Nicole E Rich1, Ju Dong Yang2, Ponni V Perumalswami3, Naim Alkhouri4, Whitney Jackson5, Neehar D Parikh6, Neil Mehta7, Reena Salgia8, Andres Duarte-Rojo9, Laura Kulik10, Mina Rakoski11, Adnan Said12, Omobonike Oloruntoba13, George N Ioannou14, Maarouf A Hoteit15, Andrew M Moon16, Amol S Rangnekar17, Sheila L Eswaran18, Elizabeth Zheng19, Janice H Jou20, James Hanje21, Anjana Pillai22, Ruben Hernaez23, Robert Wong24, Steven Scaglione25, Hrishikesh Samant26, Devika Kapuria27, Shaun Chandna28, Russell Rosenblatt29, Veeral Ajmera30, Catherine T Frenette31, Sanjaya K Satapathy32, Parvez Mantry33, Prasun Jalal34, Binu V John35, Oren K Fix36, Michael Leise37, Christina C Lindenmeyer38, Avegail Flores39, Nayan Patel40, Z Gordon Jiang41, Nyan Latt42, Renumathy Dhanasekaran43, Mobolaji Odewole44, Sofia Kagan44, Jorge A Marrero44, Amit G Singal44. 1. Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas. Electronic address: nicole.rich@utsouthwestern.edu. 2. Division of Digestive and Liver Diseases, Comprehensive Transplant Center and Samuel Oschin Comprehensive Cancer Institute, Cedars Sinai Medical Center, Los Angeles, California. 3. Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, New York. 4. Texas Liver Institute, University of Texas Health San Antonio, San Antonio, Texas. 5. Division of Gastroenterology and Hepatology, University of Colorado Denver School of Medicine, Denver, Colorado. 6. Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan. 7. Division of Gastroenterology, University of California San Francisco, San Francisco, California. 8. Division of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Michigan. 9. T.E. Starzl Transplantation Institute and Center for Liver Disease, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania. 10. Division of Hepatology, Northwestern University, Chicago, Illinois. 11. Transplantation Institute and Division of Gastroenterology, Loma Linda University Health, Loma Linda, California. 12. Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine, Madison, Wisconsin. 13. Division of Gastroenterology and Hepatology, Duke University Health Center, Durham, North Carolina. 14. Division of Gastroenterology and Research and Development, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, Washington. 15. Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania. 16. Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina. 17. Division of Gastroenterology, Georgetown University Hospital, Washington, DC. 18. Division of Gastroenterology, Rush Medical College, Chicago, Illinois. 19. Division of Digestive and Liver Diseases, Columbia University, New York, New York. 20. Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, Oregon. 21. Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio. 22. Division of Gastroenterology, Hepatology and Nutrition, University of Chicago, Chicago, Illinois. 23. Section of Gastroenterology and Hepatology, Baylor College of Medicine and Michael E. Debakey Veterans Affairs Medical Center, Houston, Texas. 24. Division of Gastroenterology and Hepatology, Alameda Health System, Oakland, California. 25. Division of Hepatology, Loyola University Medical Center and Edward Hines Veterans Affairs, Chicago, Illinois. 26. Division of Gastroenterology and Hepatology, Louisiana State University Health Sciences Center, New Orleans, Louisiana. 27. Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico. 28. Division of Gastroenterology, Hepatology and Nutrition, University of Utah, Salt Lake City, Utah. 29. Division of Gastroenterology and Hepatology, Weill Cornell Medicine - New York-Presbyterian Hospital, New York, New York. 30. Division of Gastroenterology and Hepatology, University of California San Diego, San Diego, California. 31. Division of Organ Transplantation, Scripps Green Hospital, San Diego, California. 32. Division of Transplant Surgery, University of Tennessee Health Science Center, Memphis, Tennessee. 33. Liver Institute at Methodist Dallas, Dallas, Texas. 34. Division of Abdominal Transplantation, Baylor College of Medicine, Houston, Texas. 35. Division of Gastroenterology and Hepatology, McGuire Veterans Affairs Medical Center, Richmond, Virginia. 36. Organ Transplant Department, Swedish Medical Center, Seattle, Washington. 37. Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota. 38. Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, Ohio. 39. Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri. 40. Banner Transplant Institute, Banner - University Medical Center Phoenix, Phoenix, Arizona. 41. Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts. 42. Oschner Multi-Organ Transplant Institute, Oschner Health System, New Orleans, Louisiana. 43. Division of Gastroenterology and Hepatology, Stanford University, Stanford, California. 44. Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas.
