Highlights
- •The risk of hepatocellular carcinoma is not increased after therapy with DAAs.
- •The incidence of hepatocarcinoma declines one year after the start of therapy.
- •In our cohort, tumor incidence was higher in patients without HCV eradication.
- •Risk factors of hepatocarcinoma after DAA therapy are the same as for HCV-related cirrhosis.
Background & Aims
Direct-acting antiviral agents (DAAs) are safe and effective in patients with hepatitis
C. Conflicting data were reported on the risk of hepatocellular carcinoma (HCC) during/after
therapy with DAAs. The aim of this study was to evaluate the incidence of newly diagnosed
HCC and associated risk factors in patients with advanced hepatitis C treated with
DAAs.
Methods
The study is based on the NAVIGATORE platform, a prospectively recording database
of all patients with hepatitis C receiving DAAs in the Veneto region of Italy. The
inclusion criteria were: fibrosis stage ≥F3. The exclusion criteria were: Child-Turcotte-Pugh
(CTP)-C, liver transplantation before DAAs, history or presence of HCC, follow-up
<4 weeks after starting DAAs. A total of 3,917 out of 4,234 consecutive patients were
included, with a mean follow-up of 536.2 ± 197.6 days.
Results
Overall, HCC was diagnosed in 55 patients. During the first year, HCC incidence was
0.46% (95% CI 0.12–1.17) in F3, 1.49% (1.03–2.08) in CTP-A and 3.61% (1.86–6.31) in
CTP-B cirrhotics; in the second year, HCC incidences were 0%, 0.2%, and 0.69%, respectively.
By multivariate analysis, HCC was significantly associated with an aspartate aminotransferase
to platelet ratio ≥2.5 (hazard ratio [HR] 2.03; 95% CI 1.14–3.61; p = 0.016) and hepatitis B virus infection (HR 3.99; 1.24–12.91; p = 0.021). Failure to achieve a sustained virological response was strongly associated
with development of HCC (HR 9.09; 5.2–16.1; p = 0.0001). A total of 29% of patients with HCC had an aggressive tumor, often seen
in the early phase of treatment.
Conclusions
These data, obtained in a large, prospective, population-based study, indicate that
in patients with advanced hepatitis C receiving DAAs, the risk of “de novo” hepatocarcinoma during the first year is not higher, and might be lower, than that
of untreated patients. The risk further declines thereafter. Early hepatocarcinoma
appearance may reflect pre-existing, microscopic, undetectable tumors.
Lay summary
Hepatocellular carcinoma is one of the complications of hepatitis C related cirrhosis.
Treating patients with advanced hepatitis C with the new interferon–free direct-acting
antiviral agents has been associated with improvement in liver function and survival,
while more conflicting data have been reported regarding the risk of hepatocellular
carcinoma. We report the results of a prospective population study on the incidence
of newly diagnosed hepatocellular carcinoma in patients with advanced hepatitis C
treated with direct-acting antiviral agents, clearly indicating that the residual
hepatocellular carcinoma risk is reduced and declines progressively with time after
a sustained virological response. Development of a liver tumor during/after therapy
was associated with known risk factors and with virological failure.
Graphical abstract
Graphical Abstract
Keywords
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Article info
Publication history
Published online: March 15, 2018
Accepted:
March 5,
2018
Received in revised form:
February 25,
2018
Received:
December 3,
2017
Identification
Copyright
© 2018 Published by Elsevier B.V. on behalf of European Association for the Study of the Liver.
