduced technologies has high therapeutic effectiveness, and will affect the future prevalence of HCC. These policies and technologies may accelerate the downward tendency of COI, and the relative economic burden of HCC is likely to continue to decrease.

Full Article

Abstract
Background
Hepatocellular carcinoma (HCC) is the fifth leading cause of death in Japan. The aim of this study was to calculate the social burden of HCC using the cost of illness (COI) method, and to identify the key factors driving changes in the economic burden of HCC.

Methods
Utilizing government-based statistical nationwide data, the cost of illness (COI) method was used to estimate the COI for 1996, 1999, 2002, 2005, 2008, and 2014 to make predictions for 2017, 2020, 2023, 2026, and 2029. The COI comprised direct and indirect costs (morbidity and mortality costs) of HCC.

Results
From 1996 to 2014, COI trended downward. In 2014, COI (579.2 billion JPY) was 0.71 times greater than that in 1996 (816.2 billion JPY). Mortality costs accounted for more than 70% of total COI and were a major contributing factor to the decrease in COI. It was predicted that COI would continue a downward trend until 2029, and that the rate of decline would be similar.

Conclusions
COI of HCC has been decreasing since 1996. Treatment of patients infected with hepatitis C virus using newly introduced technologies has high therapeutic effectiveness, and will affect the future prevalence of HCC. These policies and technologies may accelerate the downward tendency of COI, and the relative economic burden of HCC is likely to continue to decrease.
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0199188

60,000 adults in the UK have cirrhosis, nearly 75% percent don't know it


7 in 10 people with liver disease in the UK don’t even know they have it 
Although over 60,000 adults in the UK have cirrhosis (scarring) of the liver, nearly 75% percent don't know it, according to research published in the Lancet. For many, the first indication is following admission to Accident and Emergency when the disease is advanced and chance of survival is very low. This week, 18th to 24th June, is Love Your Liver week, and the British Liver Trust has launched a new version of an online screening tool so that people can find out if they are at risk.

Although over 60,000 adults in the UK have cirrhosis (scarring) of the liver, nearly 75% percent don't know it, according to research published in the Lancet. For many, the first indication is following admission to Accident and Emergency when the disease is advanced and chance of survival is very low. This week, 18th to 24th June, is Love Your Liver week, and the British Liver Trust has launched a new version of an online screening tool so that people can find out if they are at risk.

Liver disease is one of the leading causes of premature death in England and is responsible for more than 1 in 10 deaths of people in their 40s.

Professor Nick Sheron, a liver expert from the University of Southampton involved in the research, said: "Liver disease develops silently with no signs or symptoms and is the second leading cause of years or working life lost. If current trends continue it become the leading cause of premature mortality in the UK. Yet, most people with fatal advanced liver disease only become aware that they have a liver problem when they are admitted as an emergency. We MUST diagnose these people much earlier."

Liver problems develop silently with no obvious symptoms in the early stages yet the disease is largely preventable through lifestyle changes. The Love Your Liver awareness campaign, promoted by the British Liver Trust, aims to reach the one in five people in the UK who may have the early stages of liver disease, but are unaware of it.

More than 90% of liver disease is due to three main risk factors: obesity, alcohol and viral hepatitis.

Judi Rhys, Chief Executive, British Liver Trust said, “Helping people understand how to reduce their risk of liver damage is vital to address the increase in deaths from liver disease. Although the liver is remarkably resilient, if left too late damage is often irreversible. I would urge everyone to take our online screener on our website to see if they are at risk.”

The British Liver Trust’s Love Your Liver campaign focuses on three simple steps to Love Your Liver back to health:

- Drink within recommended limits and have three consecutive alcohol-free days every week
- Cut down on sugar, carbohydrates and fat and take more exercise
- Know the risk factors for viral hepatitis and get tested or vaccinated if at risk

Finding out your risk of liver disease only takes a few minutes. It could be the most important thing you do today. Take the British Liver Trust’s screener here

Liver disease is one of the leading causes of premature death in England and is responsible for more than 1 in 10 deaths of people in their 40s.

Professor Nick Sheron, a liver expert from the University of Southampton involved in the research, said: "Liver disease develops silently with no signs or symptoms and is the second leading cause of years or working life lost. If current trends continue it become the leading cause of premature mortality in the UK. Yet, most people with fatal advanced liver disease only become aware that they have a liver problem when they are admitted as an emergency. We MUST diagnose these people much earlier."

Liver problems develop silently with no obvious symptoms in the early stages yet the disease is largely preventable through lifestyle changes. The Love Your Liver awareness campaign, promoted by the British Liver Trust, aims to reach the one in five people in the UK who may have the early stages of liver disease, but are unaware of it.

More than 90% of liver disease is due to three main risk factors: obesity, alcohol and viral hepatitis.

Judi Rhys, Chief Executive, British Liver Trust said, “Helping people understand how to reduce their risk of liver damage is vital to address the increase in deaths from liver disease. Although the liver is remarkably resilient, if left too late damage is often irreversible. I would urge everyone to take our online screener on our website to see if they are at risk.”

Finding out your risk of liver disease only takes a few minutes. It could be the most important thing you do today. Take the British Liver Trust’s screener here

Tuesday, June 19, 2018

Methadone and buprenorphine reduce risk of death after opioid overdose

Methadone and buprenorphine reduce risk of death after opioid overdose
NIH research confirms effective treatments for opioid use disorder are underutilized.

A National Institutes of Health-funded study found that treatment of opioid use disorder with either methadone or buprenorphine following a nonfatal opioid overdose is associated with significant reductions in opioid related mortality. The research, published today (link is external) in the Annals of Internal Medicine, was co-funded by the National Institute on Drug Abuse (NIDA) and the National Center for Advancing Translational Sciences, both parts of NIH.

Study authors analyzed data from 17,568 adults in Massachusetts who survived an opioid overdose between 2012 and 2014. Compared to those not receiving medication assisted treatment, opioid overdose deaths decreased by 59 percent for those receiving methadone and 38 percent for those receiving buprenorphine over the 12 month follow-up period. The authors were unable to draw conclusions about the impact of naltrexone due to small sample size, noting that further work is needed with larger samples. Buprenorphine, methadone, and naltrexone are three FDA-approved medications used to treat opioid use disorder (OUD).

The study, the first to look at the association between using medication to treat OUD and mortality among patients experiencing a nonfatal opioid overdose, confirms previous research on the role methadone and buprenorphine can play to effectively treat OUD and prevent future deaths from overdose.

Despite compelling evidence that medication assisted treatment can help many people recover from opioid addiction, these proven medications remain greatly underutilized. The study also found that in the first year following an overdose, less than one third of patients were provided any medication for OUD, including methadone (11 percent); buprenorphine (17 percent); and naltrexone (6 percent), with 5 percent receiving more than one medication.

In an editorial commenting on the study, Dr. Nora Volkow, director of NIDA, said, “A great part of the tragedy of this opioid crisis is that, unlike in previous such crises America has seen, we now possess effective treatment strategies that could address it and save many lives, yet tens of thousands of people die each year because they have not received these treatments. Ending the crisis will require changing policies to make these medications more accessible and educating primary care and emergency providers, among others, that opioid addiction is a medical illness that must be treated aggressively with the effective tools that are available.” The editorial was co-authored by NIDA scientist Dr. Eric Wargo.

Another alarming study finding was that despite having had an opioid overdose, 34 percent of people who experienced an overdose were subsequently prescribed one or more prescriptions for opioid painkillers over the next 12 months, and 26 percent were prescribed benzodiazepines.

“Nonfatal opioid overdose is a missed opportunity to engage individuals at high risk of death,” said Marc Larochelle, M.D., the study’s lead investigator at Boston Medical Center’s Grayken Center for Addiction and Boston University School of Medicine. “We need to better understand barriers to treatment access and implement policy and practice reforms to improve both engagement and retention in effective treatment.”

The authors conclude that a nonfatal opioid overdose treated in the emergency department is a critical time to identify people with OUD, and an opportunity to offer patients access to treatment inventions, providing linkage to care following their discharge, and making improvements in treatment retention.

https://www.nih.gov/news-events/news-releases/methadone-buprenorphine-reduce-risk-death-after-opioid-overdose

High-coverage treatment scale-up is required if Australia is to eliminate HCV as a public health threat

PLoS ONE 13(6): e0198336.
Hepatitis C virus notification rates in Australia are highest in socioeconomically disadvantaged areas
Samuel W. Hainsworth, Paul M. Dietze,David P. Wilson, Brett Sutton, Margaret E. Hellard, Nick Scott

Published: June 18, 2018

High-coverage treatment scale-up is required if Australia is to eliminate HCV as a public health threat, and this scale-up is necessary now if we are to achieve the WHO elimination targets by 2030. While this is only a preliminary analysis of the HCV burden, the findings provide important information for service prioritisation and planning, highlighting that the per capita burden of HCV is greatest in socioeconomically disadvantaged areas and the unmet demand for HCV services is greatest in geographic areas outside major cities. Our results suggest that strategies for HCV prevention and treatment in Australia would benefit from considering these factors. Any future research which has access to testing and treatment data could provide greater insight for the development of needs-based service planning. Despite this, the data used in our analysis are routinely available demographic and health service data, meaning that our analysis can serve as a useful framework for the ongoing monitoring of Australia’s efforts to eliminate HCV. Additionally, a similar framework for service planning could be employed in other countries wanting to scale up HCV testing and treatment in an effort to achieve HCV elimination.


