Weekly Special: The Basics-check out these modules to learn about the basics of hepatitis C
Weekly Special: The Basics-check out these modules to learn about the basics of hepatitis C
Hepatitis C and Liver Cancer —By Alan Franciscus
Did you know…
In this article, I will focus on hepatitis C-related liver cancer—the causes, symptoms, diagnosis, prevention, and medications to delay the eventual onset of death from liver cancer.
What is Liver Cancer?
When a cell dies, an abnormal cell can take over the mechanism of the cell and grow out of control. The abnormal cells can form into cancer cells and grow into masses that can develop within an organ, can spread to nearby organs, tissues, lymph nodes and may transport themselves via the bloodstream throughout the body.
Hepatocellular cancer or hepatocellular carcinoma is the most common form of liver cancer.
The common causes of liver cancer in the United States include hepatitis C, fatty liver disease, hepatitis B, alcoholic liver disease, obesity, and diabetes. If you have more than one of these factors, it increases the risk of liver cancer especially once you develop cirrhosis. However, if you have chronic hepatitis B, you can develop liver cancer in the absence of cirrhosis. If infected with hepatitis C, liver cancer develops after severe fibrosis or cirrhosis has developed.
In early stages of liver cancer there are few symptoms. When symptoms appear they may include an ache (where the liver is located), fatigue, fever, and loss of appetite and feeling full (even after eating a small amount of food), vomiting, abnormal bruising or bleeding. Also, there may be some unexplained symptoms.
People with hepatitis C with severe fibrosis or cirrhosis should be monitored on a regular basis for liver cancer. There are three main tests—alpha-fetoprotein test (AFP), liver biopsy, and imaging tests.
The alpha-fetoprotein test (AFP) is a chemical test that may be elevated in some people with cancer. The utility of the AFP is questionable since it is a not a very accurate test for gauging liver cancer. For instance, high levels of AFP are also present in pregnant women, other forms of cancer and may not show up as elevated for liver cancer.
Liver biopsy and imaging tests are better tools for diagnosing liver cancer.
The liver biopsy does have drawbacks because it can cause bleeding and the possibility of the biopsy needle hitting a tumor. A liver biopsy could pose a risk of ‘seeding the tumor’ or spreading cancer to other parts of the liver—although this belief is controversial.
Imaging tests are the preferred way to monitor for liver cancer. The American Association for the Study of Liver Disease (AASLD) recommends two forms of imaging—computed tomography (CT scan) and magnetic resonance imaging (MRI).
CT scan is a computer-generated image of multiple x-rays of the liver that can capture different angles. CT scans use radiation to generate images. MRIs are similar but use a different technology. Both diagnostic tests are safe. Both tests require an injectable contrasting agent (ink) that will highlight blood veins and cancer tumors (if any).
The most widely used liver cancer staging system is the American Joint Committee on Cancer (AJCC) TNM method. The system includes three categories:
The stages are numbered 0 to 4: 0 is the least severe, and four is the most severe when it has spread to other organs.
There are many strategies to prevent liver cancer. For people with hepatitis C, the best option is to treat and cure hepatitis C early before severe fibrosis or cirrhosis; this will eliminate further HCV disease progression and liver cancer. People with severe fibrosis or cirrhosis, who are treated and cured, will have a reduced chance of further HCV disease progression and liver cancer.
Important strategies to further reduce the risk of liver cancer include:
There are various options to treat liver cancer—this is just a brief overview:
FDA Approved Medications
There are three medications approved by the Food and Drug Administration (FDA) to treat HCC – liver cancer:
Sorafenib Tosylate- brand name Nexavar: (pills) in clinical trials Nexavar improved overall survival by 10.7 months compared to 7.9 months for placebo.
Regorafenib-brand name Stivarga: (pills) in clinical trials Stivarga improved overall survival by 10.6 months compared to 7.8 months for placebo. It is approved to treat people who have already been treated with sorafenib (Nexavar).
Nivolumab- brand name Opidivo: (infusion) is approved for patients who had previously been treated with Nexavar. In clinical trials, Opidivo improved overall survival by 3.2 months. The clinical trial was open-label – that is there was no comparator arm. People who continued on therapy for longer periods of time continued to respond to the treatment.
There is no cure for liver cancer unless someone is lucky enough to receive a liver transplant. Liver transplants are costly, and there is a shortage of available livers to provide liver transplants to all who need them.
*Note: There are three SnapShots articles on treating people with direct-acting antivirals (DAAs) and the risk of liver cancer in the October 2017 HCV Advocate newsletter. http://hcvadvocate.org/news/NewsUpdates_pdf/Advocate_2017/advocate1017.pdf
American Cancer Society
AASLD Practice Guidelines Hepatocellular Carcinoma
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A research team at Montefiore Health System and Albert Einstein College of Medicine led by Alain Litwin, M.D., was awarded $14 million by the Patient-Centered Outcomes Research Institute (PCORI) to determine how best to treat hepatitis C among people who inject drugs (PWID), a group with a high rate of infection. A follow up portion of the study will also seek to understand why some patients develop resistance to therapies for the hepatitis C virus (HCV), which causes the damaging liver disease.
