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Nguyen N, Patel K, Uhelski AC, Waters B, Weir A. Antiviral Therapy Improves Hepatocellular Cancer Survival. Fed Pract 2021; 38:e58-e63. [PMID: 34733098 DOI: 10.12788/fp.0165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Chronic hepatitis C virus (HCV) infection is a common risk factor for hepatocellular cancer (HCC). Patients with HCV infection are at a higher risk of developing HCC because the virus induces fibrosis in the liver, which may lead to cirrhosis. Early treatment of HCV and achieving a sustained virologic response (SVR) may lead to decreased incidence and mortality associated with HCC. Methods We performed a retrospective review of patients at the Memphis Veterans Affairs Medical Center (VAMC) in Tennessee from November 2008 to March 2019 to determine whether treatment of HCV infection makes a difference in overall survival (OS) among patients who develop HCC. Patients were treated with an interferon-based regimen or direct-acting antiviral agents (DAAs). Among the patients with HCV infection who were treated, we identified those who did achieve or did not achieve SVR. Results We identified 111 patients with HCV and HCC; 68 were treated for HCV infection. Forty-eight patients received DAA and 20 patients received an interferon-based regimen and 51 achieved SVR. In a multivariate analysis accounting for severity of liver disease, treated patients had an improved 5-year OS rate, median 1338 days (95% CI, 966-3202) when compared with untreated patients whose median OS was 452 days (95% CI, 242-853) (P = .0005). The treatment group had a longer median progression-free survival (PFS) than did the nontreatment group (460 days [95% CI, 294-726] vs 286 days [95% CI, 205-405], P = .04). Patients with SVR had an increased 5-year OS compared with patients without SVR (median 1973 days [95% CI, 1222-NA] vs 470 days [95% CI, 242-853], P < .001). HCV treatment type (interferon vs DAA) was not found to be associated with either OS or PFS, regardless of time period. Advanced liver disease stage as characterized by a high model for end-stage liver disease (MELD) score (> 10) or high Child-Pugh score (B or C) was associated with worse survival outcome. Conclusions A retrospective analysis of patients with HCV infection and HCC confirms that treatment of HCV infection leads to OS benefit among patients with HCC. We further demonstrate that patients with HCV infection who achieve SVR have an OS benefit over patients unable to achieve SVR. The type of treatment, DAA vs an interferon-based regimen, did not show a significant survival benefit.
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Affiliation(s)
- Ngan Nguyen
- is a Gastroenterologist in the Gastroenterology & Hepatology Department; and is a Hematologist Oncologist, Section Chief Hematology/Oncology, both at the Memphis Veteran Affairs Medical Center in Tennessee. is a Medicine Resident Physician at Johns Hopkins Osler in Baltimore Maryland. Bradford Waters and Alva Weir are Professors; and and are Hematology Oncology Fellows, all at the University of Tennessee Health Science Center, in Memphis
| | - Kruti Patel
- is a Gastroenterologist in the Gastroenterology & Hepatology Department; and is a Hematologist Oncologist, Section Chief Hematology/Oncology, both at the Memphis Veteran Affairs Medical Center in Tennessee. is a Medicine Resident Physician at Johns Hopkins Osler in Baltimore Maryland. Bradford Waters and Alva Weir are Professors; and and are Hematology Oncology Fellows, all at the University of Tennessee Health Science Center, in Memphis
| | - Anna Carson Uhelski
- is a Gastroenterologist in the Gastroenterology & Hepatology Department; and is a Hematologist Oncologist, Section Chief Hematology/Oncology, both at the Memphis Veteran Affairs Medical Center in Tennessee. is a Medicine Resident Physician at Johns Hopkins Osler in Baltimore Maryland. Bradford Waters and Alva Weir are Professors; and and are Hematology Oncology Fellows, all at the University of Tennessee Health Science Center, in Memphis
| | - Bradford Waters
- is a Gastroenterologist in the Gastroenterology & Hepatology Department; and is a Hematologist Oncologist, Section Chief Hematology/Oncology, both at the Memphis Veteran Affairs Medical Center in Tennessee. is a Medicine Resident Physician at Johns Hopkins Osler in Baltimore Maryland. Bradford Waters and Alva Weir are Professors; and and are Hematology Oncology Fellows, all at the University of Tennessee Health Science Center, in Memphis
| | - Alva Weir
- is a Gastroenterologist in the Gastroenterology & Hepatology Department; and is a Hematologist Oncologist, Section Chief Hematology/Oncology, both at the Memphis Veteran Affairs Medical Center in Tennessee. is a Medicine Resident Physician at Johns Hopkins Osler in Baltimore Maryland. Bradford Waters and Alva Weir are Professors; and and are Hematology Oncology Fellows, all at the University of Tennessee Health Science Center, in Memphis
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Nabulsi NA, Martin MT, Sharp LK, Koren DE, Teply R, Zuckerman A, Lee TA. Predicting Treatment Failure for Initiators of Hepatitis C Virus Treatment in the era of Direct-Acting Antiviral Therapy. Front Pharmacol 2020; 11:551500. [PMID: 33364936 PMCID: PMC7751639 DOI: 10.3389/fphar.2020.551500] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 10/05/2020] [Indexed: 12/18/2022] Open
