Aa
Screening for cancer after SVR
First I want to say hello and hope everyone is benefiting from all the new treatments.
I moved to Florida and found a GI that I see locally. He wants me to have an ultrasound and a blood test for AFP every six months even though I am SVR for 4 years now and my fibrosis is improving. I searched the web for treatment recommendations for SVR patients and couldn't find anything meaningful that talked about liver cancer rates after SVR.
This seems aggressive to me and not something I am willing to do without some studies that show a high risk for liver cancer after SVR.
Anyone have any data that might be useful?
Thanks,
Eric
I moved to Florida and found a GI that I see locally. He wants me to have an ultrasound and a blood test for AFP every six months even though I am SVR for 4 years now and my fibrosis is improving. I searched the web for treatment recommendations for SVR patients and couldn't find anything meaningful that talked about liver cancer rates after SVR.
This seems aggressive to me and not something I am willing to do without some studies that show a high risk for liver cancer after SVR.
Anyone have any data that might be useful?
Thanks,
Eric
Eric, for patients with stage 3 bridging fibrosis the benefit of surveillance is unknown. This is because the incidence of HCC for patients with stage 3 fibrosis have an "Incidence of HCC" " .25 LYG)(%/year) - 1.5
"Incidence of HCC" "< 1.5%/yr"
This is in contrast to patients with cirrhosis who's "Incidence of HCC"
is "< 3-8%/yr".
-----------------------------------------------------------------------
"Management of Hepatocellular Carcinoma: An Update"
...
Definition of the At-Risk Population
"The decision to enter a patient into a surveillance program is determined by the level of risk for HCC. This, in turn, is related to the incidence of HCC, and it is incidence that most people use to assess risk. However, there are no experimental data to indicate what level of risk or what incidence of HCC should trigger surveillance. Instead, decision analysis has been used to provide some guidelines as to the incidence of HCC at which surveillance may become effective. An intervention is considered effective if it provides an increase in longevity of about 100 days, i.e., about 3 months.
Although the levels were set years ago, and may not be appropriate today, interventions that can be achieved at a cost of less than about 50,000/year
of life gained are considered cost-effective.
There are now several published decision analysis/cost-effectiveness models for HCC surveillance. The models differ in the nature of the theoretical population being analyzed, and in the intervention being applied. Nonetheless, these models have several results in common.
They all find that surveillance is cost-effective, although in some cases only marginally so, and most find that the efficacy of surveillance is highly dependent on the incidence of HCC. For example, Sarasin et al.studied a theoretical cohort of patients with Child–Pugh A cirrhosis and found that if the incidence of HCC was 1.5%/year surveillance resulted in
an increase in longevity of about 3 months. However, if the incidence of HCC was 6% the increase in survival was about 9 months. This study did not include transplantation as a treatment option.
Arguedas et al.,using a similar analysis which did include liver transplantation in a population of hepatitis C patients with cirrhosis and normal liver function, found that surveillance with either CT scanning alone or CT scanning plus ultrasound became cost-effective when the incidence of HCC was more than 1.4%. However, this study has to be interpreted cautiously, because the performance characteristics of CT scanning were derived from diagnostic studies, not surveillance studies (see Surveillance Tests). Lin et al. found that surveillance with AFP and ultrasound was cost-effective regardless of HCC incidence. Thus, for patients with cirrhosis of varying etiologies, surveillance should be offered when the risk of HCC is 1.5%/year or greater. Another more recent analysis concluded that surveillance with AFP alone was the most cost-effective strategy, although a combination of AFP plus ultrasound was the most effective strategy. The authors interpreted the literature to indicate that AFP was a more sensitive surveillance test for HCC than ultrasound. Our review of the literature comes to the opposite conclusion, in that AFP (or other serological tests)
are less sensitive than ultrasound as a screening test for HCC. Their model assumes that surveillance would identify HCC’s at three different stages,: 5 cm. The target of surveillance is identification of an HCC at its earliest possible stage when treatment has the highest possible likelihood of cure.
HCC surveillance should be able to identify a lesion smaller than 3 cm, and preferably smaller than 2 cm. Therefore, this cost-effectiveness analysis overemphasizes the effect of using AFP as a surveillance test because it includes larger HCC lesions where AFP is more likely to be elevated. Other data suggest that it is rare for the AFP to be elevated in lesions that are
smaller than 2 cm in diameter.
Table 3 describes the groups of patients in which these limits are exceeded. These groups of patients are also discussed in more detail below. The above costeffectiveness analyses, which were restricted to cirrhotic populations, cannot be applied to hepatitis B carriers without cirrhosis. A cost-effectiveness analysis of surveillance for hepatitis B carriers using ultrasound and AFP levels suggested that surveillance became costeffective once the incidence of HCC exceeds 0.2%/
year (Collier J and Sherman M, unpublished observations). The subgroups of hepatitis B carriers in which the incidence of HCC exceeds 0.2%/year are given in Table 3."
Eric, I wish you much healing of your liver. You still should have plenty of functional liver so it can continue to be able to perform all of its life giving functions. I am happy for you and glad to know you have stop the HCV from impacting your quantity and quality of life. That has made my day a better one.
BTW: My sister will be my primary care giver during my transplant early next year. She will be coming here from Bridgeport. I hope to see Fairfield county again after I recover from my transplant.
凸 (^_^) 凸
Cheers!
