Jessica P. Hwang, MD, MPH, FACP
In 2013, the Centers for Disease Control and Prevention (CDC) and the U.S. Preventive Services Task Force (USPSTF) recommended that all people born between 1945 and 1965 undergo one-time screening for the hepatitis C virus (HCV), because the rates of HCV infection are markedly higher for baby boomers than for people in other birth cohorts.1,2 Although the exact reason is not completely understood, according to the CDC, most baby boomers are believed to have become infected in the 1960s through the 1980s, when transmission of HCV was highest.3 Both the CDC and the USPSTF also recommend screening for people at high risk for HCV infection.
However, despite these recommendations, screening remains low in these populations. A recent study investigating HCV screening rates and predictors for 4 birth cohorts, including people born before 1945, from 1945 to 1965, from 1966 to 1985, and after 1985, found that screening rates in all age groups remains low, with fewer than 13% of baby boomers screened for the virus.4 According to the CDC, about 75% of people infected with HCV were born between 1945 and 1965.5
Screening every patient with cancer is important because once HCV is diagnosed and treated, liver disease progression can be halted, and overall survival outcomes can be improved.— Jessica P. Hwang, MD, MPH, FACP
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In addition to causing liver disease, cirrhosis, and liver failure, chronic HCV infection is strongly associated with the development of several cancers, most notably liver cancer, as well as non-Hodgkin lymphoma, bile duct cancer, pancreatic cancer, and head and neck cancers. The prevalence of HCV infection in the general population is estimated to be between 1% and 1.5%. In patients with cancer, HCV infection can impact overall survival, making screening for HCV in patients with cancer critically important.
Although optimal HCV screening strategies for patients with cancer have not yet been established, 2 years ago, oncologists at The University of Texas MD Anderson Cancer Center began routinely screening all newly diagnosed patients with cancer for HCV. Patients who test positive for the virus are referred to HCV specialists who manage the disease during cancer therapy; then they undergo direct-acting antiviral therapy once their cancer therapy is completed.
The ASCO Post talked with Jessica P. Hwang, MD, MPH, FACP, Professor in the Department of Internal Medicine at The University of Texas MD Anderson Cancer Center, about the risks that HCV poses for patients with cancer, including the development of second primary cancers and worse survival outcomes.
Universal HCV Screening for Patients With Cancer
Please talk about the importance of screening all patients, especially those with liver and head and neck cancers and non-Hodgkin lymphoma, for HCV.
We know that chronic HCV infection is common in patients with cancer, particularly in these cancers, and there is anecdotal evidence linking the virus to cancers of the digestive tract, thyroid, kidneys, prostate, lungs, and nonepithelial skin. Screening every patient with cancer is important because once the virus is diagnosed and treated, liver disease progression can be halted, and overall survival outcomes can be improved. In addition, treatment of HCV infection in patients may reduce the risk of second primary cancers.
Managing Clinical Care for Patients With HCV Infection
How is care managed for patients with HCV infection? Are chemotherapy and direct-acting antiviral treatments prescribed to patients simultaneously?
HCV infection can lead to elevations in transaminase levels during the continuum of anticancer therapies, possibly delaying cancer care, and may also lead to early fibrosis development. Thus, experts recommend that direct-acting antiviral therapy be considered for patients with cancer with chronic HCV infection.6-9
We are urging physicians to refer patients with HCV infection to specialists who can help manage the disease during cancer treatment and assist with direct-acting antiviral therapy.— Jessica P. Hwang, MD, MPH, FACP
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And, no, since direct-acting antiviral agents can exacerbate chemotherapy-related anemia and interfere with the effectiveness of chemotherapy, direct-acting antiviral therapy should be started following completion of active cancer therapy. Once a patient is screened for and diagnosed with HCV, notification goes to physicians in our infectious diseases group. They then consult with the patient’s oncologist on how best to manage care, including sending the patient to an HCV specialist for evaluation and a determination of the best timing for initiation of the direct-acting antiviral therapy, which can fully eradicate the virus from the patient’s body.
Improving Survival in Patients With Head and Neck Cancers
How does infection with HCV impact cancer survival outcomes? Is survival worse in patients with head and neck cancers?