Abstract
Introduction: Hepatitis C virus (HCV), the leading cause of advanced liver disease, has enormous economic burden. Identification of patients at risk of treatment failure could lead to interventions that improve cure rates. Objectives: Our goal was to develop and evaluate a prediction model for HCV treatment failure. Methods: We analyzed HCV patients initiating direct-acting antiviral therapy at four United States institutions. Treatment failure was determined by lack of sustained virologic response (SVR) 12 weeks after treatment completion. From 20 patient-level variables collected before treatment initiation, we identified a subset associated with treatment failure in bivariate analyses. In a derivation set, separate predictive models were developed from 100 bootstrap samples using logistic regression. From the 100 models, variables were ranked by frequency of selection as predictors to create four final candidate models, using cutoffs of ≥80%, ≥50%, ≥40%, and all variables. In a validation set, predictive performance was compared across models using area under the receiver operating characteristic curve. Results: In 1,253 HCV patients, overall SVR rate was 86.1% (95% CI = 84.1%, 88.0%). The AUCs of the four final candidate models were: ≥80% = 0.576; ≥50% = 0.605; ≥40% = 0.684; all = 0.681. The best performing model (≥40%) had significantly better predictive ability than the ≥50% (p = 0.03) and ≥80% models (p = 0.02). Strongest predictors of treatment failure were older age, history of hepatocellular carcinoma, and private (vs. government) insurance. Conclusion: This study highlighted baseline factors associated with HCV treatment failure. Treatment failure prediction may facilitate development of data-driven clinical tools to identify patients who would benefit from interventions to improve SVR rates.
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Affiliation(s)
- Nadia A Nabulsi
- University of Illinois at Chicago College of Pharmacy, Chicago, IL, United States
| | - Michelle T Martin
- University of Illinois at Chicago College of Pharmacy, Chicago, IL, United States.,University of Illinois Hospital and Health Sciences System, Chicago, IL, United States
| | - Lisa K Sharp
- University of Illinois at Chicago College of Pharmacy, Chicago, IL, United States
| | - David E Koren
- Temple University Hospital, Philadelphia, PA, United States
| | - Robyn Teply
- Creighton University School of Pharmacy and Health Professions, Omaha, NE, United States
| | - Autumn Zuckerman
- Vanderbilt University Medical Center - Specialty Pharmacy Services, Nashville, TN, United States
| | - Todd A Lee
- University of Illinois at Chicago College of Pharmacy, Chicago, IL, United States
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Darvishian M, Wong S, Binka M, Yu A, Ramji A, Yoshida EM, Wong J, Rossi C, Butt ZA, Bartlett S, Pearce ME, Samji H, Cook D, Alvarez M, Chong M, Tyndall M, Krajden M, Janjua NZ. Loss to follow-up: A significant barrier in the treatment cascade with direct-acting therapies. J Viral Hepat 2020; 27:243-260. [PMID: 31664755 DOI: 10.1111/jvh.13228] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 09/19/2019] [Accepted: 10/22/2019] [Indexed: 12/15/2022]
Abstract
Effectiveness of direct-acting antiviral (DAA) therapies could be influenced by patient characteristics such as comorbid conditions, which could lead to premature treatment discontinuation and/or irregular medical follow-ups. Here, we evaluate loss to follow-up and treatment effectiveness of sofosbuvir/ledipasvir ± ribavirin (SOF/LDV ± RBV), ombitasvir/paritaprevir/ritonavir + dasabuvir ± ribavirin (OBV/PTV/r + DSV ± RBV) for hepatitis C virus (HCV) genotype 1 (GT1) and sofosbuvir + ribavirin (SOF + RBV) for genotype 3 (GT3) in British Columbia Canada: The British Columbia Hepatitis Testers Cohort includes data on individuals tested for HCV since 1992, integrated with medical visit, hospitalization and prescription drug data. HCV-positive individuals who initiated DAA regimens, irrespective of treatment completion, for GT1 and GT3 until 31 December, 2017 were included. Factors associated with sustained virological response (SVR) and loss to follow-up were assessed by using multivariable logistic regression models. In total 4477 individuals initiated DAAs. The most common prescribed DAA was SOF/LDV ± RBV with SVR of 95%. The highest SVR of 99.5% was observed among OBV/PTV/r + DSV-treated patients. Overall, 453 (10.1%) individuals were lost to follow-up. Higher loss to follow-up was observed among GT1 patients treated with OBV (17.8%) and GT3 patients (15.7%). The loss to follow-up rate was significantly higher among individuals aged <60 years, those with a history of injection drug use (IDU), on opioid substitution therapy and with cirrhosis. Our findings indicate that loss to follow-up exceeds viral failure in HCV DAA therapy and its rate varies significantly by genotype and treatment regimen. Depending on the aetiology of lost to follow-up, personalized case management for those with medical complications and supporting services among IDU are needed to achieve the full benefits of effective treatments.
