The other day, on Facebook, I witnessed a patient, looking for advice, be given some very poor advice. Where poor = wrong and potentially lethal. I provided some accurate commentary which was deleted, leaving a whole lot of no doubt well-meaning, but nevertheless incorrect information.
So the question to hand was “My father has sourced DAAs privately and has started taking them (< 2 weeks ago) – he has just been diagnosed with HCC and his doctor has recommended stopping the medication while TACE or RFA is done”.
The short story is that the patient’s doctor’s advice was correct, and the Facebook advice to continue DAAs was wrong.
Here is an explanation in plain English.
Patients who do not have cirrhosis have a low risk of HCC and can just be treated. They also have a low risk of any problems on treatment and a high probability of cure meaning that in a number of countries no real medical oversight is required during or after treatment.
Patients who do have cirrhosis have an approximately 1/30 chance of developing HCC every year and as a result, need monitoring tests that typically only a doctor can order.
For patients with cirrhosis and who have already had an HCC their risk of getting another one is higher than the 1/30 for a patient with cirrhosis but no history of HCC.
Hep C causes the immune system to attack the liver – that’s all the liver – normal liver and cancer liver. So when we treat with DAAs and get rid of the Hep C we make it easier for HCC to flourish.
Here are the rules:
- If you do not have cirrhosis you can just treat with DAAs and not worry too much about HCC or indeed on/post-treatment monitoring
- If you do have cirrhosis, but have never had HCC, you can treat with DAAs but you have a persistent risk of developing HCC and need regular (6 monthly) Ultrasound/CT/MRI
- If you do have cirrhosis, and have had an HCC treated with resection/TACE/RFA, you can treat with DAAs but need very close follow up (say 3 monthly US/CT/MRI) as your risk of a recurrence is significant
- If you have had a liver transplant DAA treatment itself is similar to 1 but the liver transplant needs monitoring and there are some drug-drug interactions to be aware of.
- If you have an active HCC you should defer DAA treatment until after transplant/resection/TACE/RFA because
- DAA success rates are around 74% in patients with HCC so there is a pretty high chance of treatment failure
- DAA treatment is likely to accelerate the progression of the HCC and being HepC free but dead of HCC is not a good outcome.
While rules are meant to be broken these rules have a good basis in fact. The full details of the current expert advice can be found here:
http://www.easl.eu/medias/cpg/2018/EASL%20Recommendations%20on%20Treatment%20of%20Hepatitis%20C%202018/English-report.pdf
Facebook is great for peer group support, but if you have a serious medical condition – like Hep C and cirrhosis +/- HCC you really need expert local doctor care.