We do not have conclusive data on how the virus affects cancer survival. However, a study by my colleagues, Harrys A. Torres, MD, FACP, FIDSA [Associate Professor, Department of Infectious Diseases at The University of Texas MD Anderson Cancer Center], and Erich Sturgis, MD, MPH, FACS [Professor, Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center], of the impact of chronic HCV infection on the survival of patients with oropharyngeal cancer found that the 5-year overall and progression-free survival rates were significantly higher for HCV-negative patients than for HCV-positive patients. In addition, among HCV-positive patients with oropharyngeal cancer, the 5-year overall and progression-free survival rates were significantly higher for those who underwent antiviral treatment for HCV infection than for those patients who did not undergo the therapy.10
Patients who are cured of their cancer but not their HCV infection may be at increased risk for second primary cancers and other health complications.— Jessica P. Hwang, MD, MPH, FACP
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In addition, treating HCV infection in patients with non-Hodgkin lymphoma also appears to improve oncologic outcomes.11 Although the exact benefits of HCV treatment are not well known in patients with other cancers, curing the virus is likely to have long-term positive health effects beyond the prevention or slowing of damage to the liver caused by cirrhosis.
Dr. Torres, Dr. Sturgis, and I, along with members of the ASCO Cancer Prevention Committee, are helping to develop an educational commentary about the role HCV plays in patients with any type of cancer, and the statement should be published soon. First, we are advising physicians to screen every patient with cancer for HCV. Second, we are urging physicians to refer patients with HCV infection to specialists who can help manage the disease during cancer treatment and assist with direct-acting antiviral therapy.
Reducing the Risk of Second Primary Cancers
Do patients with cancer typically know whether they are infected with HCV?
An estimated 3.2 million people in the United States are infected with HCV and don’t know it, because chronic HCV infection doesn’t always cause symptoms until there is liver damage. Thus, it’s likely that most patients with cancer who have HCV infection are not aware they are infected, even in late-stage disease, when symptoms may appear.
Although symptoms of cirrhosis, such as eye and skin jaundice and abdominal swelling, are fairly easy to detect, it is important for oncologists to be mindful of the fact that early HCV infection often does not produce symptoms. Thus, it would be beneficial for every patient with cancer to be considered for HCV screening and treatment for the virus.
The good news is that once patients with HCV infection are cured of their cancer and their viral infection, they are likely to have good long-term outcomes. However, patients who are cured of their cancer but not their HCV infection may be at increased risk for second primary cancers and other health complications, so we need to do our best to screen every patient with HCV and treat every patient with HCV infection to reduce the risk of second primary cancers and improve survival outcomes. ■
DISCLOSURE: Dr. Hwang has received research funding from Gilead Sciences and Merck Sharp & Dohme.
1. Centers for Disease Control and Prevention: Hepatitis C: Why baby boomers should get tested. Available at www.cdc.gov/knowmorehepatitis/media/pdfs/factsheet-boomers.pdf. Accessed April 17, 2019.
2. Smith BD, Morgan RL, Beckett GA, et al: Hepatitis C virus testing of persons born during 1945-1965: Recommendations from the Centers for Disease Control and Prevention. Ann Intern Med 157:817-822, 2012.
3. Moyer VA: Screening for hepatitis C virus infection in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 159:349-357, 2013.
4. Kasting ML, Giuliano AR, Reich RR, et al: Hepatitis C virus screening trends: Serial cross-sectional analysis of the National Health Interview Survey Population, 2013-2015. Cancer Epidemiol Biomarkers Prev 27:503-513, 2018.
5. Centers for Disease Control and Prevention: CDC recommendation: Adults born from 1945-1965 (baby boomers) get tested for hepatitis C. Available at www.cdc.gov/hepatitis/populations/1945-1965.htm. Accessed April 17, 2019.
6. Torres HA, Shigle TL, Hammoudi N, et al: The oncologic burden of hepatitis C virus infection: A clinical perspective. CA Cancer J Clin 67:411-431, 2017.
7. Kaplan JE, Benson C, Holmes KK, et al: Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: Recommendations from the CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR Recomm Rep 58(RR-4):1-207, 2009.
8. Torres HA, McDonald GB: How I treat hepatitis C virus infection in patients with hematologic malignancies. Blood 128:1449-1457, 2016.
9. Torres HA, Chong PP, De Lima M, et al: Hepatitis C virus infection among hematopoietic cell transplant donors and recipients: American Society for Blood and Marrow Transplantation Task Force Recommendations. Biol Blood Marrow Transplant 21:1870-1882, 2015.
10. Economides MP, Amit M, Mahale PS, et al: Impact of chronic hepatitis C virus infection on the survival of patients with oropharyngeal cancer. Cancer 124:960-965, 2018.
11. Zelenetz AD, Gordon LI, Abramson JS, et al: National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology: B-Cell Lymphomas (Splenic Marginal Zone Lymphoma), version 2.2019. Available at www.nccn.org/professionals/physician_gls/default.aspx. Accessed April 17, 2019.