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Treating Hepatitis C in HCC

Panelists: Ghassan K. Abou-Alfa, MD, Memorial Sloan Kettering Cancer Center; Richard S. Finn, MD, Geffen School of Medicine at UCLA; Masatoshi Kudo, MD, PhD, Kindai University Faculty of Medicine; Arndt Vogel, MD, Hannover Medical School
Published: Tuesday, Aug 14, 2018



Transcript: 

Ghassan K. Abou-Alfa, MD: So, let’s go back to the point. Masatoshi, I’ll ask you, because exactly as we heard from Arndt, he would be keen on hearing if there is a resection to make sure we take care of the hepatitis C. Please tell us what’s your current practice in regard to treatment of hepatitis C in Japan.

Masatoshi Kudo, MD, PhD: Across all the hepatitis C patients with compensated cirrhosis or chronic hepatitis, we eradicate by antiviral therapy. And if the patient receives a resection or ablation and is still HCV positive, of course we treat with antiviral therapy. I remember another trial that performed interferon in the adjuvant setting.

Ghassan K. Abou-Alfa, MD: Correct.

Masatoshi Kudo, MD, PhD: But in the short period, there is no effect for suppressing a recurrence. For the long term, there is effect for suppressing the recurrence, which means secondary carcinogenesis was suppressed. So, with the antiviral therapy, many people think in the long run that the secondary carcinogenesis will be suppressed but not intrahepatic metastasis.

Ghassan K. Abou-Alfa, MD: No, that’s a great point that you bring up, because remember, this is one of the arguments in regard to performing transplant on patients with hepatitis C, especially because there is a concern about the bad soil, as Rich just mentioned to us per se. So, that’s a very important point. I think we probably all would agree that if we have a resection, there’s a curative intent to treat hepatitis C. But, Rich, I have a question for you. What’s your thought in regard if somebody has systemic disease and actually has advanced HCC, metastatic HCC—would you give antiviral therapy for hepatitis C?

Richard S. Finn, MD: You know, I don’t think that most people would treat those patients. There’s a cost-effective question. It’s very expensive, and these patients won’t live long enough to see a benefit from that systemic treatment.

Ghassan K. Abou-Alfa, MD: And I think there are no data anyway.

Richard S. Finn, MD: For sure.

Ghassan K. Abou-Alfa, MD: About the safety or even value.

Richard S. Finn, MD: Yes. I suspect safety is probably OK, but then again, it hasn’t been extensively studied. The studies of the DAAs excluded patients who had liver cancer. But, to be honest, as we see that there are some patients who are doing very well with some of the systemic treatments, it does come into play over time. Look, this patient is on a certain side of the curve. They’re a long survivor. Maybe it is considered for some of those patients.

Ghassan K. Abou-Alfa, MD: Fair, fair. I hear you. And, Arndt, would you treat anybody with hepatitis C if they have metastatic disease? What are your thoughts?

Arndt Vogel, MD: I think it’s really difficult to address. First of all, there are some data on patients who have metastatic disease and have received antiviral treatment, and they have shown that their response rate or sustained viral response rate is not as good as that of patients without tumors. So, it’s just around 70%. Usually we would expect almost 100%, so it’s obviously not as easy to treat these patients. They are a little bit more difficult to treat, but still, it’s a huge success rate; 70% is not bad, actually. So, should we treat patients? I don’t know. I think at the moment, we are not doing it. On the other hand, for hepatitis B, I think we can all agree that patients with hepatitis B will be treated and that they have a benefit from the treatment, and that the outcome is better for those patients who receive antiviral and antitumor treatment. I wonder, why would that be different in hepatitis C? In respect of immunosurveillance after curative treatment, I do get the point that there could be something. But if they have metastatic disease and if we have no effective drugs available and patients live longer, most likely, I could imagine that it could be worth to also treat these patients. But, clearly, to address this point, we would need prospective clinical trials.

Ghassan K. Abou-Alfa, MD: No, I hear you loud and clear. If anything, I totally agree, and we’re going to come to that point a little bit later as we talk about therapy. But for hepatitis B, by all means, we definitely have to treat. The virus has got to be under control. In regard to hepatitis C, really there’s no clear understanding. If anything, as we already heard or suggested, there are no data that really talk about treating hepatitis C in the setting of the presence of systemic HCC. As we heard from Dr. Finn, really, the data don’t even exist in that regard, because those trials excluded patients with HCC. If anything, there are even data that talk about potential that you might actually worsen the cancer by the treatment, even though this is extreme of the data that came from field reports here and there. So, I would say that the idea is that, as we also heard the suggestion, hepatitis B is an active virus. It truly can integrate in our DNA material, and getting rid of the virus would be very critical per se.

On the other hand, the hepatitis C really causes certain damage. It’s an RNA virus. It causes certain damage, and really, afterward, it’s the damage itself that becomes a problem, not the virus per se. And, as such, it’s understandable why the applicability of the usage of antiviral therapy for hepatitis C in the setting of metastatic HCC will require probably further data or further analysis or clinical trials, which we don’t have at this point in time.

