In patients who have received successful treatment for HCV-related hepatocellular carcinoma (HCC), eradication of the HCV infection with direct-acting antiviral (DAA) significantly reduces risk of death, researchers report in the November issue of Gastroenterology.
Chronic hepatitis C virus (HCV) infection is the most common cause of HCC in North America and Europe. DAA agents cure HCV infection and also reduce the incidence and mortality of HCC in patients with HCV infection. However, it is not clear whether DAA therapy prevents HCC recurrence in patients who had a complete response to their cancer treatment.
There have been contradictory results from studies to determine the risk of HCC recurrence after DAA therapy. In a study of a large cohort of patients with complete response to HCC treatment, DAA therapy was not associated with overall or early HCC recurrence. HCC recurrence patterns, including treatment response, were similar in DAA-treated and -untreated patients.
Amit G. Singal et al conducted a retrospective cohort study of patients with HCV-related HCC who achieved a complete response to resection, local ablation, transarterial chemo- or radioembolization (TACE) or bland embolization, transarterial radioembolization, or stereotactic body radiation therapy for the liver cancer. These authors wanted to find out if eradication of HCV infection after successful cancer treatment increased chances of survival.
Of 797 patients with HCV-related HCC, 383 (48.1%) received DAA therapy and 414 (51.9%) did not receive treatment for their HCV infection after complete response to prior HCC therapy. Among the DAA-treated patients, 43 deaths occurred during 941 person-years of follow up, compared with 103 deaths during 526.6 person-years of follow-up among patients who did not receive DAA therapy.
In inverse probability-weighted analyses, DAA therapy was associated with a 44% reduction in risk of death (see figure). This association differed by sustained virologic response to DAA therapy: risk of death was reduced by 71% in patients with sustained virologic response to DAA therapy but not in patients without a sustained virologic response
DAA therapy was associated with increased survival of patients with Child–Pugh A or B cirrhosis—it was a challenge to assess survival of patients with Child C cirrhosis because of the small sample size. Singal et al also observed a consistent benefit of DAA therapy among patients who initially had tumor burden within and beyond Milan Criteria. The reduction in mortality with DAA therapy was greater in patients who received resection or ablation than in patients who received TACE.
In a separate article in the same issue, George N. Ioannou et al report that patients with cirrhosis before a sustained virologic response to treatment for HCV infection continue to have a high risk for HCC (more than 2% per year) for many years, even if their FIB-4 score decreases. These patients should continue surveillance. Patients without cirrhosis but with FIB-4 scores of 3.25 or more have a high enough risk to consider HCC surveillance—especially if FIB-4 scores remain at 3.25 or more following a sustained virologic response to treatment.