Assessment of Incidence of and Surveillance Burden for Hepatocellular Carcinoma Among Patients With Hepatitis C in the Era of Direct-Acting Antiviral Agents

This decision analytical model study assesses the burden of hepatocellular carcinoma surveillance in the era of new hepatitis C antiviral treatments by projecting the number and the characteristics of new hepatocellular carcinoma incident cases and candidates for routine hepatocellular carcinoma surveillance. Question What are the projected changes in incidence of and surveillance burden for hepatocellular carcinoma (HCC) among populations with hepatitis C virus (HCV) in the era of direct-acting antiviral agents (DAAs)? Findings In this decision-analytical model, the incidence of HCC associated with HCV and candidates for HCC surveillance were projected to increase before starting to decrease in the era of DAAs. The burden of HCC associated with HCV was projected to shift from patients with viremia to individuals with virologically cured HCV and to older individuals. Meaning Results of this study suggest that routine HCC surveillance is needed for early detection of HCC in individuals with virologically cured hepatitis C who may no longer be receiving specialty care of liver diseases. Importance In the US, hepatocellular carcinoma (HCC), primarily associated with hepatitis C virus (HCV) infection, is the fastest rising cause of cancer-related death. Wider use of highly effective direct-acting antiviral agents (DAAs) substantially reduces the burden of chronic HCV infection, but the subsequent impacts with HCV-associated HCC remain unknown. Objective To assess projected changes in the incidence rate of and surveillance burden for HCC in the era of DAA treatment for HCV. Design, Setting, and Participants This decision analytical model study was performed from January 2019 to February 2020, using an individual-level state-transition simulation model to simulate disease progression, screening, and different waves of antiviral treatments for HCV in the US from 2012 to 2040. Interventions Current clinical management for chronic HCV infection. Main Outcomes and Measures Model outcomes were projected temporal trends and age distribution of incident HCC cases and candidates for HCC surveillance among patients with viremia and patients with virologically cured HCV. Results The simulation model projected that the annual incidence of HCC among patients with viremia and patients with virologically cured HCV will continue increasing to 24 000 (95% uncertainty interval [UI], 18 000-31 000) cases until 2021. In patients with virologically cured HCV, incident HCC cases are projected to increase from 1000 (95% UI, 500-2100) in 2012 to the peak of 7000 (95% UI, 5000-9600) in 2031 with a subsequent decrease to 6000 (95% UI, 4300-8300) by 2040. The proportion of incident HCC cases that occur in individuals with virologically cured HCV is estimated to increase from 5.3% in 2012 to 45.8% in 2040. The number of candidates for HCC surveillance in the population with virologically cured HCV is projected to increase from 106 000 (95% UI, 70 000-178 000) in 2012 to the peak of 649 000 (95% UI, 512 000-824 000) in 2030 and decrease to 539 000 (95% UI, 421 000-687 000) by 2040, while the proportion of all candidates for surveillance who are virologically cured is estimated to increase from 8.5% to 64.6% during the same period. The average age of HCC incidence and surveillance candidates is estimated to increase from 55 in 2012 to 72 and 71, respectively, by 2040. Conclusions and Relevance The results of this study suggest that the burden of HCC will shift from patients with viremia to patients with virologically cured HCV, and to older populations. Appropriate management may be warranted for early detection of HCC in patients who may no longer be receiving specialty care for liver conditions.