The burden of hepatocellular carcinoma (HCC) appears likely to move from patients who currently have hepatitis C virus (HCV) infection to those who have previously been cured, a new modeling study suggests. "The new hepatitis C treatments offer cure but many individuals, even after cure, would remain at risk of developing HCC, the most common type of liver cancer. The main implication of our study is that the future incidence and burden of HCC will shift to these individuals who achieved cure from hepatitis C," said Dr. Jagpreet Chhatwal of the Massachusetts General Hospital Institute for Technology Assessment, in Boston. "For instance," he told Reuters Health by email, "the proportion of incident HCC cases that occur in individuals with virologically cured hepatitis C will increase from 5% in 2012 to 46% in 2040." Due to the HCV epidemic, HCC is the fastest rising cause of cancer-related mortality in the U.S., Dr. Chhatwal and colleagues note in JAMA Network Open. Most HCCs are advanced when diagnosed and median survival is less than one year. In more than 90% of patients with HCV, new direct-acting antiviral agents can result in a virological cure. However, most such patients may not subsequently undergo routine HCC surveillance because of a perceived lower risk. Nevertheless, those with advanced fibrosis or cirrhosis will remain at risk of developing HCC. To examine the implications of these circumstances, the researchers employed a previously developed mathematical model, the Hepatitis C Disease Burden Simulation model (HEP-SIM). The primary outcome was the number of patients who developed HCC and the number of patients who were candidates for routine HCC surveillance from 2012 to 2040. The model projected that the annual incidence of HCC among patients with viremia and patients with virologically cured HCV, which was 18,000 in 2012, will continue to increase to 24,000 cases until 2021. In those with virologically cured HCV, incident HCC cases are projected to increase from 1,000 in 2012 to a peak of 7,000 in 2031 followed by a decrease to 6,000 by 2040. The number of surveillance candidates with virologically cured HCV, the researchers say, is projected to rise from 106,000 in 2012 to a peak of 649,000 in 2030 and decrease to 539,000 by 2040. During the same period, the proportion of all candidates for surveillance who are virologically cured is estimated to increase from 8.5% to 64.6%. Most HCC cases will arise in patients with cirrhosis and the proportion of surveillance candidates with cirrhosis is estimated to increase from 42.8% in 2012 to 49.6% in 2040. "We need appropriate screening guidelines for hepatitis C individuals to detect HCC in early stages, when it can be treated," Dr. Chhatwal said. "The number of people needing biannual screening will also increase from 106,000 in 2012 to 640,000 in 2030. Second, the average age of HCC patients will increase and many patients may not be eligible for liver transplantation." In fact, he and his colleagues note that the average age of HCC incidence and surveillance candidates is estimated to increase from 55 years in 2012 to 72 years by 2040. The corresponding proportion of those aged 65 years or more will rise from 16.1% to 73.8%. "Appropriate management may be warranted for early detection of HCC in patients who may no longer be receiving specialty care for liver conditions," the researchers conclude. Source