Full Article

Abstract
Background
Poor access to health services is a significant barrier to achieving the World Health Organization’s hepatitis C virus (HCV) elimination targets. We demonstrate how geospatial analysis can be performed with commonly available data to identify areas with the greatest unmet demand for HCV services.

Methods
We performed an Australia-wide cross-sectional analysis of 2015 HCV notification rates using local government areas (LGAs) as our unit of analysis. A zero-inflated negative binomial regression was used to determine associations between notification rates and socioeconomic/demographic factors, health service and geographic remoteness area (RA) classification variables. Additionally, component scores were extracted from a principal component analysis (PCA) of the healthcare service variables to provide rankings of relative service coverage and unmet demand across Australia.

Results
Among LGAs with non-zero notifications, higher rates were associated with areas that had increased socioeconomic disadvantage, more needle and syringe services (incidence rate ratio [IRR] 1.022; 95%CI 1.001, 1.044) and more alcohol and other drug services (IRR 1.019; 1.005, 1.034). The distribution of PCA component scores indicated that per-capita healthcare service coverage was lower in areas outside of major Australian cities. Areas outside of major cities also contained 94% of LGAs in the lowest two socioeconomic quintiles, as well as 35% of HCV notifications despite only representing 29% of the population.

Conclusions
As countries aim for HCV elimination, routinely collected data can be used to identify geographical areas for priority service delivery. In Australia, the unmet demand for HCV treatment services is greatest in socioeconomically disadvantaged and non-metropolitan areas.

Increasing success and evolving barriers in the hepatitis C cascade of care

PLoS ONE 13(6): e0199174

Increasing success and evolving barriers in the hepatitis C cascade of care during the direct acting antiviral era 
Autumn Zuckerman, Andrew Douglas, Sam Nwosu, Leena Choi, Cody Chastain
Published: June 18, 2018
https://doi.org/10.1371/journal.pone.0199174 

With DAA therapy as the new standard of care, the HCV cascade of care (CoC) has transformed, still plagued by challenges in linkage to care yet substantially improved with regards to treatment outcomes. Interventions to emphasize screening, linkage to care, and access to treatment may address some of these challenges. Though DAA agents remain expensive for all groups, efforts to enhance and improve access across payer groups should be pursued. Integration of pharmacy services demonstrated high rates of medication access compared to previous studies, even in those with Medicaid. With new medications and modern tools, HCV treatment can be well-tolerated, effective, and result in high rates of completion.
Full Article

Abstract
Barriers remain in the hepatitis C virus (HCV) cascade of care (CoC), limiting the overall impact of direct acting antivirals. This study examines movement between the stages of the HCV CoC and identifies reasons why patients and specific patient populations fail to advance through care in a real world population. We performed a single-center, ambispective cohort study of patients receiving care in an outpatient infectious diseases clinic between October 2015 and September 2016. Patients were followed from treatment referral through sustained virologic response. Univariate and multivariate analyses were performed to identify factors related to completion of each step of the CoC. Of 187 patients meeting inclusion criteria, 120 (64%) completed an evaluation for HCV treatment, 119 (64%) were prescribed treatment, 114 (61%) were approved for treatment, 113 (60%) initiated treatment, 107 (57%) completed treatment, and 100 (53%) achieved a sustained virologic response. In univariate and multivariate analyses, patients with Medicaid insurance were less likely to complete an evaluation and were less likely to be approved for treatment. Treatment completion and SVR rates are much improved from historical CoC reports. However, linkage to care following referral continues to be a formidable challenge for the HCV CoC in the DAA era. Ongoing efforts should focus on linkage to care to capitalize on DAA treatment advances and improving access for patients with Medicaid insurance.

Monday, June 18, 2018

Hepatitis C Weekend Video: NASH What Is It?


Weekend Video
Welcome, this weekend we have a few articles on a "silent" but potentially serious condition called nonalcoholic fatty liver disease (NAFLD), with a new seven part video series on nonalcoholic steatohepatitis (NASH), the most severe form of NAFLD.

Today, while the burden of liver disease from HCV decreases - lowering the number of patients waiting or undergoing liver transplant - the waitlist for nonalcoholic steatohepatitis (NASH) has increased. In addition, NASH is the Fastest Growing Cause of Hepatocellular Carcinoma in Liver Transplant Candidates.

American Liver Foundation
Non-alcoholic fatty liver disease (NAFLD) is the build up of extra fat in liver cells that is not caused by alcohol. It is normal for the liver to contain some fat. However, if more than 5% – 10% percent of the liver’s weight is fat, then it is called a fatty liver (steatosis).
Learn more, here

The Effects of Physical Exercise on Fatty Liver Disease
In people with chronic hepatitis C infection, nonalcoholic fatty liver disease (NAFLD) can contribute to and accelerate the development of fibrosis. NAFLD generally occurs in people who are overweight; obesity is key to the development of insulin resistance. For people with HCV only, weight reduction leads to a decrease in steatosis and liver enzymes, and also to an improvement in fibrosis, despite persistence of the virus. Previous research also indicates HCV patients who participated in a diet and exercise program lowered their grade of steatosis and remarkably their fibrosis score, according to a study published in Nutrition 2013. Whether you have fatty liver disease, HCV or both, click on this recent article; The Effects of Physical Exercise on Fatty Liver Disease, published in Gene Expression 2018, to learn more about the effects of exercise on NAFLD and NASH.

2016
NAFLD & Type 2 Diabetes 
Published in World J Gastroenterology 2016
"NAFLD is most prominently linked to chronic kidney disease, mellitus type 2 and cardiovascular disease, as well as a number of other severe chronic diseases. These findings demonstrate that NAFLD ranks amongst the most serious public health problems of our time."
Also noted in the article, prevalence of Nonalcoholic Steatohepatitis (NASH) in people who are obese and have type 2 diabetes may be as high as 40%, whereas it is less than 5% in people without type 2 diabetes.
Read the article, here.

2018
NAFLD Is a Growing Problem
NAFLD is the most common form of liver disease in Western countries.[4] Men are affected more than women.[5] Persons with a "high body mass index in late adolescence" are at risk for advanced liver disease and hepatocellular carcinoma (HCC)..

The term "NAFLD" describes both hepatic steatosis with hepatocyte fat accumulation in a liver lacking inflammation, whereas NASH is associated with fat accumulation, hepatic inflammation, and hepatocyte injury with or without fibrosis or cirrhosis..

Not every patient with NAFLD is obese. Seven percent of lean patients have NAFLD,[18] especially in the presence of metabolic syndrome.[19] Lean patients with fatty liver also are observed among those with polycystic ovary syndrome.[20] Compared with lean patients, obese patients with NAFLD are more likely to have greater fibrosis and a worse clinical prognosis.[21] Nonobese patients with NAFLD have a lower prevalence of hypertension, diabetes mellitus, metabolic syndrome, and steatohepatitis than obese patients[22] but remain at risk for development of advanced liver disease[23] and associated metabolic abnormalities and cardiovascular disease.[22] 
Continue reading @ Medscape
Free registration may be required. 

2017
The International Liver Congress 2017
NASH: It's Fibrosis, Not Fat, that Matters
Analysis sheds new light on what drives disease progression
AMSTERDAM -- It isn't fat but rather fibrosis that drives disease progression in people with advanced non-alcoholic steatohepatitis (NASH), a researcher said here
Continue reading....
Free registration may be required. 

2017
HCV & Steatosis
Given the development of steatosis is well-known in people with HCV, the following articles may be of interest to you, lets start with an article published in Clinical Liver Disease 2017; Metabolic Manifestations of Hepatitis C Virus
Out of excessive consumption, steatosis should be classified into 2 types according to hepatitis C virus (HCV) genotypes: metabolic steatosis, which is associated with features of metabolic syndrome and insulin resistance in patients infected with nongenotype 3, and viral steatosis, which is correlated with viral load and hyperlipemia in patients infected with genotype 3.
Download the article, here

2016
Published in the 2016 issue of International Journal of Molecular Sciences; NAFLD and NASH in HCV Infection: Prevalence and Significance in Hepatic and Extrahepatic Manifestations, researchers investigated factors associated with NAFLD/NASH in chronic HCV, and the role of “viral steatosis” associated with HCV genotype 3 infection. 

2018
Of Interest
HCV Treatment Genotype 3
The International Liver Congress, 2018
Treatment for hepatitis C genotype 3 infection can be completed in 8 weeks in people without cirrhosis, three real-world studies presented at the conference confirmed. 

