Long‐term survival after surveillance and treatment in patients with chronic viral hepatitis and hepatocellular carcinoma

Abstract

Hepatocellular carcinoma (HCC) is the main cause of mortality in patients with chronic viral hepatitis (CVH). We determined the impact of surveillance and treatments on long‐term outcomes in patients with CVH who developed HCC. Between 1984 and 2014, 333 patients with HCC and with hepatitis B or hepatitis C virus infection were evaluated. An adjusted lead time bias interval was added to patients with HCC who presented with HCC (no surveillance), and their survival was compared to patients whose HCC was detected by surveillance. After HCC treatments, survival rates within and beyond 3 years of follow‐up were compared. In 175 (53%) patients, HCC was detected through surveillance using alpha‐fetoprotein and abdominal ultrasound examinations. Compared to 158 (47%) patients with HCC who had no surveillance, more patients with HCC detected by surveillance received surgical and locoregional treatments (P < 0.0001 to P < 0.001), and their 1‐, 3‐, and 5‐year overall and disease‐free survival rates were significantly higher (P < 0.001 for both). During the first 3 years of follow‐up, patients with HCC receiving liver transplantation had similar survival rates as those with liver resection or radiofrequency ablation (RFA); however, due to HCC recurrence, survival in resection and RFA patients became significantly less when followed beyond 3 years (P = 0.001 to P = 0.04). Factors associated with mortality included tumors beyond University of California at San Francisco criteria (hazard ratio [HR] 2.02; P < 0.0001), Child‐Pugh class B and C (HR, 1.58‐2.26; P = 0.043 to P = 0.015, respectively), alpha‐fetoprotein per log ng/mL increase (HR, 1.30; P < 0.0001), previous antiviral therapy in hepatitis B virus patients (HR, 0.62; P = 0.032), and treatments other than liver transplantation (HR, 2.38‐6.45; P < 0.0001 to P < 0.003). Conclusion. Patients with HCC detected by surveillance had prolonged survival. Due to HCC recurrence, survival rates after liver resection and RFA were lower when followed beyond 3 years after treatments. (Hepatology Communications 2017;1:595–608)

An expert consensus for the management of chronic hepatitis B in Asian Americans

“…The current recommendation for HCC surveillance is every 6‐12 months in immune tolerant and low replication carriers, and every 6 months in chronic hepatitis and cirrhosis patients (Figure ). In patients with persistently elevated AFP levels with undetectable lesions by ultrasound examination and in patients receiving HCC treatment, surveillance should include contrast CT scan or MRI at 3‐month intervals, which is based on the average HCC doubling time of 4.3 months …”

Tumor growth rates and recurrence-free survival in chronic viral hepatitis patients with hepatocellular carcinoma

“…Over the last two decades, improvements in HCC survival have been made by advances in HCC treatments in surgery and interventional radiology. Furthermore, the implementation of surveillance protocols in highrisk populations has resulted in early HCC detection and improved post-treatment survival [5] . Additional factors that predict HCC survival include the degree of liver dysfunction as well as the initial tumor size and number of tumors.…”

Late development of hepatocellular carcinoma after viral clearance in patients with chronic hepatitis C: A need for continual surveillance

“…Since liver‐related complications rarely occur after viral eradication, the main concern for further follow‐up in HCV patients after an SVR is the development of HCC. Recent studies have shown that although the successful treatment of HCV infection reduces disease progression to HCC, there remains an approximate risk of 1% for HCC to develop after HCV clearance …”

“…Since the risk for hepatocarcinogenesis is not fully understood following an SVR, it is crucial to be able to identify patients who are at high risk for the development of HCC so that a more evidence‐based HCC surveillance approach may be implemented. This would allow for the diagnosis of HCC at an earlier stage, thus leading to HCC treatments with more favorable outcomes . This is especially important considering that the number of patients who will achieve an SVR is expected to increase due to high cure rates with the new direct‐acting antiviral agent regimens .…”