Behavioral Traits Plague HCV Patients Who Achieve SVR But Still Have Higher Mortality

Despite the fact that an increasingly large portion of the hepatitis-C-infected population successfully achieves a cure for the infection, called sustained viral response (SVR), this population still deals with increased mortality rates. A status of SVR means that the hepatitis C virus is no longer detected in the bloodstream during treatment and is also not detectable at 12 weeks or more after completing treatment, although patients will retain the hepatitis C antibody for life. With achievement of SVR, liver damage ceases, liver function improves, and there is a much lower risk of liver-related complications and death, although SVR status does not guarantee that any existing scarring will heal.

Given the positive prognosis that comes with SVR, it is surprising that SVR patients in a Scottish study still faced mortality rates 1.9 times more frequent than the general population. The researchers who conducted the study noted that about two-thirds of the “excess deaths” could be attributed to either liver cancer or “modifiable characteristics” such as heavy alcohol and drug use, suggesting that hepatitis C patients who have been “cured” of the infection could benefit from continued monitoring from health professionals and a direct address of the lifestyle risk factors that may have led to the infection in the first place.

To analyze mortality rates in SVR patients, the research team followed 1,824 patients who had attained SVR between 1996 and 2011. All patients began and then terminated a course of interferon (IFN)-based antiviral therapy between January 1996 and December 2010, and all showed compensated liver disease at the time of completion of the treatment. This meant that their livers may have been damaged but they were still functional. Patients also showed no HIV or hepatitis B co-infections, and the study began nine months after the antiviral treatment stopped in order to fully verify SVR status.

In the 5.2 years of the study, the predominantly male (67%) population experienced 78 deaths, a relatively high number given the median age of 40.7 years. “The number of deaths that would have been expected in our SVR cohort given general population mortality rates was 42,” said the team, noting that “significant elevations [in mortality] were observed for death due to primary liver cancer and death due to drug-related causes.”

The team pinpointed a total of seven distinct causes of death: primary liver cancer, other liver disease, external causes such as accidents, homicide, and suicide, non-liver cancers, diseases of the circulatory system, and “other” causes. Of the 78 deaths, 18 were due to drug-related causes while nine were caused by primary liver cancer. In younger patients (those under 50), more than half of the deaths were due to drug-related issues, while older patients (those over 50) were more likely to die from liver cancer. Interestingly, the Centers for Disease Control (CDC) report that men die from liver cancer at more than twice the rate of women and that as of 2013, cases of liver cancer and related deaths are on the rise.

Although the researchers emphasized that several factors were missing from the study that would provide a complete picture of the issue, they said that they were able to conclude that “health risk behaviors emerged [in the study] as the major modifiable risk factor for mortality in the [SVR] population.” The group recommended a multidisciplinary approach to hepatitis C treatment that not only offers medical treatment, but also addresses lifestyle risk factors. “The SVR time-point may be a particularly opportune moment to assess what other services and support the patient may be in need of,” they said, adding that the high incidence of liver-cancer-related deaths indicates that regular screenings for liver cancer could also improve mortality rates.

“It will be important to repeat this analysis five years hence,” they said, noting that new trends in treatment regimens that include “intensive coaching from clinicians and nursing staff” could positively affect patients’ resolve to make healthier lifestyle decisions after achieving SVR. They added that hepatitis C tends to disproportionately affect populations of lower socioeconomic status, a state that is also associated with higher mortality rates. A spokesperson for the Centers for Disease Control (CDC) agreed with the team’s conclusions about using SVR as a point at which to identify and modify risky behaviors, noting, “Once cured, it is still important for patients to protect themselves against any activity that puts them at risk of being re-infected.” Such activities, such as intravenous drug use, were pinpointed by the research team as leading to a large number of “excess” deaths in the cured population.