2018
Fatty liver is very common in hepatitis C virus (HCV) patients post-SVR 
According to data published March 21, 2018 in the online journal World J Gastroenterology, evidence of steatosis was reported to be found in close to half of patients who achieve a sustained virologic response after treating with direct-acting antivirals. 
Core tip: This is the first prospective study to assess the prevalence of fatty liver in hepatitis C patients who have achieved a sustained virological response with direct-acting antivirals. The study’s findings that fatty liver is present in 47.5% of these patients and that some steatotic patients have clinically significant fibrosis despite normal liver enzymes should raise awareness of the post-sustained virological response (SVR) prevalence of fatty liver and the importance of post-SVR assessment of steatosis and fibrosis and long-term follow up with these patients.
Full-text, here

2018
NASH Leading Cause of Liver Transplant in Women
"NASH is currently the second leading cause for LT waitlist registration/liver transplantation overall, and in females, the leading cause. Given the rate of increase, NASH will likely rise to become the leading indication for LT in males as well" according to a June 2018 study published in The American Journal of Gastroenterology.

June 2018
On June 12, 2018, the 1st International NASH Day was launched by The NASH Education Program, along with their seven part educational program to help patients understand this serious liver disease. Listen to expert interviews, learn about symptoms, non-invasive tests used to measure liver inflammation and fibrosis, and hear from patients struggling with the disease.


NASH What Is It?
The video is the first part of a WEBTV of 7 sequences about NASH
Published June 12, 2018
Speakers: Pr Stephen Harrison, Pr Sven Francque
In this first TV show you will understand – thanks to a worldwide overview – how little-known NASH is and why this situation has to be changed. Liver experts will go over non-alcoholic steatohepatitis (NASH) details, its mechanisms, consequences, symptoms and stigmas. These will also be highlighted by a patient testimony at the end of the video footage.

Part One



SUBTITLES ARE AVAILABLE IN 6 LANGUAGES, using settings of the video (Gear Icon at the bottom right of the video): English - Spanish - French - Italian - German - Portugese

Full Playlist:
PART 1 NASH What Is It?  
https://www.youtube.com/watch?v=ND3AV...
In this first TV show you will understand – thanks to a worldwide overview – how little-known NASH is and why this situation has to be changed. Liver experts will go over non-alcoholic steatohepatitis (NASH) details, its mechanisms, consequences, symptoms and stigmas. These will also be highlighted by a patient testimony at the end of the video footage.

PART 2 NASH How Common Is It?
https://www.youtube.com/watch?v=luYVh...
In this second TV show, you will understand how widespread NASH is, with prevalence figures and future projections exposed. During the interviews, livers experts will bring up information on NASH frequency, genetic predispositions, how children are now subject to this preventable disease, and which populations are most commonly affected.

PART 3 NASH: Who is at risk?  
https://www.youtube.com/watch?v=nAjMR...
In this third TV show, you will discover that NASH is much more than just a liver disease and that it is related to metabolic disorders – such as diabetes and obesity – and closely linked to modern lifestyles: unhealthy diets and lack of physicial activity. The diverse speaker panel will explain why some people are more at risk than others and how much exercise can help, if sufficient and sustained. Lastly, the video will follow patients associations in their mobilizations against NASH.

PART 4 NASH: Getting Diagnosed 
https://www.youtube.com/watch?v=x_nwF...
In this fourth TV show, you will discover how much of challenge NASH diagnosis is – mainly because NASH is a silent disease (no symptoms) which makes it difficult to diagnose – and how current procedures can be a bottleneck in the patient journey. Liver experts will explain the current invasive and non-invasive diagnostic techniques used when NASH is suspected, as well as latest research in novel diagnostic tools and what the future holds in terms of diagnosis.

PART 5 NASH: Disease evolution and consequences  
https://www.youtube.com/watch?v=Sl9Fu...
In this fifth TV show, you will learn more about the consequences of non-alcoholic steatohepatitis in the liver, but also in the rest of the body, with associated conditions. A French sports journalist will share his testimony as a NASH patient that overcame a liver transplant and a kidney as the last resort to survive, and a representative from The Liver Forum will explain how experts work to research the best patient clinical management solutions. In the end, you will know more about the consequences on health, the consequences on the economy, stigmas, lessons learned and the dire need for awareness.

PART 6 NASH: Patient care and clinical management 
https://www.youtube.com/watch?v=rWS-c...
In this sixth video, you will discover how much of a challenge patient management is, and especially, how to answer this burning question: “how can we care for patients in the absence of treatment?” – Today, on top of the lifestyle change (weight loss and exercise) ongoing research on therapeutic solutions paves the way for a better patient care. Moreover, you’ll discover how physicians are all working hand in hand to cover all the aspects of this multi-faceted disease. Finally, you will have the opportunity to hear the American Liver Foundation’s CEO’s perspectives on NASH.

PART 7 NASH: What perspectives?
https://www.youtube.com/watch?v=vDt5k...
In this seventh video, you will learn more about the next key challenges in the field of NASH, and about the crucial need for awareness and for public policy. Experts will give some forecast about NASH, ongoing research and the shed light on future management solutions You will get insights on the economic burden of NASH and the need for all stakeholders to be involved in NASH awareness. To conclude these seven sequences, there will be a special focus on how street art can help increase awareness and what we can hope for in the future.

Elsewhere
Non-alcoholic fatty liver disease: risks, prevention, and more
June 11, 2018
Lauren Phinney
Doctor Rohit Loomba appeared on KUSI News in San Diego to discuss Non-alcoholic fatty liver disease and how to prevent it. 
Watch his informative interview here.

The diagnosis and management of nonalcoholic fatty liver disease: Practice guidance from the American Association for the Study of Liver Diseases
A recent publication from the American Association for the Study of Liver Diseases (AASLD) provides guidance for the evaluation and management of patients with NAFLD.
This guidance provides a data‐supported approach to the diagnostic, therapeutic, and preventive aspects of nonalcoholic fatty liver disease (NAFLD) care. A “Guidance” document is different from a “Guideline.” Guidelines are developed by a multidisciplinary panel of experts and rate the quality (level) of the evidence and the strength of each recommendation using the Grading of Recommendations, Assessment Development, and Evaluation system. A guidance document is developed by a panel of experts in the topic, and guidance statements, not recommendations, are put forward to help clinicians understand and implement the most recent evidence. 

On This Blog 

Maybe this weekend you might think about eating right or even start walking, two key elements for keeping your liver healthy. 
Tina

Sunday, June 17, 2018

Just 12 countries worldwide on track to eliminate hepatitis C by 2030, with United Kingdom, Italy and Spain among those joining the list

Just 12 countries worldwide on track to eliminate hepatitis C infection by 2030, with United Kingdom, Italy and Spain among those joining the list

New data on the world’s hepatitis C epidemic, presented at this week’s Global Hepatitis Summit in Toronto, Canada (14-17 June) shows that only 12 countries in the world are on track to meet the WHO elimination targets that 194 countries globally signed up to in 2016. The data is presented by Dr Homie Razavi and his team from the Polaris Observatory, Center for Disease Analysis Foundation (CDAF), Lafayette, CO, USA.

Since the last global update in 2017, Italy, Spain, Switzerland, the UK and Mongolia have all been added to the list, thanks to the number of patients they treated in 2017, plus the lifting of treatment restrictions to include all patients with hepatitis C regardless of their degree of liver damage. These countries join the others already on track to eliminate by 2030: Australia, Egypt, France, Georgia, Iceland, Japan and the Netherlands. In all cases, these countries are treating at least 7% of their infected population each year, and have opened treatment up to all those infected.


Global Hepatitis Summit
Toronto June 14th – 17th, 2018
Website
Global Hepatitis Summit
Abstract Journal
Twitter
#GHS2018

Friday, June 15, 2018

Liver Cancer a Big Threat to U.S., Other Developed Nations

Liver Cancer a Big Threat to U.S., Other Developed Nations

FRIDAY, June 15, 2018 (HealthDay News) -- Liver cancer cases in several developed countries have doubled in the past 25 years, due to the continuing obesity epidemic and a spike in hepatitis infections, new research suggests.

Even worse, the sharp rise in liver cancer cases is starting to swamp the limited number of liver specialists in those nations, the researchers added.

In the four countries -- the United States, the United Kingdom, Australia and Canada -- liver cancer is the only major cancer for which death rates are rising.

The findings were to be presented Friday at the Global Hepatitis Summit, in Toronto. Research presented at meetings is considered preliminary until published in a peer-reviewed journal.


Global Hepatitis Summit
Toronto June 14th – 17th, 2018 
Twitter
#GHS2018 

Thursday, June 14, 2018

SVR 24 Two Weeks After a Tripled Dose of Daclatasvir in an HCV Genotype 3 Patient (Case Report)

Case Report
Ann Hepatol. 2018 July - August ,;17(4):661-664. doi: 10.5604/01.3001.0012.0950.

SVR 24 Achievement Two Weeks After a Tripled Dose of Daclatasvir in an HCV Genotype 3 Patient.
Lo Menzo S1, Biagi E1, Di Nuzzo M1, Grilli A1, Contini C1.

