Screenings are Important

Screening also plays an important role in reducing the risk of liver cancer in patients with HCV, as well as offering the possibility of early detection. For example, getting tested for HIV is recommended, especially in light of the “very-effective therapies” that have been developed, Ross said.

The American Association for the Study of Liver Diseases recommends that people who are at risk for liver cancer get screened for it every six months. Ross noted that this often involves abdominal ultrasound and an AFP (Alpha-Fetoprotein) blood test and said VA provides specific guidance for providers on how to use these tools.

In a report issued in April 2010 entitled “Hepatitis and Liver Cancer: Information for Healthcare Providers,” the Institute of Medicine echoed that sentiment, stating: “As most chronically infected people are unaware of their infection, it will be necessary to expand screening programs to identify those who are infected and help them find medical services.”

This approach has proven effective, says Ross, noting that VA keeps data on how much screening is done. As of 2008, he reports, the rate of surveillance was in the neighborhood of 60% -- a significant increase over past performance and much higher than the average rate of about 20% outside of VA. 

New Antivirals Raise Hopes 

The standard treatment for patients with HCV could soon change dramatically with the recent FDA approval of HCV protease inhibitors, which Ross called “game changers.”

“The arrival of the new antiviral treatment for HCV is a major breakthrough,” added El-Serag.

Until this year, Ross explained, the standard treatment was a combination of two drugs – pegylated interferon and ribavirin – given for anywhere from six months to a year, depending on which of the four major strains of HCV the patient had. While clinical trials for FDA approval showed a cure rate of about 50%, “In our populations, we probably see cure rates in the neighborhood of 20% to 25%,” said Ross, noting that cure rates are always lower “in the real world.”

While the virus is permanently eradicated when such treatments are successful, the medications are extremely toxic. “It’s like having a bad, bad flu for years; a lot of patients can’t take it,” Ross pointed out. “People get anemic and severely depressed.”

The new approach involves using this pair of drugs in combination with one of the two protease inhibitors. In clinical trials for one of the drugs – telaprevir – the cure rate was 79%, compared with 44% for the standard approach (the other drug is boceprivir). (NEJM June 23, 2010: Telaprevir for Previously Untreated Chronic Hepatitis C Virus Infection.) However, Ross said, there were additional side-effects, including an uncomfortable rash. “But the willingness of patients to take this risk may increase, now that the chances of a cure have gone up.”

VA’s current national-treatment recommendations for HCV were published in 2006, but, because of these new drugs, said Ross, it is being revised. “We hope the new recommendations will be published in the next few months or so,” he added.

In the meantime, according to El-Serag, most VA hospitals have started implementing protocols for this treatment. 

“The VA liver-transplant centers are also major advantages for the VA system, because they offer a potentially curative treatment for some patients with HCC,” he continued, noting that medical treatment with sorafenib has become available for select patients with advanced HCC disease. El-Serag said active research is under way to both expand the indications of sorafenib and to test other new medications.  

In the absence of advanced hepatic fibrosis or cirrhosis, cure from HCV virtually eliminates the risk of HCC, El-Serag pointed out, adding, “Unfortunately, however, a considerable proportion of patients -- especially veterans -- either have already advanced hepatic fibrosis or do not receive antiviral treatment.”

In a subgroup of patients who are diagnosed with early-stage disease (e.g., one small nodule in a patient with compensated cirrhosis), “receipt of potentially curative treatment such as liver resection or liver transplant is associated with dramatically improved survival of up to 70% at five years,” he added.

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