Best Practices for the Management of Hepatitis C - Episode 6

Complications of Hepatitis C: Hepatocellular Carcinoma

The panel of experts in hepatitis C continue to discuss the development of hepatocellular carcinoma in untreated patients.


  • Complications of Hepatitis C: Cirrhosis and Decompensated Cirrhosis
  • Diagnosis of Hepatitis C

Christian B. Ramers, MD, MPH, AAHIVS: We will talk later about specific drugs and indications. Is there a reason regarding which drugs you choose or whether it matters if you're decompensated or not?

Caroline Derrick, PharmD, BCPS: Protease inhibitors have a warning that we'll talk about later. Any agent that ends in -previr, which is a nice way to remember that protease inhibitors are contraindicated in decompensated disease. That's something that as pharmacists we are trying to be aware of and making sure that the delineation between compensated and decompensated is made so that our drug choice can be appropriate, so that is very important.

Christian B. Ramers, MD, MPH, AAHIVS: We just spent a couple of minutes talking about decompensation, but how common really is this in your general practice? How often do you see it?

Caroline Derrick, PharmD, BCPS: It's very uncommon. As Chris was saying, the progression to cirrhosis is somewhat uncommon, even at 10% to 30%. Then that subset population that goes on to cirrhosis, maybe 1% to 5% may decomepnsate or even less. The numbers and statistics may vary. However, it's not something that you're going to see day to day. In a specialized clinic of infectious disease practitioners, we may see it at a little bit of a higher rate. However, in your general practice it's going to be a very low chance.

Christian B. Ramers, MD, MPH, AAHIVS: If we don't scare off all our new treaters out there.

Caroline Derrick, PharmD, BCPS: Yes.

Christian B. Ramers, MD, MPH, AAHIVS: The final thing we'll talk about in this introductory section is liver cancer, also called hepatocellcular carcinoma [HCC]. Bhavesh, can you talk a little about that?

Bhavesh Shah, RPh, BCOP: Having a background in hematology-oncology, I can tell you that HCC has a very grim diagnosis. We have several treatments that are out there—immunotherapy, a lot fo tyrosine kinase inhibitors—and still to this day that 5-year overall survival is less than 10%. It's somewhere around 4% or 5%. It's a very grim diagnosis and something to be concerned about for patients with hepatitis C as a long-term outcome.

Christian B. Ramers, MD, MPH, AAHIVS: I think it's probably one of the most feared complications of hepatitis C, but actually to emphasize, this is an entirely preventable cancer. If we can diagnose people early and treat them early well before they reach cirrhosis, it's completely preventable.

I should also mention that with hepatitis C, generally patients who develop cirrhosis first before their risk for cancer really accumulates there. If we can catch people before that 10- to 30-year lag time and get their hepatitis C treated and cured, we can almost entirely prevent the liver cancer.

Christopher Hulstein, PharmD, BCPS: That was something when I was on rotation as well. The hepatologist I was working with always stated, "Not everybody with cirrhosis develops hepatocellular carcinoma, but almost everybody with hepatocellular carcinoma has cirrhosis." If you can prevent that, you'll be preventing cancer on top of that as well.