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Abstract
Directly-acting antivirals (DAA) have changed the chronic hepatitis C virus (HCV) infection therapeutic scenario allowing virus eradication in more than 95% of patients, independently from the genotype, with 12 to 24-week treatment regimens. We describe a 51-year-old Pakistani man with a chronic HCV-genotype 3 (GT3a) infection with moderate liver fibrosis, who achieved sustained virological response (SVR) 24 after a tripled dose of Daclatasvir (DCV) taken erroneously associated to Sofosbuvir (SOF). The patient had a concomitant intestinal TB infection whose treatment had been delayed in order to firstly eradicate HCV to reduce the liver toxicity of anti-mycobacterial drugs. Thanks to the cultural mediator support, we explained to the patient the correct posology of each drug to take during the day consisting of 12 week SOF (400 mg daily) plus DCV (60 mg daily) regimen. He returned 13 days after for a programmed visit and we were surprised to learn that he had taken 3 pills of DCV (180 mg/daily) instead of one, thus ending DCV assumption after only 9 days while SOF was taken correctly. He complained no symptoms. We immediately performed blood test that showed alteration of lactate dehydrogenase, creatine phosphokinase, and creatin kinase MB activity. At day 15 we stopped SOF closely monitoring the patient. Blood test alterations returned normal after one week of treatment suspension, HCV viremia remained suppressed after 4, 12 and 24 weeks proving HCV eradication. If confirmed, these data could suggest that higher doses of DCV, if tolerated, might be employed in short-time HCV-GT3 treatment.

PMID: 29893709 DOI: 10.5604/01.3001.0012.0950 

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Diagnosis and Treatment of HCC Varies by Race

Diagnosis and Treatment of HCC Varies by Race
Blacks and Hispanics less likely to get surveillance, early diagnosis, and curative treatment
by Diana Swift, Contributing Writer June 14, 2018

A large retrospective study of hepatocellular (HCC) patients in Texas found racial and ethnic differences in outcomes, with blacks and Hispanics less likely than whites to get early diagnosis and curative treatment, and blacks less likely to survive.

"Our findings have important implications for health policy and highlight the need for further study on racial-ethnic disparities in HCC, including identification of additional actionable intervention," wrote Amit Singal, MD, MS, of the University of Texas (UT) Southwestern Medical Center's Simmons Cancer in Dallas, and colleagues in Clinical Gastroenterology and Hepatology
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Canadian team reports success in transplanting hepatitis C organs

Toronto doctors safely transplant lungs from hepatitis C-infected donors
by Sheryl Ubelacker, The Canadian Press
Last Updated Jun 14, 2018 at 8:24 am EDT

Toronto doctors have successfully transplanted lungs from deceased donors with hepatitis C into patients in need of the lifesaving organs, followed by treatment to prevent them from becoming infected with the potentially liver-destroying virus.

Since October, surgeons at Toronto General Hospital have performed the transplants in 11 patients as part of a pilot study to evaluate the safety of using lungs from hepatitis C-infected donors — a previously untenable idea.

That’s because antiviral drugs can now cure the disease in 98 per cent of people infected with hepatitis C, which affects an estimated 250,000 Canadians, about 40 to 70 per cent of them unaware they harbour the blood-borne virus.

“With the opioid crisis and persistent high rates of intravenous drug use, we have a great number of potential lung donors who are hepatitis C-positive, many of whom didn’t even know they were sick when they were alive,” said Dr. Marcelo Cypel, a thoracic surgeon at TGH and principal investigator of the study.

Canadian team reports success in transplanting hepatitis C organs
WASHINGTON: A long-running shortage in donor organs has pushed doctors to find ways to use those with hepatitis C, an infection that is increasingly common in the United States due to the opioid crisis, and which can be cured with medicine.

Some US hospitals, particularly in Boston, have already transplanted infected donor organs into people without hepatitis C. These patients are swiftly treated with drugs to eliminate the virus.

In Toronto, Canada, another team of doctors on Thursday announced early results from a trial using a different technique, involving 10 people who received lung transplants from donors with hepatitis C.

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Wednesday, June 13, 2018

Liver Cancer After Treatment For Hepatitis C


Page updated: June 2018

Liver Cancer After Treatment For Hepatitis C
Research demonstrates that while SVR markedly reduced liver-related complications and liver cancer, some long-term risk for liver cancer remained in those who were cured of Hepatitis C. But after direct-acting antiviral therapy does the risk of developing liver cancer increase?

This page offers an index of links to current data investigating the possible risk of developing liver cancer (hepatocellular carcinoma, or HCC) during and after direct-acting antiviral therapy in patients with hepatitis C.

June 2018
June 15 2018
Alimentary Pharmacology & Therapeutics
Direct-acting Antiviral Treatment for Hepatitis C Virus Infection and Risk of Incident Liver Cancer
Does DAA-based HCV treatment reduce the risk of incident liver cancer compared to untreated HCV or interferon-based treatment?

May 2018
May 12, 2018
Nature reviews gastroenterology & hepatology
HCV therapy and risk of liver cancer recurrence: who to treat?
Article shared and download by Henry E. Chang on Twitter

May 4, 2018
This large real-life study proves that the efficacy of DAA in cirrhotic patients is not impaired by successfully treated HCC.

April 2018
April 21, 2018
Editorial
Hepatocellular carcinoma as a consequence of hepatitis C direct-acting anti-virals-the great urban myth of hepatology
Aliment Pharmacol Ther. 2018 May;47(10):1418-1419. doi: 10.1111/apt.14634.

April 17, 2018
Does interferon-free therapy for hepatitis C after curative treatment for hepatocellular carcinoma lead to unexpected recurrences of HCC?
PLOS ONE | https://doi.org/10.1371/journal.pone.0194704

April 11, 2018
New At Healio: 8 reports on liver cancer outcomes with HCV, DAA therapy

April 5, 2018
Hepatitis C - Interferon-free therapy did not increase the risk of liver cancer
LAY SUMMARY: We examined the risk of liver cancer among 857 patients with cirrhosis in Scotland who received hepatitis C antiviral therapy and achieved a cure. We compared the risk of first-time liver cancer in patients treated with the newest interferon-free regimens, to patients treated with interferon. After accounting for the different characteristics of these two treatment groups, we found no evidence that interferon-free therapy is associated with a higher risk of liver cancer.

Mar 19, 2018
Patients with hepatitis C who are successfully treated with direct-acting antiviral agents experience a dramatic reduction in their risk for liver cancer, new data show. However, the decrease is much lower for those diagnosed with cirrhosis before starting a DAA.

Mar 13, 2018
Persistence of hepatocellular carcinoma risk in hepatitis C patients with a response to IFN & cirrhosis

Stagnation of fibrosis regression is associated with a high risk for HCC after SVR

Mar 3, 2018

Feb 12, 2018
Hepatocellular carcinoma - Updated and evidence-based review
Alejandro Forner, MD, MD Alejandro Forner
Published: 04 January 2018
DOI: http://dx.doi.org/10.1016/S0140-6736(18)30010-2

Full Text
Hepatocellular carcinoma appears frequently in patients with cirrhosis. Surveillance by biannual ultrasound is recommended for such patients because it allows diagnosis at an early stage, when effective therapies are feasible. The best candidates for resection are patients with a solitary tumour and preserved liver function. Liver transplantation benefits patients who are not good candidates for surgical resection, and the best candidates are those within Milan criteria (solitary tumour ≤5 cm or up to three nodules ≤3 cm). Image-guided ablation is the most frequently used therapeutic strategy, but its efficacy is limited by the size of the tumour and its localisation. Chemoembolisation has survival benefit in asymptomatic patients with multifocal disease without vascular invasion or extrahepatic spread. Finally, sorafenib, lenvatinib, which is non-inferior to sorafenib, and regorafenib increase survival and are the standard treatments in advanced hepatocellular carcinoma. This Seminar summarises the scientific evidence that supports the current recommendations for clinical practice, and discusses the areas in which more research is needed....

Future perspectives
In the past 10 years, treatment of hepatocellular carcinoma has evolved considerably. Nowadays, patients with hepatocellular carcinoma can benefit from effective options that improve their survival whatever the evolutionary stage of disease at diagnosis. However, improvement can still be made in several areas. Prevention of the acquisition of the risk factors for development of hepatocellular carcinoma is the best strategy for decreasing mortality. The high efficacy of direct acting antivirals in elimination of chronic hepatitis C virus infection is expected to have an impact on the incidence of hepatocellular carcinoma, but further information about disease evolution in the patients after viral cure needs to be collected.......

Article Downloaded & shared by @HenryEChang via Twitter.
View Article: https://jumpshare.com/v/La5WS4Mn8Uwpi927nbeU

December 2017
Healio - December 8, 2017
Liver cancer incidence after HCV therapy linked to risk factors, not treatment
Li DK, et al. Hepatol. 2017;doi:10.1002/hep.29707. 
Direct-acting antiviral treatment for hepatitis C did not correlate with an increased risk for hepatocellular carcinoma in a large cohort study of both treated and untreated patients with or without cirrhosis. Those with incident HCC after DAA treatment had higher risk factors at baseline. “There was no increased risk for HCC as a result of having received DAA therapy whatsoever,” Raymond T. Chung, PhD, director of Hepatology and Liver Center at Massachusetts General Hospital, told Healio Gastroenterology and Liver Disease. “The risk was related to their preexisting likelihood of developing HCC. The fact that HCC developed post-DAA, we think, is more likely to be an accident of timing than the idea that it's related to receipt of DAA — these persons were at risk for HCC whether they received DAAs or not.”