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Affiliation(s)
- Maryam Darvishian
- BC Centre for Disease Control, Vancouver, BC, Canada.,University of British Columbia, Vancouver, BC, Canada.,BC Cancer Research Centre, Vancouver, BC, Canada.,Population Oncology, Vancouver, BC, Canada
| | - Stanley Wong
- BC Centre for Disease Control, Vancouver, BC, Canada
| | - Mawuena Binka
- BC Centre for Disease Control, Vancouver, BC, Canada
| | - Amanda Yu
- BC Centre for Disease Control, Vancouver, BC, Canada
| | - Alnoor Ramji
- University of British Columbia, Vancouver, BC, Canada
| | - Eric M Yoshida
- Division of Gastroenterology of the Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jason Wong
- BC Centre for Disease Control, Vancouver, BC, Canada.,University of British Columbia, Vancouver, BC, Canada
| | - Carmine Rossi
- BC Centre for Disease Control, Vancouver, BC, Canada.,University of British Columbia, Vancouver, BC, Canada
| | - Zahid A Butt
- BC Centre for Disease Control, Vancouver, BC, Canada.,University of British Columbia, Vancouver, BC, Canada
| | - Sofia Bartlett
- BC Centre for Disease Control, Vancouver, BC, Canada.,University of British Columbia, Vancouver, BC, Canada
| | - Margo E Pearce
- BC Centre for Disease Control, Vancouver, BC, Canada.,University of British Columbia, Vancouver, BC, Canada
| | - Hasina Samji
- BC Centre for Disease Control, Vancouver, BC, Canada.,Simon Fraser University, Burnaby, BC, Canada
| | - Darrel Cook
- BC Centre for Disease Control, Vancouver, BC, Canada
| | - Maria Alvarez
- BC Centre for Disease Control, Vancouver, BC, Canada
| | - Mei Chong
- BC Centre for Disease Control, Vancouver, BC, Canada
| | - Mark Tyndall
- BC Centre for Disease Control, Vancouver, BC, Canada.,University of British Columbia, Vancouver, BC, Canada
| | - Mel Krajden
- BC Centre for Disease Control, Vancouver, BC, Canada.,University of British Columbia, Vancouver, BC, Canada
| | - Naveed Z Janjua
- BC Centre for Disease Control, Vancouver, BC, Canada.,University of British Columbia, Vancouver, BC, Canada
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Health-related quality of life in hepatitis C patients who achieve sustained virological response to direct-acting antivirals: a comparison with the general population. Qual Life Res 2019; 28:1477-1484. [PMID: 30666549 DOI: 10.1007/s11136-019-02111-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2019] [Indexed: 12/18/2022]
Abstract
PURPOSE To compare health-related quality of life (HRQoL) between hepatitis C patients who achieve sustained virological response (SVR) to direct-acting antivirals and a sex- and age-paired sample of the general population. METHODS HRQoL was evaluated in patients recruited in Navarre, Spain, from May 2016 to April 2017 at baseline and after SVR, using the EQ-5D-5L questionnaire. Both results were compared to those of general population of the same sex and age obtained from the 2011/12 National Health Survey in Spain. Observed/expected (O/E) ratios for health dimensions and differences between O-E in EQ-5D utility and visual analogical scale (VAS) scores were calculated. RESULTS 206 patients were studied. Before treatment, patients had more problems than the general population in every domain of EQ-5D-5L, except in self-care dimension (O/E = 1.1). After SVR, patients continued having more limitation, especially for usual activities (O/E = 3.1), anxiety/depression (O/E = 2.8) and EQ-5D utility (- 0.086, p < 0.001); however, differences in VAS score between patients and general population disappeared (74.8 vs 76.5, p = 0.210). F0-F1 patients with SVR had minor differences with the general population in EQ-5D-5L dimensions, utility and VAS score. Although cirrhotic patients also reduced that difference, they still had worse HRQoL, especially in usual activities, self-care, EQ-5D utility (- 0.152, p < 0.001) and VAS score (- 8.5, p = 0.005). CONCLUSIONS HRQoL of chronic hepatitis C patients remains lower than that of the general population despite viral clearance, with primary problems in usual activities and anxiety/depression. Knowledge of these on-going problems despite cure serves to guide healthcare interventions and patient's follow-up.
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