William M. Lee, MD, of the Division of Digestive and Liver Diseases at the University of Texas Southwestern Medical Center at Dallas discusses the way forward for primary care.
Hepatitis C screening, surveillance, and treatment: what challenges remain for the primary care provider?
While current antiviral treatments for HCV are safe and highly effective, there are still some considerable challenges in that are relevant to the primary care practitioner. In this interview, we discuss the current state of affairs with William M. Lee, MD, the Meredith Mosle Chair in Liver Diseases and Professor of Internal Medicine in the Division of Digestive and Liver Diseases at the University of Texas Southwestern Medical Center at Dallas.
Dr. Lee and colleague Jordan Mayberry, PA-C, recently described the revolution in hepatitis C treatment, and what it means for the internist, in a review article appearing in Medical Clinics of North America. Read on as Dr. Lee discusses the challenges that remain for hepatitis C screening, surveillance, and treatment of special populations.
Patient Care: What is the most pressing challenge today for internists and other primary care providers with regard to the management of hepatitis C?
Dr Lee: I think probably the most pressing challenge now is to be sure that we're not letting patients fall through the cracks by failing to screen them for hepatitis C. The Centers for Disease Control and Prevention originally wanted us to screen all baby boomers, but we're now in the current opioid epidemic we are seeing younger patients with new infections that might be missed if hepatitis C testing is not considered. The number one goal is to stay extra vigilant about screening for hepatitis C, particularly because it's so eminently treatable.
Given the shift in demographics, should screening recommendations be reconsidered? Is there a role for universal screening?
Dr Lee: Some experts think that all individuals should be screened for hepatitis C virus (HCV) at some point, because acute infections are often unrecognized, and the risk of chronic hepatitis C is high after the initial exposure, as we noted in our recent review article. In most cases, the infection will be totally asymptomatic, and if one exposure to somebody else’s needle is enough to transmit infection, I think we eventually will come to universal testing on hospital/clinic admission, much like HIV testing. Nowadays, everybody gets tested for HIV, and I think we probably need to go to that level now with HCV. The tests are inexpensive, though to be clear, a positive antibody test just indicates exposure, and needs to be confirmed with HCV RNA testing.
Next: Biggest challenge after hep C identification
What’s the biggest challenge after hepatitis C has been identified?
If a patient with hepatitis C has any suggestion that they have cirrhosis either from prior imaging or biopsies, then they require ongoing surveillance for liver cancer even after the hepatitis C is eradicated. We still see too many cancers in people who either weren't recognized as being cirrhotic or didn’t even know that they had hepatitis C. Patients with known cirrhosis should undergo consistent surveillance for hepatocellular carcinoma, which is ideally by ultrasonography every six months. If we find tumors less than four to five centimeters, we can treat them locally. They may be resectable or can be treated with local therapy or the patient may in some instances require a liver transplant that would also be curative.
Unfortunately, even though patients may have cirrhosis on their chart, it may not trigger their doctors to order sonograms at suitable intervals. In one recent studyby my colleague Amit Singal and co-authors, fewer than 2% of patients with cirrhosis were getting consistent surveillance, defined as one ultrasound every six months. Getting one sonogram a year would probably be better than none, but that isn't ideal because the doubling time for these tumors is around six months, so it could go from two centimeters to four or five centimeters in six months’ time. Most of these tumors will be asymptomatic until they are football-sized, so they're not readily identified clinically; if you identify them when they have pain or notice a mass, it's too late.
Is treating HCV infection itself fairly straightforward now in the era of highly effective antiviral therapy? Are there any challenges left in hepatitis C treatment?
Dr Lee: Treatment is incredibly straightforward now. Amazingly, there are very few challenges left in hepatitis C. Almost everyone is cured with their first round of treatment, so it's remarkably easy. Very few have issues of compliance, failing to complete therapy correctly. The people that may have more difficulty clearing the virus are that one or two percent who have been treated in the past with interferon or earlier direct-acting antivirals. Basically, less than 1% of patients are truly refractory to treatment. The current treatment regimens are well-tolerated. There are concerns about compliance in some patient populations, such as injection drug users, but recent studies have shown that even actively injecting drug users can be effectively treated with a reasonable cure rate. So we're trying to extend treatment to every possible infected patient, partly to decrease the transmission rate from patient to patient, because that's where it comes from.
What's in store for the future of hepatitis C screening and treatment, in your opinion?
People are talking about elimination of hepatitis C, which in the short term is unrealistic, but then people also talk about micro-elimination, which means eliminating it in one area, like a township or a county. So that's the vision of the future, which is to completely eliminate this virus, like polio. What's encouraging us in that direction is the fact that once you've eradicated the virus, there doesn't seem to be any internal reservoirs where the virus is sitting, waiting to relapse. So people use the word cure, I think appropriately. It will be another generation or so before we're anywhere near even regional elimination, but getting the number of ongoing infections or new infections to zero would be a great victory.