Innes H, et al. J Hepatol. 2017;doi:10.1016/j.jhep.2017.10.033.
Recently published data suggest that higher hepatocellular carcinoma incidence after sustained virologic response with interferon-free hepatitis C treatment correlates to patient baseline risk factors, such as age, Child-Turcotte Pugh score and prior treatment, rather than IFN-free therapy.

HCV Clearance Lowers Liver Cancer Risk by 70% no Matter Drug of Choice
Reaching sustained virologic response with direct-acting antivirals reduced the occurrence of hepatocellular carcinoma by 71%, but all treatments that cleared the virus saw a similar reduction in risk, according to a presenter at The Liver Meeting 2017.


November 2017
HCV Advocate – Direct-Acting Antiviral Treatment & Decrease a Incidence of Liver Cancer
The studies on this blog looked at treatment with DAAs to find out if curing hepatitis C (HCV) with DAAs improved HCV disease progression and reduced the risk of liver cancer.

October 2017
Oct 23, 2017
The Liver Meeting® 2017 - Vets with HCV Might Settle Cancer Controversy
In the largest cohort analyzed to date -- some 62,000 patients in the VA system -- there is no evidence that therapy with newer agents that act directly against the virus (DAAs) increases the risk of hepatocellular carcinoma (HCC), according to George Ioannou, BMBCh, of the Veterans Affairs Puget Sound Health Care System in Seattle.

Oct 20, 2017
The Liver Meeting® - Direct‐Acting Antiviral Therapy Cuts Liver Cancer Risk By 71%
The study’s findings showed that DAA‐induced sustained virological response is associated with a 71 percent reduction in patients’ liver cancer risk, and showed treatment with DAAs is not associated with increased liver cancer risk compared to treatment with interferon.

Oct 16, 2017
Short-term risk of hepatocellular carcinoma after hepatitis C virus eradication following direct-acting anti-viral treatment
In conclusion, our data showed no evidence of an increased risk of de novo HCC or recurrence by patients treated with interferon-free SOF-based regimens. However, cirrhosis was strongly associated with the short-term development of HCC after HCV eradication. Moreover, our findings underscore the fact that the serum EOT-AFP level is a useful marker for predicting de novo HCC for cirrhotic patients and that close HCC surveillance should be required for patients with a past history of HCC, especially for patients treated with noncurative procedures. Going forward, further studies will be required to elucidate the risk of HCC development over the long-term.....

Oct 3, 2017
HCV Treatment Not Associated with Liver Cancer, New Evidence Suggests
Kenneth Bender
An assessment of over 62,000 patients treated for hepatitis C (HCV) revealed no evidence to support the suggestion that direct acting antiviral (DAA) agents promote recurrence of hepatocellular carcinoma (HCC), and found instead that successful treatment with or without DAAs is associated with reduced risk of HCC.

September 2017
Sep 18, 2017
Coverage OncLive - 2017 International Liver Cancer Association Annual Conference
Study Shows DAAs Are Not Associated With Increased HCC Recurrence Risk
Angelica Welch
Published Online: Monday, Sep 18, 2017
Direct acting antivirals (DAA) are a novel and completely oral hepatitis C therapy that is associated with a high response rate. DAAs are used in most patients being treated for hepatitis C, including those with decompensated cirrhosis.

Sep 12, 2017
Full Text Article Provided by NATAP
"Most HCV-infected patients in the United States will undergo DAA-based antiviral treatment in the next few years and the vast majority of them will achieve SVR. Our results suggest that DAA-induced SVR is associated with a 71% reduction in HCC risk (AHR 0.29, 95% CI 0.23-0.37) compared to treatment failure. The reduction in HCC risk associated with SVR was similar irrespective of whether SVR was achieved by DAA-ONLY, DAA+IFN or IFN-ONLY regimens. This suggests that eradication of HCV reduces HCC risk independently of how it is achieved. In contrast to prior reports that suggested an increased HCC risk in patients treated with DAAs[[3], [7]], we found that receipt of DAA-ONLY antiviral treatment was not associated with increased risk of HCC when compared to receipt of IFN-ONLY antiviral treatment.....We found no evidence that treatment with DAAs was associated with increased risk of HCC compared to treatment with IFN.

Sept 5, 2017
Risk for hepatocellular carcinoma after HCV antiviral therapy with DAAs: case closed?
Several studies of patients treated with interferon -based therapy nicely documented that the risk for hepatocellular carcinoma (HCC) was markedly lower in patients who achieved SVR compared to those without SVR. 5-7 As a result, it was naturally assumed that with higher cure rates with DAAs, cancer rates would start to decline. It was therefore surprising and unsettling in 2016 to see a series of reports of unexpectedly high rates of ‘early’ HCC recurrence after ‘curative’ therapy as well as higher than expected rates of de novo HCC in patients who achieved SVR with DAAs.
PDF Full Text Article - Provided by @HenryEChang via Twitter

August 2017
Aug 15, 2017
How Do Direct-Acting Antivirals for HCV Affect HCC Risk?
The latest data on the controversial hepatitis C-hepatocellular carcinoma treatment link are examined.

Aug 10, 2017
The risks of hepatocellular carcinoma development after HCV eradication are similar between patients treated with peg-interferon plus ribavirin and direct-acting antiviral therapy
The risk of hepatocellular carcinoma (HCC) development is reduced following viral elimination by interferon therapy in chronic hepatitis C patients. However, the risk in patients treated with interferon-free direct-acting antivirals (DAAs) is unknown. We evaluated chronic hepatitis C patients who achieved viral eradication by pegylated-interferon plus ribavirin (PEG-IFN/RBV, n = 244) or daclatasvir plus asunaprevir (DCV/ASV, n = 154) therapy...

Aug 4, 2017
Liver cancer, mortality risks decrease with SVR after direct-acting antivirals
Patients who achieved sustained virologic response after direct-acting antiviral treatment also had significantly lower all-cause mortality and lower incident rates of…

July 2017
July 26, 2017
Medscape
With Hepatitis C Virus on the Run, Meet the New Challenge: Hepatocellular Carcinoma
Significant advances in the clinical practice of hepatology were addressed during this year's Digestive Disease Week. This review focuses on the concerns related to the apparent increase in the incidence of hepatocellular carcinoma (HCC).

July 16
Hepatitis C virus eradication with direct antiviral agents and liver cancer recurrence: Is the best the enemy of the good? Antiviral therapy has long been perceived as an adjuvant treatment modality worth to be offered to patients with chronic hepatitis C virus (HCV) infection after successful removal of a hepatocellular carcinoma (HCC), an approach dating more than two decades since interferon was first employed to treat non-A, non-B hepatitis.

July 10
DAAs do not affect HCC risk, SVR reduces risk
July 10, 2017
Recently published data showed a link between sustained virologic response and a reduced risk for hepatocellular carcinoma among patients treated with direct-acting…

July 3
Sustained response to direct-acting HCV antivirals tied to lower HCC risk
July 3, 2017
by Marilynn Larkin
NEW YORK (Reuters Health) - A sustained virologic response to direct-acting antiviral treatment of hepatitis C (HCV) is associated with a “considerable” reduction in the risk of hepatocellular carcinoma (HCC), researchers say. Dr. Fasiha Kanwal of Baylor College of Medicine in Houston, Texas and colleagues analyzed data on 22,500 HCV patients (mean age 62) from 129 Veterans Health Administration hospitals who filled more than one prescription of sofosbuvir, simeprevir, ledipasvir, a combination of paritaprevir/ritonavir or ombitasvir and dasabuvir, and daclatasvir in 2015.

June 2017
June 26, 2017
Challenges in Treatment of Hepatitis C among Patients with Hepatocellular Carcinoma

June 3, 2017
Medscape Coverage from the International Liver Congress (ILC) 2017
Navigating the Hep C Treatment and Cancer Risk Minefield

May 2017
May 26
Hepatocellular carcinoma and direct- acting antivirals: A never ending story?
Vincenza Calvaruso* andAntonio Craxì Version of Record online: 24 MAY 2017 DOI: 10.1111/liv.13421
Liver International
Volume 37, Issue 6, pages 812–814, June 2017

Key Points
• The benefit of SVR is higher in patients without clinically significant portal hypertension
• HCC occurrence in patients with compensated cirrhosis is comparable to historical controls of patients who achieved SVR after interferon-based therapy.
• Patients who achieve SVR with DAAs had a lower risk of developing liver cancer than those patients whose HCV infection was not cured.
• Data available on patients with previous HCC do not show an increased risk of HCC recurrence and report a comparable rate of reappearance of cancer among DAA-treated and untreated patients.

Full Text

Link Provided By
Henry E. Chang via Twitter

May 26
Summary Of  Available Data:
New Hep C Treatment Not Linked to Liver Cancer
Contrary to some earlier research, most recent studies see no association between response to DAAs and HCC

Do HCV DAAs Increase HCC Recurrence Risk or Not?
Does the administration of direct-acting antiviral (DAA) therapy increase a patient’s risk of hepatocellular carcinoma (HCC) recurrence?

