for Health Care Providers
3: Would you treat a case of hepatitis C compensated cirrhosis with nonmetastatic lung cancer?
Mr. C.L. is a 55-year-old African American man with hepatitis C virus (genotype 1) and a high viral load. Cirrhosis was diagnosed by biopsy 3 years ago. He drank alcohol very heavily for 20 years, but quit 4 years ago. He has a past medical history of posttraumatic stress disorder and is taking oral medications for diabetes mellitus.
Two years ago, he began treatment for hepatitis C with Pegasys and ribavirin. At one point, he had his ribavirin dosage reduced, and then used growth factors, but ultimately had to discontinue the ribavirin because of persistent anemia. He achieved an early virologic response (EVR) and was able to complete 46 weeks of Pegasys treatment without the full course of ribavirin, but he did not achieve a sustained virologic response (SVR).
However, at week 35 into his treatment, he was diagnosed with lung cancer: non-small cell carcinoma, stage Ib (T2 N0 M0). He had no metastatic findings, so he underwent resection with a right upper and middle lobectomy. His postoperative course was complicated by Staphylococcus bacteremia, prolonged intubation, tracheostomy, and a unilateral foot drop. Owing to his poor clinical status, he did not receive adjuvant chemotherapy. After a 2-month intensive care unit and hospital stay, he was discharged, but still requires home oxygen at night.
Current physical exam: No stigmata of liver disease except mild hepatomegaly.
- Alanine aminotransferase (ALT): 20-30 U/L
- Aspartate aminotransferase (AST): 20-30 U/L
- Albumin: 4.0 g/dL
- Platelet count: 130,000-140,000 cells/µL
- Alpha-fetoprotein: 4 µg/L
- Hemoglobin A1c: 5-6%
- Model End-Stage Liver Disease (MELD) score: 6
Question: It has been 2 years since the patient underwent the lung resection. He is very interested in being re-treated for hepatitis C cirrhosis. Would you re-treat?
Speaker 1: This 55-year-old African American male has well-compensated cirrhosis, genotype 1, and a high viral load. He has been previously treated with Pegasys monotherapy, but was unable to tolerate ribavirin and did not have an SVR.
Now, he has another problem. He has stage Ib non-small cell lung cancer, has undergone resection, and is on home oxygen at night.
So he wants to be re-treated for hepatitis C. Would you re-treat this patient? The poor man has gone through a lot and has recovered. His liver is actually incredible! He has had major lung surgery, and despite this, his cirrhosis has remained compensated, which means that he is a really, really well compensated cirrhotic patient.
Participant: The patient had an early virological response, but he really did not get a complete course of combination therapy, and there was no sustained response. I think it would be best to put him on a maintenance therapy with 90 µg of pegylated interferon, just so we can prevent progression into decompensation.
Speaker 1: Do we have some other discussion about this idea for maintenance with pegylated interferon?
Participant: What about the prognosis from his lung cancer?
Speaker 1: Exactly! This is really the main issue--this patient has had a lung cancer. So what we really need to know is the prediction for survival by this patient with regard to the lung cancer. We know his chances of surviving cirrhosis--in terms of that, there is a median survival rate of 10 years at this point. That gives him some time, but he was a nonresponder to treatment initially, so the chances of responding to the same course of treatment are essentially zero.
For treatment then, you are correct in saying that the only reasonable re-treatment course would be maintenance with pegylated interferon.
So now we are debating the pros and cons of maintenance interferon in compensated quiescent cirrhosis with the lung cancer.
In this situation, I think it would be overkill to re-treat the cirrhosis now that he has a major disease--lung cancer--that can lead to death much more quickly than stable cirrhosis. I think one always has to evaluate what is important in each patient's life, first and foremost. And in this man's life, the cirrhosis is a much lesser issue at this point.
Speaker 2: I agree. Even though this patient has cirrhosis, we would hold off on treatment because of the comorbidity of the lung cancer and the likelihood that the lung cancer is going to cause him more difficulty and be more likely than his hepatitis C to cause death.
Speaker 3: I think the general point is that hepatitis C is never a good thing, but sometimes it just may not be the most important thing. So, anybody with hepatitis C viremia can be considered for therapy. But even in a patient with cirrhosis, when there are other active things going on, hepatitis C may not be the main disease determining the patient's quality of life or chances of survival.
Speaker 1: Now, let's say he does not have lung cancer and has not been treated in the past. If he's a treatment-naïve patient that I find has very well compensated cirrhosis, then I would treat, and the cirrhosis itself would give me a degree of urgency in treating.
- Evaluating whether to treat hepatitis C virus (HCV) infection should always include an assessment of any comorbidities.
- When considering competing non-HCV health conditions, one should broadly consider the patient's life expectancy if the HCV is treated or if it is left untreated. If HCV treatment is not likely to improve life expectancy or quality of life because of age or competing issues, HCV treatment is not right for that patient.
- For re-treatment of HCV compensated cirrhosis with prior nonresponse or relapse, consider a regimen of low-dose pegylated interferon monotherapy (90 µg subcutaneously weekly).
- Ann Busch, Liver Transplant Clinical Nurse Specialist, Portland VAMC
- Sue Currie, Associate Director, HCRC, San Francisco VAMC
- Guadalupe Garcia-Tsao, Director, HCRC, Connecticut VAMC
- Douglas Heuman, Liver Transplant Program Director, Richmond VAMC
- Alexander Monto, Director, HCRC, San Francisco VAMC
- Roberta Ruimy, Manager, Liver/Kidney Transplant Programs, Portland VAMC
- Brenda Salvas, Health System Specialist, Manager, Liver and Kidney Transplant Program, VA Transplant Program, VA Central Office, Washington, DC
- Anna Sasaki, Staff Physician, Portland VAMC
- Kristine Stick, Nurse Practitioner for Hepatology, San Francisco VAMC
- Suchat Wongcharatrawee, Associate Director HCRC, Connecticut VAMC
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