Hepatocellular carcinoma (HCC) is the fourth highest cause of cancer-related death worldwide, and incidence in the US has tripled in the last four decades. Chronic viral hepatitis is the leading pathway to HCC in the US, followed by noninfectious causes like obesity, type-2 diabetes, non-alcoholic fatty liver disease (NAFLD), and non-alcoholic steatohepatitis (NASH), which have each been growing rapidly. We will describe viral hepatitis (HCV and HBV) pathways in this blog, and the prevention, diagnosis, and treatment options for this pathway.

 

In a previous blog on HCC care considerations, we described four leading risk factors and causal pathways for the development of HCC. This blog describes the leading pathway and one that can develop quietly and insidiously. We provide some tools and resources to help you to identify HCC, ways to link your patient to suitable specialists, and to help you find appropriate studies and trials for your patient.

Four leading HCC risk factors:

  1. Hepatitis B
  2. Hepatitis C
  3. Excessive alcohol consumption
  4. Nonalcoholic fatty liver disease (NAFLD) leading to nonalcoholic steatohepatitis (NASH)

Figure 1 HCC Pathways (c) @Creativemeddose

Hepatitis B is a DNA virus and remains the main causative infectious agent of HCC. It is responsible for most liver cancer cases in Asia and Africa. Hepatitis C is an RNA virus and, sadly, a major contributor to liver cancer in Egypt, Africa, Japan, and most of the Western Hemisphere.

The pathway from HBV to HCC is both indirect and direct

    1. Indirect: Necro-inflammation and regeneration injury
    2. Direct: Integration of HBV DNA in the host genome pathways

The most effective means to prevent HBV-related HCC is vaccination, and there are interferon-based approaches for those already infected. (Michielsen & Ho, 2011)

The pathway from HCV to HCC is a multistep process. It is thought to be a combination of pathway alterations caused directly by viral factors or chronic liver inflammation. Direct-acting antivirals can reduce the rate of HCC in HCV patients (Vescovo, Refolo, Vitagliano, Fimia, & Piacentini, 2016), but no vaccine currently exists.

Figure 2 Viral HCC Pathways (c) @Creativemeddose

How you are likely to encounter HBV and HCV in patients

Approximately 78% of people with HCC also have hepatitis B and/or C. Up to 2.2 million people in the United States have hepatitis B. Approximately 4 million people in the United States have hepatitis C. For decades, HCV infection was the most common cause of HCC in the US. Due to the curative drugs on the market, this trend is changing. It should be noted that although atypical, HCC can be the result of maternal HBV or HCV infection passed on vertically to children. For example, read the medical memoir Better Off Bald: A Life in 147 Days.

HBV Risk Factors (Mayo Clinic)

  • Unprotected sex or multiple sex partners
  • Needle sharing
  • Men who have sex with other men
  • Living with someone with chronic HBV
  • Infants born to an infected mother
  • Work with exposure to human blood
  • Travel to regions with high infection rates of HBV, including Africa, Asia, Eastern Europe, Pacific Islands

HCV Risk Factors (Mayo Clinic)

  • Healthcare workers exposed to infected blood – Needle-stick, etc.
  • Ever injected or inhaled illicit drugs
  • HIV positive
  • Piercings or tattoos in an unclean environment (unsterile equipment)
  • Blood transfusion or organ transplant before 1992
  • Clotting factor concentrates before 1987
  • Hemodialysis treatments for a long period
  • Infants born to an infected mother
  • Ever in prison
  • Born between 1945 and 1965 (Highest incidence of HCV infection)

Figure 3 Viral Outcomes Pathways (c) @Creativemeddose

 

How to Discuss Staging With Patients

Discussing staging with patients can be difficult. The public literature available to patients often contains misleading information, while the most trustworthy and authoritative information is usually aimed at clinicians and often only available behind paywalls. Blue Faery provides clinically accurate materials that patients will find understandable. These materials are designed to assist physicians in describing staging and to help patients understand where they are in the spectrum.

These materials include:

  • The HCC patient education brochures, written in layman’s terms and intended for patients to read.
  • The Blue Faery HCC staging discussion pad, which contains anatomical graphics and easily understood text. Each double-sided sheet has space for clinicians to add notes for their patients to use after an appointment.
  • The Patient Resource Guide for Liver Canceris a 20-page booklet with explanations and resources pertinent to patients with HCC and their caregivers.

Blue Faery will send these free materials to any requesting physician.

How to find HCC specialists, Tx options, clinical trials

The treatment of HCC is best approached with a multidisciplinary team coordinated by a primary care physician. The most effective approach will likely require the expertise of multiple medical professionals and may include an oncologist with experience in HCC, a gastroenterologist, hepatologist, interventional radiologist, radiation oncologist, surgical oncologist, and a transplant surgeon.

To find all clinical trials, the best option is clinicaltrials.gov, but this website can be confusing and difficult to navigate. To assist clinicians in guiding patients to relevant trials, Blue Faery provides a custom HCC clinical trial navigator.

Community Support for Patients With HCC

Patient communities help provide patients with practical tips for their care journey and are often a source of emotional support by people who understand the experience.

The Blue Faery Liver Cancer Community is a free, HIPAA-compliant online community where patients and caregivers are welcome to join and to seek or exchange information relevant to HCC care. Members ask questions, discuss concerns, and find common ground as they navigate their cancer journeys. The forum moderators include community ambassadors who were former caregivers of patients with HCC.

For one-on-one patient support, Blue Faery has partnered with Imerman Angels, a nonprofit organization that provides peer-to-peer support services for the liver cancer community. Blue Faery and Imerman Angels believe that no one should face cancer alone.

Conclusion

With adequate screening, testing, and inoculation, the viral pathway to HCC can often be interrupted. To aid in the care of those who have developed HCC, Blue Faery provides free, patient-readable, and clinically accurate materials to assist clinicians in discussing their patients’ staging, options, and resources.

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