Finally, Prof. Gamal Shiha of the Egyptian
Liver Research Institute and Hospital and colleagues aimed
to develop a non-invasive scoring model for individualised HCC risk prediction
for people with advanced fibrosis or cirrhosis. He noted that a "one size
fits all" screening strategy for a growing population of people treated
for hepatitis C may not be feasible, particularly in low- and middle-income
The researchers screened more than 200,000
people for hepatitis C in 73 villages in Egypt. Of those screened, 7.8% were found
to be HCV RNA positive and offered DAA treatment. The investigators identified
2372 people with no evidence of existing liver cancer who achieved SVR and completed
at least a year of follow-up; nearly three-quarters had cirrhosis while the
rest had stage F3 fibrosis.
Over a median two years of observation, 109
people (4.6%) developed HCC after the end of treatment. All but eight already
had cirrhosis before HCV treatment initiation. Age over 54 years, male sex,
pre-treatment fibrosis stage (F4 vs F3) and AFP and albumin levels were
identified as risk factors for the development of HCC.
The researchers used these factors to
develop a GES score by assigning points for each relevant variable.
Participants were stratified into three groups with low risk (a score of 6.0 or
lower; 58%), intermediate risk (6.0-7.5; 25%) or high risk (over 7.5; 18%). The
score demonstrated high predictive accuracy, with HCC incidence rates of 1.2%
for the low risk group, 3.3% for the intermediate risk group and 7.1%for the
high risk group.
The GES score was then validated in two
other groups. In an internal cohort of 422 patients with cirrhosis and 265 with
stage F3 fibrosis, 70%, 14% and 17%, respectively, were classified low,
intermediate and high risk. Over a median nine months of observation after the
end of treatment, 14 people developed HCC: two (0.2%) in the low risk group,
two (2.1%) in the intermediate group and 10 (8.7%) in the high risk group.
In an external cohort of 947 patients with
cirrhosis and 394 with stage F3 fibrosis, 34%, 18% and 48% were deemed low,
intermediate and high risk. Over about two years of post-treatment follow-up,
only one person (0%) in the low risk group, six people (2.1%) in the
intermediate group and 39 (6.1%) in the high risk group developed HCC.
This simple GES score using readily
available parameters "can accurately stratify patients according to HCC
risk," the researchers concluded. Shiha suggested that identifying people
who will not benefit from continued HCC surveillance based on their estimated
risk could enable a personalised surveillance strategy targeting those who are
at high risk.
"These three studies reflect the complexity of
understanding hepatocarcinogenesis and refute the idea that cure of HCV is
equal to eliminating the risk of liver cancer," said Prof. Jordi Bruix of
the University of Barcelona. "The proposed scores potentially represent a
useful clinical tool to help inform patients about the risk of developing HCC
after HCV is cured. These data also reinforce the importance of implementing
HCC screening programmes in DAA-treated patients and the need to reinforce
research efforts to identify the causes of liver cancer development despite
cure of HCV."