Hector
"Incidence of HCC" "< 1.5%/yr"
This is in contrast to patients with cirrhosis who's "Incidence of HCC"
is "< 3-8%/yr".
-----------------------------------------------------------------------
"Management of Hepatocellular Carcinoma: An Update"
...
Definition of the At-Risk Population
"The decision to enter a patient into a surveillance program is determined by the level of risk for HCC. This, in turn, is related to the incidence of HCC, and it is incidence that most people use to assess risk. However, there are no experimental data to indicate what level of risk or what incidence of HCC should trigger surveillance. Instead, decision analysis has been used to provide some guidelines as to the incidence of HCC at which surveillance may become effective. An intervention is considered effective if it provides an increase in longevity of about 100 days, i.e., about 3 months.
Although the levels were set years ago, and may not be appropriate today, interventions that can be achieved at a cost of less than about 50,000/year
of life gained are considered cost-effective.
There are now several published decision analysis/cost-effectiveness models for HCC surveillance. The models differ in the nature of the theoretical population being analyzed, and in the intervention being applied. Nonetheless, these models have several results in common.
They all find that surveillance is cost-effective, although in some cases only marginally so, and most find that the efficacy of surveillance is highly dependent on the incidence of HCC. For example, Sarasin et al.studied a theoretical cohort of patients with Child–Pugh A cirrhosis and found that if the incidence of HCC was 1.5%/year surveillance resulted in
an increase in longevity of about 3 months. However, if the incidence of HCC was 6% the increase in survival was about 9 months. This study did not include transplantation as a treatment option.
Arguedas et al.,using a similar analysis which did include liver transplantation in a population of hepatitis C patients with cirrhosis and normal liver function, found that surveillance with either CT scanning alone or CT scanning plus ultrasound became cost-effective when the incidence of HCC was more than 1.4%. However, this study has to be interpreted cautiously, because the performance characteristics of CT scanning were derived from diagnostic studies, not surveillance studies (see Surveillance Tests). Lin et al. found that surveillance with AFP and ultrasound was cost-effective regardless of HCC incidence. Thus, for patients with cirrhosis of varying etiologies, surveillance should be offered when the risk of HCC is 1.5%/year or greater. Another more recent analysis concluded that surveillance with AFP alone was the most cost-effective strategy, although a combination of AFP plus ultrasound was the most effective strategy. The authors interpreted the literature to indicate that AFP was a more sensitive surveillance test for HCC than ultrasound. Our review of the literature comes to the opposite conclusion, in that AFP (or other serological tests)
are less sensitive than ultrasound as a screening test for HCC. Their model assumes that surveillance would identify HCC’s at three different stages,: 5 cm. The target of surveillance is identification of an HCC at its earliest possible stage when treatment has the highest possible likelihood of cure.
HCC surveillance should be able to identify a lesion smaller than 3 cm, and preferably smaller than 2 cm. Therefore, this cost-effectiveness analysis overemphasizes the effect of using AFP as a surveillance test because it includes larger HCC lesions where AFP is more likely to be elevated. Other data suggest that it is rare for the AFP to be elevated in lesions that are
smaller than 2 cm in diameter.
Table 3 describes the groups of patients in which these limits are exceeded. These groups of patients are also discussed in more detail below. The above costeffectiveness analyses, which were restricted to cirrhotic populations, cannot be applied to hepatitis B carriers without cirrhosis. A cost-effectiveness analysis of surveillance for hepatitis B carriers using ultrasound and AFP levels suggested that surveillance became costeffective once the incidence of HCC exceeds 0.2%/
year (Collier J and Sherman M, unpublished observations). The subgroups of hepatitis B carriers in which the incidence of HCC exceeds 0.2%/year are given in Table 3."
Eric, I wish you much healing of your liver. You still should have plenty of functional liver so it can continue to be able to perform all of its life giving functions. I am happy for you and glad to know you have stop the HCV from impacting your quantity and quality of life. That has made my day a better one.
BTW: My sister will be my primary care giver during my transplant early next year. She will be coming here from Bridgeport. I hope to see Fairfield county again after I recover from my transplant.
凸 (^_^) 凸
Cheers!
Hector
I am stage 2 now. I improved one stage since SVR. I didn't get a fibroscan yet this year, so I am hopeful there is further improvement.
I was just in Ct for a few weeks last month. It was hotter than Florida!!
Eric
I was just in Ct for a few weeks last month. It was hotter than Florida!!
Eric
So now they recommend people that are stage 2 screen for cancer? Thats a first for me.
I don't think they do. I was stage 3 - 4 transitional and that's the starting point they use. Reading Hector's post, it seems that it's prudent for me to screen for a few years until more data is available.
Best to you Eric, as its best to be safe then sorry. When you say more data available are you talking about actual liver improvement once one becomes SVR?
Have an Answer?
You are reading content posted in the Hepatitis C Community
Learn about this treatable virus.
Getting tested for this viral infection.
3 key steps to getting on treatment.
4 steps to getting on therapy.
What you need to know about Hep C drugs.
How the drugs might affect you.
These tips may up your chances of a cure.
A list of national and international resources and hotlines to help connect you to needed health and medical services.
Herpes sores blister, then burst, scab and heal.
Herpes spreads by oral, vaginal and anal sex.
STIs are the most common cause of genital sores.
Condoms are the most effective way to prevent HIV and STDs.
PrEP is used by people with high risk to prevent HIV infection.