Transcript Edited for Clarity 

Brought to you in part by Eisai

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Transcript: 

Ghassan K. Abou-Alfa, MD: So, let’s go back to the point. Masatoshi, I’ll ask you, because exactly as we heard from Arndt, he would be keen on hearing if there is a resection to make sure we take care of the hepatitis C. Please tell us what’s your current practice in regard to treatment of hepatitis C in Japan.

Masatoshi Kudo, MD, PhD: Across all the hepatitis C patients with compensated cirrhosis or chronic hepatitis, we eradicate by antiviral therapy. And if the patient receives a resection or ablation and is still HCV positive, of course we treat with antiviral therapy. I remember another trial that performed interferon in the adjuvant setting.

Ghassan K. Abou-Alfa, MD: Correct.

Masatoshi Kudo, MD, PhD: But in the short period, there is no effect for suppressing a recurrence. For the long term, there is effect for suppressing the recurrence, which means secondary carcinogenesis was suppressed. So, with the antiviral therapy, many people think in the long run that the secondary carcinogenesis will be suppressed but not intrahepatic metastasis.

Ghassan K. Abou-Alfa, MD: No, that’s a great point that you bring up, because remember, this is one of the arguments in regard to performing transplant on patients with hepatitis C, especially because there is a concern about the bad soil, as Rich just mentioned to us per se. So, that’s a very important point. I think we probably all would agree that if we have a resection, there’s a curative intent to treat hepatitis C. But, Rich, I have a question for you. What’s your thought in regard if somebody has systemic disease and actually has advanced HCC, metastatic HCC—would you give antiviral therapy for hepatitis C?

Richard S. Finn, MD: You know, I don’t think that most people would treat those patients. There’s a cost-effective question. It’s very expensive, and these patients won’t live long enough to see a benefit from that systemic treatment.

Ghassan K. Abou-Alfa, MD: And I think there are no data anyway.

Richard S. Finn, MD: For sure.

Ghassan K. Abou-Alfa, MD: About the safety or even value.

Richard S. Finn, MD: Yes. I suspect safety is probably OK, but then again, it hasn’t been extensively studied. The studies of the DAAs excluded patients who had liver cancer. But, to be honest, as we see that there are some patients who are doing very well with some of the systemic treatments, it does come into play over time. Look, this patient is on a certain side of the curve. They’re a long survivor. Maybe it is considered for some of those patients.

Ghassan K. Abou-Alfa, MD: Fair, fair. I hear you. And, Arndt, would you treat anybody with hepatitis C if they have metastatic disease? What are your thoughts?

Arndt Vogel, MD: I think it’s really difficult to address. First of all, there are some data on patients who have metastatic disease and have received antiviral treatment, and they have shown that their response rate or sustained viral response rate is not as good as that of patients without tumors. So, it’s just around 70%. Usually we would expect almost 100%, so it’s obviously not as easy to treat these patients. They are a little bit more difficult to treat, but still, it’s a huge success rate; 70% is not bad, actually. So, should we treat patients? I don’t know. I think at the moment, we are not doing it. On the other hand, for hepatitis B, I think we can all agree that patients with hepatitis B will be treated and that they have a benefit from the treatment, and that the outcome is better for those patients who receive antiviral and antitumor treatment. I wonder, why would that be different in hepatitis C? In respect of immunosurveillance after curative treatment, I do get the point that there could be something. But if they have metastatic disease and if we have no effective drugs available and patients live longer, most likely, I could imagine that it could be worth to also treat these patients. But, clearly, to address this point, we would need prospective clinical trials.

Ghassan K. Abou-Alfa, MD: No, I hear you loud and clear. If anything, I totally agree, and we’re going to come to that point a little bit later as we talk about therapy. But for hepatitis B, by all means, we definitely have to treat. The virus has got to be under control. In regard to hepatitis C, really there’s no clear understanding. If anything, as we already heard or suggested, there are no data that really talk about treating hepatitis C in the setting of the presence of systemic HCC. As we heard from Dr. Finn, really, the data don’t even exist in that regard, because those trials excluded patients with HCC. If anything, there are even data that talk about potential that you might actually worsen the cancer by the treatment, even though this is extreme of the data that came from field reports here and there. So, I would say that the idea is that, as we also heard the suggestion, hepatitis B is an active virus. It truly can integrate in our DNA material, and getting rid of the virus would be very critical per se.

On the other hand, the hepatitis C really causes certain damage. It’s an RNA virus. It causes certain damage, and really, afterward, it’s the damage itself that becomes a problem, not the virus per se. And, as such, it’s understandable why the applicability of the usage of antiviral therapy for hepatitis C in the setting of metastatic HCC will require probably further data or further analysis or clinical trials, which we don’t have at this point in time.

Transcript Edited for Clarity 

Brought to you in part by Eisai
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