Incidence of liver cancer among people with HIV has increased dramatically over the past decade, Spanish investigators
report in the online edition of Clinical
Infectious Diseases. All the cases involved individuals with viral
hepatitis co-infection. Prognosis was poor and only a minority of people received
potentially curative therapy.
Liver disease is an increasingly important
cause of serious illness and death in people with HIV, and is mainly driven
by co-infection with hepatitis C virus (HCV). Investigators in Spain wanted to
see if incidence of hepatocellular carcinoma (HCC, the most common liver cancer in patients with hepatitis C) was increasing
in co-infected people. They therefore analysed data gathered between 1999 and
2010 from 18 hospitals.
A total of 82 cases of liver cancer
involving HIV-positive people were identified. All the cases were related to
viral hepatitis co-infection: 66 people
(81%) were co-infected with hepatitis C; six (7%) were
co-infected with hepatitis B; and ten individuals (12%) were infected with both
hepatitis C and hepatitis B.
Only 22 (29%) of the participants infected with
hepatitis C had previously received antiviral therapy for this infection. Six
of these people achieved a sustained virological response, or SVR, considered a cure. A meta-analysis published in BMJ Open shows that antiviral therapy for hepatitis C reduces the risk of HCC, even in patients who do not achieve a SVR.
time between SVR and diagnosis with liver cancer was 28 months.
“This finding reinforces the need to
continue performing ultrasound examinations in patients who respond to anti-HCV
therapy to rule out HCC,” write the authors.
At the time of diagnosis with liver cancer,
77 people (94%) had evidence of cirrhosis.
The first case of liver cancer was
diagnosed in 1999. Thereafter, there was a steady increase in the frequency of
such diagnoses, and this increase became dramatic in the last few years.
Some 66 new cases (81%) were diagnosed
Incidence of liver cancer related to
hepatitis C co-infection was between 0 to 0.6 cases per 1000 person-years
before 2003. By 2008-09, incidence had increased to 2.8 cases per 1000 person-years.
The investigators believe this 14-fold
increase in the incidence of liver cancer among people co-infected with
hepatitis C is “remarkable”.
Most cases of liver cancer were diagnosed
late. Only 26 people (32%) had the malignancy detected during routine
clinical care. The remaining people were diagnosed after presenting with
After diagnosis, 33 participants (40%) received
therapy for liver cancer. Of these individuals, eleven received potentially
curative therapy (e.g. liver transplant or resection).
Prognosis was poor. Some 65 people (79%)
died. Median survival after the diagnosis of liver cancer was just 91 days.
However, mortality rates were significantly
lower among people who received potentially curative therapy (29%) compared
to those who did not receive such treatment (87%).
There was clear evidence that early
diagnosis was associated with an improvement in prognosis. The median duration
of survival was 22 months for those
whose cancer was diagnosed during routine care, compared to only two months for
individuals whose cancer was detected because of symptoms.
“This study suggests that the incidence of
HCC is increasing in HIV-infected patients in recent years in Spain,” comment
the investigators. “This observation was mainly driven by a notable rise of the
incidence of HCC among HIV/HCV-coinfected patients.”
The authors offer several reasons for the
dramatic increase in liver cancer:
- Improvements in HIV therapy
mean that people co-infected with viral hepatitis are living long enough for
liver cancer to develop.
- Hepatitis C therapy has poor
efficacy in people co-infected with HIV.
- HIV may accelerate hepatitis C
- There have been improvements in
the management of liver cirrhosis in co-infected people, resulting in longer
survival enabling liver cancer to develop.
“HCC is an emerging complication of chronic
liver disease in HIV-infected patients, especially in those who are also
infected with HCV,” conclude the authors. “Earlier diagnosis in time to offer
potentially curative therapy continues to be the main challenge for
clinicians…treatment for HCV infection should also be offered to all potential
candidates, in order to achieve SVR, which may prevent the emergence of HCC.”