Direct-acting-antivirals (DAA) can cure patients of the life-threating hepatitis C virus (HCV) infection, with cure rates exceeding 95%. However, questions have been raised about the long-term consequences of curing patients with DAAs, including a potential link between DAA treatment and the development of hepatocellular carcinoma (HCC).

Improved survival of patients with hepatocellular carcinoma and compensated HCV-related cirrhosis who attained SVR
Few studies examined the outcome of patients with HCV-related cirrhosis who developed hepatocellular carcinoma (HCC). The relative weight as determinant of death for cancer versus endstage-liver-disease (ESLD) and the benefit of HCV eradication remain undefined. This multicenter, retrospective analysis evaluates overall survival (OS), rate of decompensation and tumor recurrence in compensated HCC patients treated with IFN according to HCV status since HCC diagnosis.

Of Interest
HCC in presence of HCV decreases cure rate in DAA treatment
Patients with hepatocellular carcinoma and hepatitis C were less likely to achieve sustained virologic response while receiving direct-acting antiviral therapy compared with patients without HCC, according to results of a retrospective study.

International Liver Congress
April 21,2017
Direct-acting antivirals for hepatitis C not linked to higher liver cancer risk in most studies
People with hepatitis C who take treatment with direct-acting antivirals (DAAs) do not appear to have a higher risk of developing liver cancer compared to those treated with interferon, and the seemingly higher rates seen in some studies are attributable to risk factors such as older age and more advanced liver disease, according to a set of studies presented on Thursday at the International Liver Congress in Amsterdam. The congress is the annual meeting of the European Association for the Study of the Liver (EASL).

April 20, 2017
#ILC 2017: Is direct-acting antiviral therapy for Hepatitis C associated with an increased risk of liver cancer? The debate continues
Eight studies being presented at The International Liver Congress™ 2017 demonstrate contrasting evidence on the potential link between direct-acting antiviral treatment for Hepatitis C and liver cancer

Commentary on this study
Hepatitis C Patients At No Elevated Risk of Developing HCC Following DAA Compared To Interferon
Patients were at no elevated risk of developing hepatocellular carcinoma (HCC) after achieving sustained virologic response (SVR) following treatment with direct-acting antiviral therapy (DAA) for hepatitis C compared to interferon therapy, according to results of a meta-analysis reported at the 2017 International Liver Congress (ILC).

Timing of DAA therapy and HCC response may impact recurrence rate
April 20, 2017
AMSTERDAM — Unexpectedly high hepatocellular carcinoma recurrence rates were reported among patients who achieved sustained virologic response after receiving direct-acting antiviral therapy, according to data presented at the International Liver Congress.
“This update further supports our findings about an unexpected high recurrence rate associated in time with DAA, but also exposes a more aggressive pattern of recurrence and faster tumor evolution,” Maria Reig, MD, of the Barcelona Clinic Liver Cancer Group, Liver Unit, Hospital Clinic Barcelona, at the University of Barcelona, said in her presentation.

Liver International
April 20, 2017
Download PDF - Full Text
Direct-acting antiviral therapy decreases hepatocellular carcinoma recurrence rate in cirrhotic patients with chronic hepatitis C
Arrival of direct-acting antiviral (DAA) agents against hepatitis C virus (HCV) with high-sustained virological response (SVR) rates and very few side effects has drastically changed the management of HCV infection. The impact of DAA exposure on hepatocellular carcinoma (HCC) recurrence after a first remission in patients with advanced fibrosis remains to be clarified

Editorial - Healio
April 20, 2017
HCC After DAAs Requires More Study, but no Cause for Withheld Treatment
HCV Next, April 2017
As we continue to see the success of direct-acting antiviral therapy in treating hepatitis C virus, we must be aware of any potential complications from the underlying liver disease after successful treatment, especially hepatocellular carcinoma.

March 15, 2017
Full Text - Download PDF
Hepatitis C-related hepatocellular carcinoma in the era of new generation antivirals
Abstract
Hepatitis C virus infection is a major cause of hepatocellular carcinoma worldwide. Interferon has been the major antiviral treatment, yielding viral clearance in approximately half of patients. New direct-acting antivirals substantially improved the cure rate to above 90%. However, access to therapies remains limited due to the high costs and under-diagnosis of infection in specific subpopulations, e.g., baby boomers, inmates, and injection drug users, and therefore, hepatocellular carcinoma incidence is predicted to increase in the next decades even in high-resource countries. Moreover, cancer risk persists even after 10 years of viral cure, and thus a clinical strategy for its monitoring is urgently needed. Several risk-predictive host factors, e.g., advanced liver fibrosis, older age, accompanying metabolic diseases such as diabetes, persisting hepatic inflammation, and elevated alpha-fetoprotein, as well as viral factors, e.g., core protein variants and genotype 3, have been reported. Indeed, a molecular signature in the liver has been associated with cancer risk even after viral cure. Direct-acting antivirals may affect cancer development and recurrence, which needs to be determined in further investigation.
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Feb 27, 2017
People with HIV and hepatitis C virus (HCV) co-infection who are successfully treated for hepatitis C using interferon-free direct-acting antiviral (DAA) therapy do not appear to have an increased likelihood of developing hepatocellular carcinoma (HCC), according to a study presented at the Conference on Retroviruses and Opportunistic Infections (CROI 2017) this month in Seattle.

Accepted Manuscript
Gastroenterology Accepted Date: 23 January 2017
Genome-wide Association Study Identifies TLL1 Variant Associated With Development of Hepatocellular Carcinoma After Eradication of Hepatitis C Virus Infection

Media Coverage of this Article
Feb 22, 2017
Genetic variant linked to risk of liver cancer after hep C eradication
NEW YORK (Reuters Health) – A single nucleotide polymorphism (SNP) in the tolloid-like 1 (TLL1) gene is associated with the development of hepatocellular carcinoma (HCC) after eradication of hepatitis C virus (HCV) infection, researchers from Japan report.
“When we constructed different models for predicting HCC in patients with mild as opposed to advanced hepatic fibrosis by combining this TLL1 variant with other distinct risk factors, these proposed models including TLL1 variant could be useful for predicting the occurrence of HCC after achieving sustained virological response (SVR) in the clinical practice,” Dr. Yasuhito Tanaka from Nagoya City University Graduate School of Medical Sciences told Reuters Health by email.
Continue reading...

Feb 8, 2017
High Rates of Hepatocellular Carcinoma After Hepatitis C Treatment
NEW YORK (Reuters Health) - Patients treated with direct-acting antiviral (DAA) therapy for hepatitis C virus (HCV)-related cirrhosis appear to have high rates of hepatocellular carcinoma (HCC).

"If these findings are confirmed from other centers, studies are suggested to examine mechanisms of these findings," Dr. Ashwani Singal from University of Alabama at Birmingham told Reuters Health by email.

Some studies have shown unexpectedly high HCC recurrence rates after DAA therapy, whereas others have shown no such association.

Dr. Singal and colleagues examined the occurrence of de novo HCC in their retrospective study of 66 patients with HCV-related cirrhosis who received DAA between 2015 and 2016.

Typically, patients with HCV cirrhosis have an HCC incidence of 3%-5% per year, the researchers say.

But six of these patients (9.1%) developed HCC during or within six months after treatment, and two additional patients (3%) developed indeterminate liver lesions, according to their letter online February 1st in Gastroenterology.

They note that another study showed a reduced risk of HCC occurrence among DAA-treated patients who achieved sustained viral responses (SVR) versus those not achieving SVR, so they suggest prospective multicenter studies to confirm these findings.

"Be aware of this potential issue and consider more intensive HCC surveillance of HCV cirrhotics during and after HCV therapy," Dr. Singal concluded.

Dr. Gaetano Serviddio from University of Foggia, Italy, who has reported on the outcomes of DAA therapy, told Reuters Health by email, "DAAs have completely changed the prognosis of chronic hepatitis C patients who have a unique possibility to be cured definitively. To discover that such drugs have some tumor risks is particularly terrible. In any case, the number of events is small, and the data are not enough to support the hypothesis that the risk is directly related to the drugs."

"DAAs are safe and powerful drugs; millions of lives will be saved with such drugs," he said. "Studies should be supported to completely define patients at risk of HCC recurrence."
SOURCE: http://bit.ly/2lmDbXa
Gastroenterol 2017.

January 2017
In Press, Corrected Proof
Digestive and Liver Disease
Available online 21 January 2017
HCV clearance by direct antiviral therapy and occurrence/recurrence of hepatocellular carcinoma: A “true-or-false game”
Three years ago, the new direct antiviral therapies (DAAs) were approved for HCV treatment and the scenario completely changed. The share of patients in whom eradication is obtained raised to over 90% [7], the limits in the stage of the disease that can be treated disappeared, but solid data on the long-term outcome of cirrhotics treated with these new drugs are lacking.

A totally unexpected, intriguing and somehow hard-to-believe report of an increased incidence of HCC with rapid recurrence after HCV eradication with DAAs was first presented at the 2016 EASL meeting and then published in the Journal of Hepatology.....
Continue to full text article...

2016
AASLD 2016 and International Liver Congress 2016
Two studies presented at The Liver Meeting® 2016, and research presented in April at the International Liver Congress 2016.

