Can surveillance for hepatocellular carcinoma (HCC) be stopped in patients with cirrhosis who have achieved sustained virologic response (SVR) in Hepatitis C (HCV)?

Surveillance for Hepatocellular Carcinoma Must Continue After SVR in Hepatitis C Patients with Cirrhosis

Patients with cirrhosis who achieve sustained virologic response (SVR) after hepatitis C virus (HCV) treatment should continue indefinite surveillance for hepatocellular carcinoma (HCC) every 6 months. This recommendation is based on strong evidence that the risk of HCC persists despite viral eradication.

Risk of HCC After SVR

Despite achieving SVR, patients with cirrhosis remain at significant risk for developing HCC:

• The 2017 EASL guidelines explicitly state that "patients with advanced fibrosis (F3) and cirrhotic patients with SVR should undergo surveillance for HCC every 6 months by means of ultrasound" 1
• The 2020 EASL update reaffirms that "patients with advanced fibrosis (F3) or cirrhosis (F4) with SVR should undergo surveillance for HCC every 6 months by means of ultrasound, because the risk of de novo or incident HCC is reduced but not abolished by SVR" 1
• The American Gastroenterological Association's 2017 clinical practice update emphasizes that "the ongoing risk of HCC in patients with pre-existing cirrhosis, although lower compared with untreated or unsuccessfully treated patients, has led to a widespread consensus that continued surveillance for HCC is warranted regardless of other risk factors" 1

Evidence for Persistent Risk

Multiple studies demonstrate that HCC risk continues for many years after SVR:

• Long-term follow-up studies show that the cumulative risk of HCC continues to rise through 15 years after achieving SVR 1
• In Japanese studies, cumulative HCC rates were 3.1%, 10.1%, and 15.9% at 5,10, and 15 years respectively after SVR 1
• A large US Veterans Affairs study found a cumulative rate of HCC after SVR in patients with cirrhosis of 1.39% per year 1
• A 2019 study showed that in patients with cirrhosis, annual HCC risk remained above 2%/year even 10 years after SVR with interferon-based treatment 2

Surveillance Protocol

The recommended surveillance protocol includes:

• Ultrasound examination every 6 months 1
• With or without alpha-fetoprotein (AFP) measurement 1
• For patients with obesity or inadequate ultrasound visualization, consider alternating MRI and ultrasound 1
• Surveillance should continue indefinitely 1

Risk Factors for HCC After SVR

Several factors are associated with higher HCC risk after SVR:

• Age ≥50-60 years at the time of SVR 1
• Male sex 1
• Advanced fibrosis (F3) or cirrhosis (F4) 1
• Elevated AFP levels (≥8-10 ng/mL) 1
• Alcohol consumption 1
• Diabetes 1
• Hispanic ethnicity 1
• HCV genotype 3 1

Clinical Pitfalls to Avoid

1. Do not discontinue surveillance based on fibrosis regression: Despite evidence of fibrosis regression after SVR, both invasive and non-invasive tools have suboptimal diagnostic accuracy for confirming complete regression 3

2. Do not rely solely on normal liver enzymes: Normal ALT after SVR does not indicate elimination of HCC risk in cirrhotic patients 1

3. Do not use inadequate imaging: In patients with obesity or poor ultrasound visualization, consider alternative imaging modalities like MRI 1

4. Do not ignore other risk factors: Patients with additional risk factors (alcohol use, diabetes, etc.) may have higher HCC risk even after SVR 1

In conclusion, while achieving SVR significantly reduces HCC risk, it does not eliminate it in patients with cirrhosis. Therefore, lifelong surveillance for HCC remains essential in this population to detect and treat HCC at an early, potentially curable stage.