- Category: Liver Cancer/HCC
- Published on Monday, 25 April 2016 00:00
- Written by Liz Highleyman
Hepatitis C patients with cirrhosis who were treated with direct-acting antivirals had about twice the expected likelihood of developing hepatocellular carcinoma (HCC), with the excess risk seen in people with a previous history of HCC, according to research presented at the recent European Association for the Study of the Liver's International Liver Congress (EASL 2016) in Barcelona. These findings underline the importance of ongoing liver cancer monitoring even after successful hepatitis C treatment.
The advent of interferon-free direct-acting antiviral (DAA) therapy has brought about a revolution in hepatitis C treatment, with more than 90% of patients achieving a cure. As with interferon-based therapy, sustained virological response (SVR) to DAA treatment -- or permanent clearance of hepatitis C virus (HCV) -- is expected to slow liver disease progression and reduce the chances of adverse outcomes such as liver cancer or decompensation, but some risk remains even after the virus is eradicated. Most HCC occurs in people who have developed cirrhosis or scarring of the liver, which can result from chronic viral hepatitis, heavy alcohol use, or other causes.
Federica Buonfiglioli and Stefano Brillanti from the University of Bologna and colleagues analyzed a cohort of hepatitis C patients with cirrhosis treated with DAAs at a referral center in Italy between March and November 2015.
The study included 344 HIV-negative participants with hepatitis C-related cirrhosis. A majority (60%) were men and the median age was 63 years. The most common HCV genotype was 1 (69%) and 55% had experienced previous treatment failure using pegylated interferon and ribavirin.
Participants had Child-Pugh class A or B cirrhosis. Child-Pugh scores are used to assess liver disease prognosis; class A indicates well-preserved liver function, class B indicates significant functional impairment, and class C indicates decompensation.
Participants were treated with interferon-free DAA regimens including:
- Sofosbuvir (Sovaldi) + simeprevir (Olysio): 34%;
- Ombitasvir/paritaprevir/ritonavir/dasabuvir (Viekira Pak or "3D"): 22%;
- Sofosbuvir + ribavirin: 17%;
- Sofosbuvir + daclatasvir (Daklinza): 16%;
- Sofosbuvir/ledipasvir (Harvoni): 10%.
At the start of the study participants did not have active liver cancer. However, 17% had a history of prior HCC treated with chemoembolization or radiation and had magnetic resonance imaging(MRI) or computed tomography (CT) scans showing no evidence of active tumors. Occurrence of HCC during the 24-week post-treatment follow-up period was assessed by ultrasonography and confirmed with MRI or CT scans.
- At 12 weeks post-treatment, 89% of patients achieved SVR12, which is considered a cure.
- Overall, active HCC was detected in 26 patients (7.6%) between the end of treatment and 24 weeks of follow-up -- 22 (85%) of whom had achieved SVR.
- Most patients (81%) had only a single detectable HCC nodule, but 5 people (19%) had multiple nodules.
- Liver cancer developed in 17 (29%) of the 59 patients with a history of previous HCC.
- However, among participants with no prior history of HCC, just 9 patients or 3.2% developed new HCC -- not much higher that the expected rate.
- Among the patients with HCC, the median age was 58 years -- younger than the study population as a whole -- and more than twice as many were men.
- People with Child Pugh class B were significantly more likely to develop HCC (although the numerical majority of those who developed HCC were class A).
- HCC was also associated with greater liver stiffness according to FibroScan and lower platelet counts.
- There was no difference in HCC occurrence or recurrence according to HCV genotype or specific DAA regimen.
- At the time HCC was detected only 2 patients (8%) had elevated levels of alpha-fetoprotein (AFP), a biomarker often measured to monitor for HCC.
"In cirrhotic patients treated with DAAs, development of HCC represents a significant clinical problem, despite a high rate of SVR," the researchers concluded. "This seems particularly true [of] those patients with a history of previous HCC, in whom a surprisingly high rate of HCC recurrence was observed, over a relatively short period of time."
"We believe our findings justify close monitoring for all cirrhotic patients on such treatments," Buonfiglioli said in an EASL press release.
Speaking at an EASL press conference, Brillanti said while a history of previous HCC was the strongest predictor of developing new HCC after DAA therapy, the reason for the unexpectedly high recurrence rate is not known -- though it is too soon to blame DAA treatment.
EASL secretary general Laurent Castera noted that a higher than expected rate of HCC recurrence was alsoseen in a recent Spanish study published online in the current edition of Journal of Hepatology.
That study, by Jordi Bruix from Hospital Clinic Barcelona and colleagues, looked at 103 hepatitis C patients with a prior history of HCC but who had achieved complete response to liver cancer treatment. Among 58 patients who achieved SVR with DAA therapy -- those treated with interferon were excluded -- 16 (28%) had a recurrence of HCC over a median follow-up period of about 23 weeks, about the same rate as in the Italian study.
"Our data show an unexpected high rate and pattern of tumor recurrence coinciding with HCV clearance and, though based in a very small cohort of patients, should be taken as a note of caution and prime a large scale assessment that exceeds the individual investigators capacity," the study authors wrote. They suggested disruption of immune surveillance may contribute to the increased risk of liver cancer recurrence in this group.
F Buonfiglioli, F Conti, A Andreone, S Brillanti, et al. Development of hepatocellular carcinoma in HCV cirrhotic patients treated with direct acting antivirals. EASL International Liver Congress 2016. Barcelona, April 13-17, 2016. Abstract GS01. Abstract LBP506.
M Reig, Z Marino, C Perello, J Bruix, et al. Unexpected early tumor recurrence in patients with hepatitis C virus -related hepatocellular carcinoma undergoing interferon-free therapy: a note of caution. Journal of Hepatology. April 12, 2016 (online ahead of print).
EASL. ILC 2016: High rate of cancer recurrence in Hepatitis C patients despite successful virus eradication by direct-acting antiviral therapy. Press release. April 13, 2016.