Patients With HCV Who Treated With Interferon-based Therapy  
We begin with a study presented at AASLD 2016; The impact of sustained virological response to HCV infection on long term risk of hepatocellular carcinoma: the BC Hepatitis Testers Cohort, that suggested patients achieving SVR were still at risk for hepatocellular carcinoma, more specifically older patients and those with cirrhosis, commentary on the study is available over at Healio; SVR post–interferon-based therapy reduces, not eliminates risk for HCC, below is a summary of the study followed by slides @ NATAP 

Liver cancer risk reduced in patients cured of HCV
A large study found that the risk of hepatocellular carcinoma was reduced by 80% in people cured of HCV compared to those who were not cured.

This was a study of the entire population of people treated for HCV in British Columbia province, Canada, between 1990 and 2013. The study identified 8147 people treated with interferon-based regimens, 57% of whom were cured. Treated individuals were followed for a median of 5.6 years.

The liver cancer incidence was highest among those with cirrhosis who did not achieve a SVR (21 cases per 1000 patient-years of follow-up). In comparison, the liver cancer incidence was 6.4 per 1000 patient-years in those with cirrhosis who achieved SVR, 7.2 in those without cirrhosis who did not achieve SVR12 and 1.1 per 1000 patient-years in those without cirrhosis who achieved SVR12.

In a multivariable analysis liver cancer was associated with cirrhosis, age over 50 years, genotype three infection versus genotype one, alcohol consumption and being male in those who were not cured. In those who were cured of hepatitis C, only cirrhosis, age over 50 and being male were associated with an increased risk of liver cancer.

The researchers concluded that although curing HCV greatly reduces the risk of developing liver cancer, it does not eliminate the risk entirely. Older people and those with cirrhosis are at higher risk than others, underlining the importance of early diagnosis and treatment.

Reference
The impact of sustained virological response to HCV infection on long term risk of hepatocellular carcinoma: the BC Hepatitis Testers Cohort. Janjua NZ et al. The 67th Meeting of the American Association for the Study of Liver Diseases, Boston 2016. Abstract 175
Summary Source - https://www.basl.org.uk/

Review Slides

Patients With HCV Who Treated With Oral DAAs
In a prospective study presented at the 2016 AASLD; Incidence and pattern of "de novo" hepatocellular carcinoma in HCV patients treated with oral DAAs, reported that treatment with direct-acting antiviral therapy did not increase the risk of developing hepatocellular carcinoma in patients with HCV, but patients with advanced liver disease should continue to be monitored for liver cancer after treatment, here is the AASLD press release, followed by slides @ NATAP.

AASLD Press Release;
AASLD 2016 - Is There an Increased Risk of Cancer After Taking Direct-Acting Antiviral Medication?
BOSTON, Nov. 11, 2016
A new study presented this week at The Liver Meeting® — held by the American Association for the Study of Liver Diseases — found patients with hepatitis C who take direct-acting antiviral medication are at no higher risk for developing liver cancer than those who do not take the medication. However, they might be at an increased for more aggressive, infiltrative patterns of cancer, should they develop it.

"Data on clinical outcomes in cirrhotic patients with hepatitis C treated with direct-acting antiviral agents (DAAs) are still scanty and somehow controversial, and this is particularly true for development of a liver cancer, one of the most frequent and deadly complications of the disease," says Alfredo Alberti; professor of gastroenterology at University of Padova in Padova, Italy, and lead investigator in the study.

Recent studies have suggested the possibility of increased risk of developing liver cancer (hepatocellular carcinoma, or HCC) during and after DAA treatment in patients with hepatitis C (HCV). Dr. Alberti's team recently looked at the incidence of new cases of liver cancer among 3,075 HCV patients with advanced liver disease who were treated with DAAs. Almost 70 percent of the patients studied were men, and nearly 86 percent had cirrhosis (scarring of the liver). HCV genotypes one through four were all represented in the study, and patients with a past history of liver cancer were excluded.

All participants were treated with oral DAA therapy and monitored monthly. At the time of Dr. Alberti's team's analysis, patients had an average follow up of nearly 305 days from the time they started DAA therapy. During this period, the researchers found 41 patients had developed liver cancer, and the overall incidence (per 100 patient years) was 1.64.

Dr. Alberti's team further noted an incidence rate of 0.23 in patients without cirrhosis and of 1.93 in those with cirrhosis (1.93 for men and 1.94 for women). Incidence rates varied among HCV genotypes as well, with HCV-1 at the low end (1.70) and HCV-3 at the high end (2.44). Finally, cirrhotic patients with a Child-Pugh score of 'A' had an incidence rate of 1.64 and those with more advanced disease and a score of 'B' had a rate of 2.92.

"These rate incidences were not significantly different from those observed in historical control cohorts of similar patients from the same geographic area, not receiving antiviral therapy, indicating that the risk of developing HCC is not increased by oral DAAs, being closely dependent on stage of disease as in untreated cases," says Dr. Alberti.

Liver cancer was diagnosed four weeks after starting DAA therapy in three patients, at week eight in three patients, week 12 in six patients, between week 12 and 24 in thirteen patients, and after treatment ended in sixteen patients. Fifty percent of patients who developed liver cancer developed a single nodular cancer with a typical vascular pattern, while 50 percent had a more aggressive pattern. Finally, 28 out of the 41 patients who developed cancer were successfully cured of HCV (reaching a sustained virological response at 12 weeks), while the remaining 13 relapsed.

In different analyses of the data, Dr. Alberti's team found elevated liver enzymes and low platelet count to be associated with liver cancer risk, while gender, age, HCV genotype and DAA regimen were not. The best baseline predictor of liver cancer risk was APRI scores (which calculate scarring in the liver). The researchers find the risk of developing liver cancer increased linearly by 10 percent at each one-point increase in APRI value.

"The results of this study, while confirming that DAAs treatment doesn't increase the overall risk of HCC, indicate that there is no pharmacological prevention of HCC even with successful antiviral therapy, at least during the first six to 12 months after initiation of treatment when microscopic and therefore initially invisible HCC foci might even be boosted in their growth as consequence of the profound immunological and molecular changes in the liver microenvironment following abrupt cessation of HCV replication," explains Dr. Alberti. "Therefore, it is mandatory that patients treated with DAAs with advanced liver disease should continue to be monitored for HCC."

This release contains updated data. Dr. Alberti will present these findings at AASLD's press conference in Room 313 at John B. Hynes Veterans Memorial Convention Center in Boston on Saturday, November 12 at 4pm. The study entitled "Incidence and pattern of "de novo" hepatocellular carcinoma in HCV patients treated with oral DAAs" will be presented by Antonietta Romano, MD in Ballroom A on Sunday, November 13 at 10am. The corresponding abstract (number 19) can be found in the journal, Hepatology – Special Issue: The 67th Annual Meeting of the American Association for the Study of Liver Diseases: The Liver Meeting 2016.

View the slides @ NATAP Reported by Jules Levin
"Incidence and pattern of "de novo" hepatocellular carcinoma in HCV patients treated with oral DAAs"
Another look at both studies;  Incidence and pattern of `de novo` hepatocellular carcinoma in HCV patients treated with oral DAAs and The impact of sustained virological response to HCV infection on long term risk of hepatocellular carcinoma: the BC Hepatitis Testers Cohort.

Liver cancer risk reduced after hepatitis C treatment, but vigilance needed for aggressive cancers in months after treatment
Keith Alcorn
People who are cured of hepatitis C after a course of direct-acting antiviral treatment do not have a higher risk of developing liver cancer (hepatocellular carcinoma), and probably have a reduced risk, studies from Italy and Canada presented at The Liver Meeting this week in Boston have shown. However, Italian researchers also found that those people who did develop liver cancer during or shortly after antiviral treatment were more likely to develop an aggressive form of liver cancer, perhaps because of changes in immune surveillance in the liver as a result of treatment.

Patients With HCV And History Of Liver Cancer Who Treated With New Antivirals
As a reference point two studies presented in April at the International Liver Congress 2016 found; patients with a history of hepatocellular carcinoma have the highest risk of developing a tumor after direct-acting antiviral therapy, but new diagnoses were also reported. ​​Read the report; Liver Cancer Found in Hepatitis C Patients on New Antivirals provided below, or over at Medscape.

Liver Cancer Found in Hepatitis C Patients on New Antivirals
Kate Johnson
April 15, 2016
BARCELONA, Spain — In a surprising number of patients with hepatitis C and cirrhosis, hepatocellular carcinoma develops within weeks of starting treatment with direct-acting antivirals, new research suggests.

"I do not think that direct-acting antivirals are directly responsible," said lead investigator Stefano Brillanti, MD, from the University of Bologna, Italy.

"The hypothesis is that immune surveillance may be reduced too rapidly," he told Medscape Medical News. "You have an immediate drop in viremia, but also attenuation of inflammation. I think inflammation is a bad thing in terms of hepatitis progression, but it may be a good thing in terms of controlling cancer."

The study by Dr Brillanti's team, presented here at the International Liver Congress 2016, suggests that patients with hepatitis C should be closely monitored after treatment with direct-acting antivirals. Two days earlier, a study conducted by a team from the University of Barcelona in Spain suggested the same thing (J Hepatol. Published online April 12, 2016).

