During a presentation at the 2017 International Liver Cancer Association Annual Conference, Amit G. Singal, MD, MS, stressed that precision screening for hepatocellular carcinoma (HCC) could improve on current screening techniques through its risk-stratifying approach.
The current standard of care for HCC surveillance is ultrasound with or without serum biomarker including alpha fetoprotein. Not only is this approach highly operator-dependent, but patient characteristics such as obesity, liver nodularity and echogenicity, and presence of ascites can limit accuracy.
“The highest rates of HCC are in east Asia and Africa, primarily driven by high rates of hepatitis B in those areas. While the incidence of HCC is lower in the United States and Europe, it is gaining a lot of attention because HCC has the largest increasing incidence among all solid tumors over the past 10 years as assessed by SEER,” said Singal, medical director of the Liver Tumor Program at UT Southwestern Medical Center. “Some projections have HCC becoming a top 5 cause of cancer-related death over the next decade in the United States. One of the key ways to curb this increased mortality is to increase rates of early tumor detection and curative treatment.”
The problem with hepatitis C infections in the U.S. has several fronts: new patients from injection drug users caught up in the opioid crisis, a large population in prison that may not be getting tested and treated and a large number of Baby Boomers, many of whom don’t know they are infected, said a senior scientist with the Centers for Disease Control and Prevention.
Early intervention and timely testing and treatment could be key to addressing the problem, Dr. William Thompson said.
He spoke Thursday to the new Department of Population Health Sciences at Medical College of Georgia at Augusta University. The largest current group of people in the U.S with hepatitis C, which is estimated to be nearly 4 million, are Baby Boomers, where 3 percent have had it at some point whether they know it or not, Thompson said. Prior to 1992, when screening for it in blood products became widespread, many were unknowingly infected through transfusions.
Note: This is an awesome report that could identify much more people with hepatitis C, drive down costs and save many lives. Alan
Costs associated with treating hepatitis C could decrease substantially if the Centers for Disease Control and Prevention broadened its policy for who should receive the one-time HCV antibody test, new research has found.
A simulation performed by researchers at the University of Chicago projects that expanding the CDC’s one-time HCV testing recommendations to include patients 18 years and older could be more cost-effective, improve quality of life, and save a larger number of lives even if a low number of people are screened.
David B. Rein, PhD, program area director of the public health analytics program at the National Opinion Research Center at the University of Chicago, and leader of the study group, said patients could benefit from the policy change because it would require that they be screened earlier. “When you’re tested earlier, it doesn’t progress to more severe disease stages,” Dr. Rein said. “You avoid those [treatment] costs, and you avoid those health outcomes associated with treating later-stage hepatitis C.”
The Canadian Task Force on Preventive Health Care recommends against screening for chronic hepatitis C virus (HCV) in adults at low risk in a guideline published in CMAJ (Canadian Medical Association Journal).
“Given the lack of direct evidence that mass screening is beneficial and that patients identified by screening will either never develop symptoms of hepatitis C, or will remain well for decades after infection, we have recommended against screening for HCV in adults who are not at elevated risk,” said Dr. Roland Grad, member of the task force and chair of the guideline work group.
This is the first hepatitis C screening guideline from the task force. The task force looked for the highest-quality scientific evidence available about the effectiveness (benefits and harms) of screening to develop its recommendation. The recommendation is based on the following:
Article: Uptake of hepatitis C screening, characteristics of patients tested, and intervention costs in the BEST-C study—J E Brady et al.
Source: Hepatology. 2017 Jan;65(1):44-53. doi: 10.1002/hep.28880. Epub 2016 Nov 25.
Study Aims and Results
It is estimated that 4 of 5 HCV patients diagnoses are missed based on risk based testing—the current standard of care. Risk based HCV antibody testing includes Baby Boomer testing. In order to understand the most effective testing model a study was conducted using three interventions or testing models at different centers:
Center 1: A letter delivered to Baby Boomers by the United States Post Office advising them to be tested
Center 2: Electronic health record (EHR)-best practice alert (BPA) that would alert the medical provider to ask the patient if they wanted to be tested for hepatitis C
Center 3: Physician office based direct patient solicitation – the medical provider would ask a patient (Baby Boomer) if they wanted to be tested for hepatitis C
The goal is to increase the number of people who would be identified with HCV and compare the results to the current —risk based testing (standard of care (SOC)). The start-up costs and the costs of the antibody test were factored in to the interventions.
Electronic health record (EHR-the best practice alert (BPA) intervention was found to have the lowest incremental cost ($24.00 with fixed startup costs, $3 without) and “the lowest cost per new case identified after omitting fixed startup costs ($1691).”
Electronic health records are a good strategy to trigger a medical provider to ask patients to be tested for hepatitis C. The results of aged-based testing of hepatitis C has not been as successful in driving the undiagnosed HCV patients to medical care as originally believed. There will need to be a large investment in electronic health records as the next logical step. I have to wonder how this would be received in a physician’s office because of the time constraints that so many primary care offices are under these days.
Alan Franciscus is the Executive Director of the Hepatitis C Support Project and the Editor-in-Chief of the HCV Advocate Website
MedicalResearch.com: What is the background for this study?
Response: It is estimated that there are over 3 million people in the United States living with Hepatitis C virus (HCV) infection. Risk factors for infection include, but are not limited to, injection drug use, history of incarceration, HIV coinfection, and blood transfusion prior to July 1992. Several direct acting antiviral medications have recently been approved to treat, and in the majority of cases, cure HCV.
The first step in identifying infected persons so that they may be cured of this infection is a blood test for antibodies to HCV.
The greatest burden of HCV is among persons born from 1945 through 1965; the baby boomer birth cohort. Therefore, in 2012, the Centers for Disease Control and Prevention (CDC) published updated HCV antibody testing recommendations to include one-time testing of persons in the birth cohort. The United States Preventive Services Task Force (USPSTF) published similar recommendations the following year. Additionally, in recent years there has been an increase in HCV infections related to injection drug use among younger people.
We used commercial insurance claims data to describe trends in HCV antibody testing over a 10-year period (2005 – 2014), both to assess the impact of the CDC and USPSTF testing recommendations, and to better understanding how trends varied by gender, age group, and geography.
Tahlequah, Okla. – The Cherokee Nation has screened 23,000 Native American patients for hepatitis C, a year after becoming the first tribe in the nation to launch a hepatitis C elimination project with assistance from the U.S. Centers for Disease Control and Prevention (CDC).
Last fall, the Cherokee Nation announced its study, Optimizing Care and Setting a Path Towards Elimination of Disease and Disparity, with researchers to prevent and treat the virus.
Cherokee Nation Health Services department partnered with CDC, the Oklahoma Department of Health and the University of Oklahoma to help research and track results. The Gilead Foundation donated $1.5 million to help with screening kits and research.
A mobile testing unit will be at the Wendy’s at 2053 West Lawrence Avenue, between 4 p.m. and 8 p.m. Monday, offering free HIV and Hepatitis tests. The Ride for Aids Chicago tour in partnership with the Test Positive Aware Network will be held on July 9-10 for amateur cyclists and enthusiasts alike.