Prof. Farci: Thanks for asking me these questions. I believe that the epidemiology of HCV associated hepatocellular carcinoma worldwide shows some changes, for instance in the United States now there is an increasing incidence of hepatocellular carcinoma. It has become probably the fastest cause of cancer related deaths compared maybe to Italy or Japan where the peak has already been reached so it depends also per country. In the United States now it is the most important cause of liver transplantation and it is also the cause of an increasing rate of hepatocellular carcinoma with HCV infection.
Prof. Farci: I think that we need to distinguish patients without cirrhosis and patients with cirrhosis. I believe that in patients without cirrhosis it will be very likely that the patient will recover completely, not only in terms of clearing the virus but also in terms of the liver pathology. In patients with cirrhosis there are some encouraging results but probably we need to wait a little bit more in order to establish the effect of the DAA treatment on patients with cirrhosis and the risk of developing hepatocellular carcinoma. We do not have all the data so far. I think it is too early. There are some encouraging data that once that you clear the virus there is an improvement in fibrosis but to fully determine how much the risk will decrease in patients with cirrhosis and the risk of developing hepatocellular carcinoma, I think we need to wait more and to have more data.
Prof. Farci: This is a good question. I think that there are several factors for sure in patients that have a sustained virological response. If they are not cirrhotic and if they do not have other risk factors like abuse of alcohol or other factors, probably the chance of developing hepatocellular carcinoma is low. However if you clear the virus but the patient has cirrhosis and maybe other diseases like NASH or diabetes or other factors, I think it may increase regardless or not there is a presence of HCV even if they clear the virus but of course if you clear the virus and you do not have other risk factors, then I do not think the risk of developing hepatocellular carcinoma will be as high as if you have the virus.
Prof. Farci: This is an important question. I think we do not yet have the data to make sure how much this will decrease the risk of developing hepatocellular carcinoma in patients with cirrhosis that clear the virus. I believe that until this data is really clear we should continue to monitor the patients with at least, it depends on their clinical picture, if they have an alpha fetoprotein that is elevated then I think we need to monitor with an ultrasound every six months. This would make me I feel more comfortable in patients with cirrhosis.
Prof. Farci: I think that whilst you have hepatocellular carcinoma unfortunately there are not very many effective treatments except the liver transplantation or resection but even then the tumor must be very small. I do not think there is so much difference in terms of the outcome according to the virus especially now that we have very good and important antivirals. I do not think that once a patient has hepatocellular carcinoma there is a significant difference in the outcome if you have hepatocellular carcinoma with HCV in my experience.