Liver Cancer on the Rise in Backdrop of Undiagnosed Hep C

Neil Osterweil

April 05, 2018

PARIS — Liver cancer, one of the greatest challenges to hepatologists today, will be in the spotlight at the upcoming International Liver Congress (ILC) 2018.

It will become an even greater challenge in the near future, said Morris Sherman, PhD, from the University of Toronto, who is chair of the Canadian Liver Foundation.

"Liver cancer is increasing in most Western countries, partly because of the hepatitis C epidemic that occurred in the 1950s and 1960s," he told Medscape Medical News. "These people are now 60 to 70 years old and have had their disease a very long time. They now they are starting to come down with end-stage liver cancer."

"We're not 100% sure of this, but certainly in the United States, and probably in Canada, the majority of patients with hepatitis C have not yet been diagnosed," he added.

Although there are a handful of existing and emerging treatments for advanced hepatocellular carcinoma, they are not highly effective, he said.

"We're not going to be able to transplant everybody, so we need to be able to manage end-stage liver disease better than we currently do," Sherman explained. And there is currently a shortage of centers equipped to manage what is expected to be the burgeoning number of patients with end-stage liver cancer.

Details of new clinical practice guidelines for liver disease — including one on the management of patients with hepatocellular carcinoma — will be released by the European Association for the Study of the Liver, which is sponsoring the congress.

A session on guidelines for the management of decompensated cirrhosis and nutrition will include a panel discussion that will highlight the changes and updates that will most affect clinical practice.

Nonalcoholic Fatty Liver and Steatohepatitis

With the advent of highly effective, albeit expensive, drug regimens, there has been a decline in the use of hepatitis C infection as an indication for liver transplantation. This indicator is rapidly being replaced by nonalcoholic fatty liver and steatohepatitis.

"In the past, hepatitis C dominated liver meetings in the United States, as well as in Europe, but now we are seeing a lot more information and more drug studies about NASH and information about the natural history of nonalcoholic fatty liver disease," said Michael Fried, MD, from the University of North Carolina at Chapel Hill, who is president-elect of the American Association for the Study of Liver Diseases.

A symposium on the management of nonalcoholic fatty liver disease will address who and how to screen, noninvasive diagnostic and follow-up techniques, lifestyle interventions that can help decrease the incidence and severity of nonalcoholic steatohepatitis, and pharmacologic approaches on the near horizon.

An oral session examining nonalcoholic fatty liver disease diagnostics and noninvasive assessment will include presentations on new scoring systems for disease-related fibrosis, serum biomarkers that might help discriminate between nonalcoholic steatohepatitis and simple steatosis, and the noninvasive prediction of esophageal varices in patients with related liver cirrhosis.

Sherman, however, said he is currently skeptical about the ability of the field of hepatology to do much about this growing problem.

"Liver disease due to NASH or nonalcoholic fatty liver is getting to be a growing concern, and will likely be a major issue in the future," he told Medscape Medical News.

He noted that diagnostics and biomarkers are only relevant if actual therapies — not lifestyle interventions — are available.

"There is a growing awareness of the impact that NASH has on patients in a multisystem way," Fried said. "The interactions between diabetes and NASH, metabolic syndrome, and the impact of cardiovascular disease are all important topics. There has to be greater awareness of this, not just among hepatologists, but also among general practitioners and specialists, such as endocrinologists, who certainly will see patients who potentially have NASH."

Many Diseases, Common Symptoms

One symposium — Symptom Management Across Liver Diseases: Is There a Big Picture? — will unite clinicians and patients to address the overarching question of whether there can be a common approach to treating the symptoms of many different types of liver disease, such as fatigue, pruritus, mental health issues, and quality-of-life concerns.

Two central questions will be addressed during the symposium, which is sponsored by the European Liver Patients' Association: Are some approaches helpful to the management of symptoms across different liver diseases, regardless of diagnosis? And how do symptoms, their causes, and management options differ in relation to the underlying disease and even the individual patient?

This might be a bigger challenge than many realize, Sherman told Medscape Medical News.

"There are a variety of symptoms that have been attributed to liver disease," he noted. "Most of them are not specific and, really, the liver has so much reserve that you really only start getting symptoms that you can definitely attribute to the liver when the liver starts to fail."

Although hepatitis C infection has gotten the bulk of attention in recent years, hepatitis B virus infection "remains a major public health issue worldwide, despite the availability of an effective vaccine and potent antiviral treatments that are able to suppress viral replication," according to the congress program.

One symposium — Current Management and Emerging Treatment in HBV — will address some of the most important issues related to hepatitis B, such as the prevention and treatment of infection with limited resources, whether is it a wise strategy to stop nucleoside analogs before the hepatitis B surface antigen is lost, and upcoming immunologic and antiviral treatment strategies.

During the grand rounds session, tag teams that consist of senior faculty members from major European institutions and their junior colleagues will present challenging cases of broad interest to hepatologists, including primary biliary cholangitis, cirrhosis complications, hepatocellular carcinoma in noncirrhotic liver, fatty liver in a lean patient, and severe alcoholic hepatitis.

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