Abstract
BACKGROUND & AIMS: Direct-acting antivirals (DAAs) are effective against hepatitis C virus and sustained virologic response is associated with reduced incidence of hepatocellular carcinoma (HCC). However, there is controversy over the use of DAAs in patients with active or treated HCC and uncertainty about optimal management of these patients. We aimed to characterize attitudes and practice patterns of hepatology practitioners in the United States regarding the use of DAAs in patients with HCC. METHODS: We conducted a survey of hepatology providers at 47 tertiary care centers in 25 states. Surveys were sent to 476 providers and we received 279 responses (58.6%). RESULTS: Provider beliefs about risk of HCC recurrence after DAA therapy varied: 48% responded that DAAs reduce risk, 36% responded that DAAs do not change risk, and 16% responded that DAAs increase risk of HCC recurrence. However, most providers believed DAAs to be beneficial to and reduce mortality of patients with complete response to HCC treatment. Accordingly, nearly all providers (94.9%) reported recommending DAA therapy to patients with early-stage HCC who received curative treatment. However, fewer providers recommended DAA therapy for patients with intermediate (72.9%) or advanced (57.5%) HCC undergoing palliative therapies. Timing of DAA initiation varied among providers based on HCC treatment modality: 49.1% of providers reported they would initiate DAA therapy within 3 months of surgical resection whereas 45.9% and 5.0% would delay DAA initiation for 3-12 months and >1 year post-surgery, respectively. For patients undergoing transarterial chemoembolization (TACE), 42.0% of providers would provide DAAs within 3 months of the procedure, 46.7% would delay DAAs until 3-12 months afterward, and 11.3% would delay DAAs more than 1 year after TACE. CONCLUSIONS: Based on a survey sent to hepatology providers, there is variation in provider attitudes and practice patterns regarding use and timing of DAAs for patients with HCC. Further studies are needed to characterize the risks and benefits of DAA therapy in this patient population.
BACKGROUND & AIMS: Direct-acting antivirals (DAAs) are effective against hepatitis C virus and sustained virologic response is associated with reduced incidence of hepatocellular carcinoma (HCC). However, there is controversy over the use of DAAs in patients with active or treated HCC and uncertainty about optimal management of these patients. We aimed to characterize attitudes and practice patterns of hepatology practitioners in the United States regarding the use of DAAs in patients with HCC. METHODS: We conducted a survey of hepatology providers at 47 tertiary care centers in 25 states. Surveys were sent to 476 providers and we received 279 responses (58.6%). RESULTS: Provider beliefs about risk of HCC recurrence after DAA therapy varied: 48% responded that DAAs reduce risk, 36% responded that DAAs do not change risk, and 16% responded that DAAs increase risk of HCC recurrence. However, most providers believed DAAs to be beneficial to and reduce mortality of patients with complete response to HCC treatment. Accordingly, nearly all providers (94.9%) reported recommending DAA therapy to patients with early-stage HCC who received curative treatment. However, fewer providers recommended DAA therapy for patients with intermediate (72.9%) or advanced (57.5%) HCC undergoing palliative therapies. Timing of DAA initiation varied among providers based on HCC treatment modality: 49.1% of providers reported they would initiate DAA therapy within 3 months of surgical resection whereas 45.9% and 5.0% would delay DAA initiation for 3-12 months and >1 year post-surgery, respectively. For patients undergoing transarterial chemoembolization (TACE), 42.0% of providers would provide DAAs within 3 months of the procedure, 46.7% would delay DAAs until 3-12 months afterward, and 11.3% would delay DAAs more than 1 year after TACE. CONCLUSIONS: Based on a survey sent to hepatology providers, there is variation in provider attitudes and practice patterns regarding use and timing of DAAs for patients with HCC. Further studies are needed to characterize the risks and benefits of DAA therapy in this patient population.
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