“This study has major implications for controlling hepatitis C infection and reinfection rates,” said Dr. Litwin, attending physician, internal medicine, Montefiore Health System and professor of medicine, Albert Einstein College of Medicine. “Unfortunately, people who inject drugs rarely get effective, safe treatments because there is a concern that they won’t take their medication or that they might become reinfected. Determining the best model of care will help us avert grave consequences of chronic infection for many people and reduce the spread of the virus in the communities we serve and beyond.”
The national, multi-site study, titled Patient-Centered Models of HCV Care for People Who Inject Drugs, will involve 1,000 PWID infected with HCV. Investigators will compare two models of care that have proven effective: directly observed treatment (DOT), where patients take medication in front of a staff member, and the Patient Navigator (PN) model, where patients take their medications home and receive support and education from public health workers. The research team will evaluate which model produces the best results and is preferred by patients.
This fact sheet will discuss screening, prevalence and treatment of incarcerated people infected with hepatitis C in prisons.
Jails are funded and staffed by local and state governments. People are housed
in jails for being accused of a crime or who are waiting for a trial whether they
are innocent or guilty. The length of time that people are held in jails can be
up to one year or longer. Jails typically have a more transient population. Jails
offer educational, substance abuse, and vocational (work) programs.
Jails do not routinely screen for hepatitis C and seldom, if ever, offer
treatment. But jails would be a good place to test and provide referrals to
People who are convicted of a felony are generally sentenced for a year or
more and are sent to a prison. State and federal governments operate prisons
or contract with the private prison industry. A person who is convicted of
a crime and who is incarcerated in a prison is a felon. Prisons can have a
minimum, medium, and maximum security. There are also halfway houses,
work related programs, and community restitution programs.
The average length of time a person is incarcerated is a couple of years.
The Federal Bureau of Prisons (FBOP) recommends opting-out of hepatitis C
Note: Erythema multiforme is skin disorders – it doesn’t mention whether the skin disorders are major or minor. INR are chemical tests to measure blood clotting time. The statement “Section 6: Adverse Reactions the following statement was deleted….” leads me to believe that there were some serious rashes. I will follow-up when more information is released.
VIEKIRA PAK™ (ombitasvir, paritaprevir, and ritonavir tablets, 12.5 mg/75 mg/50 mg; dasabuvir tablets, 250 mg), VIEKIRA XR (dasabuvir, ombitasvir, paritaprevir, and ritonavir), and TECHNIVIE (ombitasvir, paritaprevir, and ritonavir) labels were updated to include information pertaining to changes in International Normalized Ratio (INR) values in patients receiving warfarin.
The following sections were updated:
Note: International Normalized Ratio (INR) is a chemical test that is done to find out how long it takes the blood to clot. Atorvastatin (brand name Lipitor) is a drug to lower cholesterol. Myopathy is muscle inflammation, damage or disease.
The Sovaldi (sofosbuvir), Harvoni (ledipasvir and sofosbuvir), Epclusa (sofosbuvir and velpatasvir) and Vosevi (sofosbuvir, velpatasvir, and voxilaprevir) labels were updated to include information pertaining to changes in International Normalized Ratio (INR) values in patients receiving warfarin.
Section 7: DRUG INTERACTIONS was updated to state fluctuations in INR values may occur in patients receiving warfarin concomitant with HCV treatment. Frequent monitoring of INR values is recommended during treatment and post-treatment follow-up
The Harvoni, Epclusa, and Vosevi labels were updated to include drug interaction information when these drugs are used with atorvastatin because coadministration of these drugs with atorvastatin may be associated with increased risk of myopathy, including rhabdomyolysis and to monitor closely for HMG-CoA reductase inhibitor-associated adverse reactions, such as myopathy and rhabdomyolysis.
Section 12: CLINICAL PHARMACOLOGY was updated to state when a single 40 mg dose of atorvastatin was given with Epclusa, atorvastatin AUC and Cmax increased 54% and 68%, respectively.
OLYSIO (simeprevir), DAKLINZA (daclatasvir) and ZEPATIER (grazoprevir/elbasvir) labels were updated to include information pertaining to changes in International Normalized Ratio (INR) values in patients receiving warfarin.
Section 7: DRUG INTERACTIONS was updated to state fluctuations in INR values may occur in patients receiving warfarin concomitant with HCV treatment. Frequent monitoring of INR values is recommended during treatment and post-treatment follow-up.Share This Page