Both studies indicate that patients with a history of hepatocellular carcinoma have the highest risk of developing a tumor after direct-acting antiviral therapy, but new diagnoses were also reported.

The EMA has extended the scope of its review of the six direct-acting antivirals approved for use in the European Union for the treatment of chronic hepatitis  C infection to include the risk for early liver cancer recurrence, the agency reported.

Tumor Risk
"Patients with previous hepatocellular carcinoma are, of course, at risk of recurrence anyway," Dr Brillanti said. "A 30% rate over 3 years from initial surgery or ablation is normal. What was surprising to us was that we were observing 4 cm lesions after 12 weeks."

The retrospective cohort study involved 344 consecutive patients with hepatitis C and cirrhosis who were treated with one or two direct-acting antivirals and followed for 24 weeks after therapy. Median age was 63 years.
In this cohort, 237 patients were infected with hepatitis C genotype 1, 191 had received previous antiviral treatment, and 59 had been successfully treated for hepatocellular carcinoma.

Contrast-enhanced ultrasonography and CT scans or MRIs were performed at baseline to exclude active hepatocellular carcinoma, and then again 12 and 24 weeks after treatment.
During the follow-up period, 26 of the 344 patients (7.6%) were diagnosed with hepatocellular carcinoma. This included 17 of the 59 patients previously treated for hepatocellular carcinoma, and nine of the 285 patients (3.2%) with no history of carcinoma.

There was no association between recurrence and hepatitis C genotype, direct-acting antiviral regimen, or treatment response for patients who did not develop hepatocellular carcinoma or for those who did. The sustained viral response rate at 12 weeks was 89% in the two groups.
For patients with a history of hepatocellular carcinoma, those who developed a recurrence were significantly younger than those who did not (56 vs 73 years), were more frequently treatment-experienced (88.2% vs 61.9%), and had more advanced liver fibrosis at baseline.

More patients who developed hepatocellular carcinoma during the follow-up period, regardless of history, had advanced cirrhosis than those who did not, indicated by a Child-Pugh class B score (26.9% vs 10.1%; P =.02). They also had more liver stiffness, indicated by a measure above 21.3 Kpa (61.5% vs 31.8%; P = .005), and fewer platelets at baseline (102.3 vs 124.4 × 1000/mm³; P = .02).

Second Study
In the Spanish study, all 58 hepatitis C patients had a history of hepatocellular carcinoma (with complete radiologic response), and all but three were cirrhotic at the start of direct-acting antiviral therapy. After a median follow-up of 5.7 months, the rate of tumor recurrence was 27.6%, with a median time to recurrence of 3.5 months. The sustained viral response rate at 12 weeks was 97.5%.

In their publication, the Spanish authors note that these findings "raise a concern about the benefits" of direct-acting antiviral therapy in the subgroup of hepatitis C patients with a history of hepatocellular carcinoma. Although the therapies "offer a major hope for current and future patients, we may face a drawback that may change these predictions in specific groups of patients," they point out.

Dr Brillanti said he is less concerned. "Clones of the hepatocellular carcinoma were present before the therapy," he pointed out, suggesting that direct-acting antivirals simply accelerated their inevitable progression. Either way, he said, an increased risk for hepatocellular carcinoma should not deter clinicians or patients from pursuing treatment with direct-acting antivirals when it is needed.

"This is a different cancer than elsewhere in oncology — it is a cancer within an advanced chronic disease — so the prognosis, the life expectancy, is related not only to the liver cancer but also to the liver disease and liver function," he explained. "If you don't treat these patients and ameliorate their liver function, and if hepatocellular carcinoma occurs, you have no chance of curing them. But if you ameliorate liver function and they develop hepatocellular carcinoma, you can cure it better because their improved liver function will allow an ablation."

This finding is "quite striking and unexpected, but we have to be cautious," said Laurent Castera, MD, PhD, from Hôpital Beaujon in Clichy, France, who is vice-secretary of the European Association for the Study of the Liver, and was not involved with the research.

"It is potentially worrying, but these are retrospective studies, with possible referral bias, and no long-term follow-up," he told Medscape Medical News.

Dr Brillanti reports receiving research grants from Gilead Sciences and being on the advisory board for Janssen and Gilead Sciences. Dr Castera reports serving on the speaker's bureau for Echosens.
International Liver Congress (ILC) 2016: Abstract LBP506. Presented April 14, 2016.
Source - Medscape

Feb 2017
Of Interest - In The News
Risk of liver cancer low in patients with cirrhosis, study finds
01 Feb 2017
The results of a study by researchers at The University of Nottingham suggest that the risk of liver cancer in patients with cirrhosis may be much lower than previously thought.

Liver cancer – or hepatocellular carcinoma (HCC) – is one of the most serious complications of cirrhosis, or scarring of the liver, caused by long-term liver damage.

However, an analysis of health records, published in the academic journal Alimentary Pharmacology and Therapeutics, found that the 10-year incidence of HCC in UK patients with cirrhosis is actually only four per cent, or lower.

Joe West, Professor of Epidemiology in the University’s School of Medicine, led the study and believes that the results could better inform doctors on how best to focus resources for the benefit of patients with liver damage.

He said: “This very low incidence of HCC occurrence in people with cirrhosis caused by alcohol or of unknown origin suggests that surveillance for HCC among these groups is likely to benefit patients little.

“As surveillance incurs substantial cost, it is therefore unlikely to represent value for money for the NHS. There may well be other ways of spending this money that would benefit patients far more.”

Cirrhosis is caused by long-term damage to the liver, which leads to a build-up of scar tissue which replaces healthy tissue and eventually can result in liver failure.

The researchers identified more than 3,000 patients with cirrhosis of the liver using the UK’s General Practice Research Database between 1987 and 2006 and then cross-referenced this information with diagnoses of HCC on linked national cancer registries.

The study found that only 1.2 per cent of patients with alcoholic cirrhosis and 1.1 per cent of patients with cirrhosis of unknown cause will develop HCC within a decade. The highest 10-year incidence of HCC was among those with cirrhosis due to chronic viral hepatitis (four per cent).
http://www.nottingham.ac.uk/news/pressreleases/2017/january/risk-of-liver-cancer-low-in-patients-with-cirrhosis-study-finds.aspx

March 2017
Antiviral medication successful for treating HCV in hepatocellular carcinoma

Hepatocellular Carcinoma Decreases the Chance of Successful Hepatitis C Virus Therapy with Direct-Acting Antivirals
The new medications for hepatitis C have excellent cure rates. However, our study shows that in patients with both liver cancer and hepatitis C, they do not achieve these cure rates. Patients with liver cancer are almost 6 times more likely to fail hepatitis C treatment than patients without liver cancer

AGA Institute Clinical Practice Update: Care of Patients Who Have Achieved a Sustained Virologic Response (SVR) Following Antiviral Therapy for Chronic Hepatitis C Infection
Ira M. Jacobson M.D., Joseph K. Lim, M.D., and Michael W. Fried, M.D.
ACCEPTED MANUSCRIPT
DOI: http://dx.doi.org/10.1053/j.gastro.2017.03.018

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Abstract
Chronic hepatitis C virus (HCV) infection is well-recognized as a common blood borne infection with global public health impact, affecting 3 to 5 million persons in the U.S. and over 170 million persons worldwide. Chronic HCV infection is associated with significant morbidity and mortality due to complications of liver cirrhosis and hepatocellular carcinoma (HCC). Current therapies with all-oral directly acting antiviral agents (DAAs) are associated with high rates of sustained virologic response (SVR), generally exceeding 90%. SVR is associated with a reduced risk of liver cirrhosis, hepatic decompensation, need for liver transplantation, and both liver-related and all-cause mortality. However, a subset of patients who achieve SVR will remain at long-term risk for progression to cirrhosis, liver failure, HCC, and liver-related mortality. Limited evidence is available to guide clinicians on which post-SVR patients should be monitored versus discharged, how to monitor and with which tests, how frequently should monitoring occur, and for how long. In this clinical practice update, available evidence and expert opinion are used to generate best practice recommendations on the care of patients with chronic HCV who have achieved SVR.

Index
Assessment of HCV RNA after SVR12 has been attained
With the initiation of trials of DAA regimens, initially in combination with interferon and later without it, the attainment of SVR 12 weeks after completion of treatment replaced SVR24 as the primary endpoint, defined as undetectable HCV RNA on a highly sensitive PCR assay (lower limit of detection <12 IU/mL). This transition was based upon the rarity of relapse after follow up week 12, and it helped move the field ahead by shortening the intervals between successive trials in development programs (22). It has become apparent that late relapse beyond this time point is no more common, and perhaps less so, than it was after interferon-based therapy
Ongoing surveillance for hepatocellular carcinoma after SVR Is HCC risk after SVR exclusive to patients with advanced fibrosis and cirrhosis?
Can HCC surveillance ever be discontinued?
How should screening for, and management of, varices be affected by SVR?
Should patients be routinely monitored for regression of advanced fibrosis or
cirrhosis?
Recurrent HCC After SVR
Reinfection
Lifestyle Measures
Conclusions
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