Hepatocellular carcinoma (HCC) risk stratification after virological cure for hepatitis C virus (HCV)-induced cirrhosis: time to refine predictive models

摘要

Direct-acting antivirals (DAAs) have revolutionized antiviral treatment for chronic hepatitis C virus (HCV) infection, especially with the interferon-free regimens of the past 5 years. Having a cure for a virus that has been identified (only) 30 years ago is unique in medical history. Importantly, even in case of advanced liver disease, cohort studies showed that patients attaining a sustained virological response (SVR) have a 3- to 4-fold reduced risk of hepatocellular carcinoma (HCC) (1-3). Despite this favourable perspective, the risk of HCC is not eradicated upon viral clearance among patients with cirrhosis. In fact, albeit within a biased population of predominantly male American veterans with frequent comorbidities, the annual HCC rate following SVR was substantial and appeared to remain rather stable over long periods of follow-up (4). As SVR is now increasingly achieved in HCV-infected patients with the highest risk of cirrhosis-related complications due to the general use of highly effective DAAs with good safety profile, we should expect to encounter HCC following HCV eradication more frequently in the upcoming years. Guidelines indeed recommend physicians to continue costly and intensive HCC surveillance following successful antiviral therapy in all patients with cirrhosis (5,6). As our experience with advanced liver disease and SVR increases and prolongs, research will focus on long-term individual HCC risk stratification. How can we optimize the cost-efficacy of surveillance programs? Which patients can and should be safely discharged?