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Abstract Details
Long-term risk of hepatocellular carcinoma in HCV patients treated with direct acting antiviral agents
Kanwal F1,2,3, Kramer JR1,3, Asch SM4,5, Cao Y1,3, Li L6, El-Serag HB1,2. Hepatology. 2019 Jun 20. doi: 10.1002/hep.30823. [Epub ahead of print]
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Abstract
Sustained virologic response (SVR) after direct acting antiviral agents (DAA) holds promise for reducing hepatocellular cancer (HCC). DAA have recently been available long enough to estimate the long-term risk. We conducted a retrospective cohort study of HCV patients who achieved SVR with DAA from 129 Veterans Health Administration hospitals between 1/1/2015 and 12/31/2015 with follow-up through 09/30/2018. We calculated the overall and quarterly HCC incidence rates. We examined the effect of demographic, clinical, and behavioral factors and the decline or increase of FIB-4 and AST to platelet ratio index (APRI) on HCC risk. Among 18,076 patients with SVR, 544 incident cases of HCC were diagnosed during mean 2.9 years of follow-up. The cumulative 1, 2 and 3-year risks of HCC were 1.1%, 1.9% and 2.8%, respectively. Cirrhosis was strongly associated with HCC risk (adjusted hazard ratio=4.13, 95%CI=3.34-5.11). The quarterly incidence rate of HCC remained stable between 1.00 and 1.23/100 PY and 1.5 to 2.3/100 PY in patients with cirrhosis. The risk of HCC was the highest in patients who had persistently high FIB-4/APRI in both cirrhosis and non-cirrhosis patients. HCC risk fell in cirrhosis patients who experienced decrease of FIB-4/APRI scores yet remained higher than the accepted threshold for HCC surveillance. HCC risk was also higher in patients with alcohol use, older age and infection with HCV genotype 3. Most patients treated at an early stage of liver fibrosis had stable low risk. In conclusion, patients successfully treated with DAA, HCC risk did not regress after 3.6 years of follow-up. HCC risk remained above the accepted thresholds for surveillance in patients with cirrhosis. These data have important implications for HCC surveillance in cured HCV patients.