Dual Challenges: Managing Hepatocellular Carcinoma with Hepatitis B Co-Infection

Dr. Takemoto:

You’re listening to Project Oncology on ReachMD. I’m Dr. Jody Takemoto, and we’ll be discussing approaches to caring for patients with hepatocellular carcinoma with hepatitis B coinfection with Dr. Robert Wong. He’s a Clinical Associate Professor of Medicine in the Division of Gastroenterology and Hepatology at Stanford University School of Medicine and a physician at the Veterans Affairs Palo Alto Healthcare System.

To start us off, Dr. Wong, can you tell us about the treatment landscape for patients with hepatocellular carcinoma alone?

Dr. Wong:

Yeah. So the approach to HCC diagnosis and treatment is constantly evolving, and I think it’s very exciting to see the many new therapies that we have on the horizon. It’s important to remember that with HCC, the earlier you diagnose patients the better because that really expands the treatment options. And treatment can range from potentially curative, which is primarily surgical based, and what we call palliative, but really these are local regional therapies, meaning targeted therapies to ablate and embolize and then also cancer-directed therapies with systemic therapies. So the treatment landscape for HCC first depends on stage of disease, and then based on the stage, it really helps guide what the preferred recommended therapies are. 

Dr. Takemoto:

And how does the approach change, if at all, based on a patient’s hepatitis B status?

Dr. Wong:

Yeah, great question. You know, hepatitis B is definitely a hot topic. If you think about the global burden, it’s probably one of the leading causes of liver cancer globally. In the U.S. probably less so because the burden of hepatitis B in the U.S. is lower than in places like the Asia Pacific region, but still, in the U.S., we had some recent data that suggests there’s probably over 2,000,000 individuals with chronic hepatitis B.  Many of them are undiagnosed. So for hepatitis B, it’s so important to screen, diagnose, and link to care, and there always has been major gaps in diagnosis and linkage to care, but recently, we’ve seen some encouraging public policy changes that, hopefully, will lead to better diagnosis. 

The CDC recommendations now are to screen all adults for hepatitis B with hepatitis B surface antigen, surface antibody, and core antibody. That’s so key because before it was risk-based, meaning you have to identify who should be screened and who should not based on their risk factors and their country of birth, so as you can imagine, that introduces a lot of stigma because basically, what you’re saying is “You are high risk, and you are not,” so it kind of labels people, and that contributes to people feeling stigma, maybe not wanting to come to care because they feel targeted, so I think this is a huge step by normalizing screening. The same way we screen everyone for HIV, now we should screen everyone for hepatitis B and hepatitis C, and that, I think, will lead to improved diagnosis. 

But that’s not the end of it. You know, diagnosis is one important step, but once you’re diagnosed, it’s important to link these people to appropriate care because they need to be monitored, lab tests, imaging, to make sure when they need treatment that we implement antiviral therapy in a timely manner. I think the other important effort that many people are focusing on is trying to better improve linkage to care of patients with diagnosed hepatitis B and how we can better plug them into, clinical monitoring so we can assess them for antiviral therapy. 

Dr. Takemoto:

With that being said, can you tell us more about the impacts of antiviral therapy?

Dr. Wong:

For the most part, therapy now for hepatitis B is easy. It’s one pill a day.  It’s safe and effective at suppressing virus, reduces risk of transmission, and reduces your risk of liver cancer. So it’s available, and I think really the goal is we need to get all of these patients plugged in and on treatment in a timely manner, and that in and of itself—as we’ve seen in a lot of existing studies—antiviral therapy does reduce risk of liver cancer in patients with hepatitis B, and that’s the main outcome. We want to improve patients’ lives. We want to reduce their risk of disease progression. And I think getting patients screened, diagnosed, and linked to care and treatment is such an important step in improving long-term outcomes.

Dr. Takemoto:

For those just tuning in, you’re listening to Project Oncology on ReachMD. I’m Dr. Jody Takemoto, and today I’m speaking with Dr. Robert Wong about how we can manage patients with hepatocellular carcinoma with hepatitis B coinfection.

Now along similar lines to what we were just talking about, Dr. Wong, can you tell us about any drug interactions with antiviral therapies and any cancer agents as well?

Dr. Wong:

Yeah. So with any kind of medication therapy, it’s always important to really assess drug-drug interactions, adverse effects, etc. And many patients, especially as patients get older, have a lot of comorbidities, and they may be on a host of other medications that treat their other illnesses or disease states, so with antiviral therapy, it’s always important, and this is where our pharmacy colleagues are so helpful and important in helping us review drug-drug interactions and make sure that it’s safe whether the dosing needs to be adjusted. 

And it’s not just their other medications, but for some of these antiviral therapies, we also have to look at their kidney function, their renal clearance, because some of these you have to adjust the dose of antiviral therapy based on the renal function. So all of these things have to be taken into consideration because you don’t want to overdose or underdose these antiviral therapies, especially those that have some early form of kidney disease or on other therapies that may have some interaction.

Dr. Takemoto:

Any final thoughts or hopes in this area?

Dr. Wong:

Yeah. For hepatitis B, as I mentioned, we have therapies out there that are safe, effective, and relatively cheap, but it’s not a cure. Currently, it’s suppressive therapy. Cure, or I guess what we call “functional cure,” is still a little bit of a lofty goal, but there are a lot of therapies in early-stage development that look very promising. So I think one of the bright hopes of the near future is a new antiviral therapy for hepatitis B that can achieve functional cure. And what that means is that patients no longer have to be on lifelong therapy, and their risk of cancer is reduced, so that’s one, I think, hope or light at the end of the hopefully short tunnel that we see for hepatitis B.

The other important or exciting aspect of hepatitis B is hepatitis delta. I think that doesn’t get a lot of press. But hepatitis delta is another virus that affects the liver. It’s one of the most severe forms of hepatitis.  But the unique features of hepatitis delta is it only occurs in a setting of hepatitis B because it’s a defective virus, so it can’t replicate by itself. It needs the hepatitis B machinery to replicate. 

The challenges with hepatitis delta are not very well known; most people don’t screen for it because they’re not aware of it, and because of that, it goes undiagnosed most of the time, and for that reason, it leads to very quick, progressive liver damage. In the U.S., hopefully soon, we will have therapy. We do have therapy approved in Europe, a medication called bulevirtide. In the U.S., we don’t have that approved yet, but hopefully, very soon we’ll have a potential therapy for hepatitis delta.

There’s also other therapies for delta on the horizon being developed, so that’s another area of novelty in viral hepatitis therapeutics that looks very exciting, not just for hepatitis B but also hepatitis delta, especially given how severe the damage is from this virus.

Dr. Takemoto:

Well, with that hopeful look ahead to the future in mind, I want to thank my guest, Dr. Robert Wong, for joining me to discuss management strategies for patients with hepatocellular carcinoma and hepatitis B.

For ReachMD, I’m Dr. Takemoto. To access this and other episodes in our series, visit Project Oncology on ReachMD dot com, where you can Be Part of the Knowledge. Thanks for listening!