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[33,34]
[33,34,36,37]
[33,36]
[33,34]
[34,37]
Figure 1. Proposed mechanisms for lower SVR rates in HCV in the presence of HCC, compared with non-HCC HCV [34-37]
cancer evasion from the host immune system [41,42] . On reassessment of the data, the apparent increase in
HCC seen in the post-DAA population is at least in part thought attributable to bias within the patient
[44]
cohorts [33,35,43] . A recent systematic review by Waziry et al. was unable to find evidence that DAA therapy
is associated with subsequent HCC development when compared with IFN therapy, though the reviewed
studies were small, observational and sometimes lacking in useful clinical detail with significant inter-trial
heterogeneity also noted. Furthermore, when assessing overall incidence of HCC rather than recurrence
alone, the risk of developing HCC reduces by 71% in DAA-induced SVR compared with treatment
failure .
[45]
We eagerly await the outcome of ongoing clinical trials that are studying this potential association, which
aim to assess recurrence rate of HCC as well as mapping the behaviour of HCC during and after DAA
treatment of HCV [46-50] . Further research and debate are ongoing and in depth discussion on this topic is
beyond the scope of this review.
HEPATITIS C DAA TREATMENT CONSIDERATIONS BASED ON HCC THERAPY
DAAs and locoregional therapies
LRT is used with curative intention in the early stages of HCC (for example microwave ablation,
radiofrequency ablation, ethanol injection) and as palliative interventions in the intermediate/advanced
stages [for example chemoembolization, selective internal radiation therapy (SIRT), stereotactic body
[51]
radiotherapy (SBRT)] . Multiple factors should be considered when deciding whether or not to prescribe
DAAs in patients with HCC amenable to LRTs, and when.
Firstly, because LRTs are recommended only in patients with well-compensated liver disease , achieving
[51]
