A higher MELD score (> 10) and a higher Child-Pugh class (B or C) score are associated with worse survival outcome regardless of SVR status. While patients with a low MELD score (≤ 10) have a better survival rate (HR 0.49), a higher MELD score has a significantly higher HR and therefore worse survival outcomes (HR, 2.20). Similarly, patients with Child-Pugh A (HR, 0.39) have a better survival outcome compared with those patients with Child-Pugh class B or C (HR, 2.57). This finding is consistent with results of multiple studies indicating that advanced liver disease, as measured by a high MELD score and Child-Pugh class score, can be used to predict the survival outcome in patients with HCV-related HCC.20-22
Unlike other studies that look at a single prognostic variable, our study evaluated prognostic impacts of multiple variables (age, SVR status, the order of SVR in relation to HCC development, HCV treatment type, MELD score and Child-Pugh class) in patients with HCC. The study included patients treated for HCV after development of HCC along with other multiple variables leading to OS benefit. It is one of the only studies in the United States that compared 5-year OS and PFS among patients with HCC treated for HCV and achieved SVR. The studies by Nagaoki and colleagues and Sou and colleagues were conducted in Japan, and some of their subset analyses were univariate. Among our study population of veterans, 50% were African American patients, suggesting that they may have similar OS benefit when compared to White patients with HCC and HCV treatment.
Limitations
Our findings were limited in that our study population is too small to conduct further subset analysis that would allow statistical significance of those subsets, such as the suggested benefit of SVR in patients who presented with HCC after antiviral therapy. Another limitation is the all-male population, likely a result of the older veteran population at the Memphis VAMC. The mean age at diagnosis was 65 years, which is slightly higher than the general population. Compared to the SEER database, HCC is most frequently diagnosed among people aged 55 to 64 years.23 The age difference was likely due to our aging veteran population.
Further studies are needed to determine the significance of SVR on HCC recurrence and treatment. Immunotherapy is now first-line treatment for patients with local advanced HCC. All the immunotherapy studies excluded patients with active HCV infection. Hence, we need more data on HCV treatment timing among patients scheduled to start treatment with immunotherapy.
Conclusions
In a population of older veterans, treatment of HCV infection leads to OS benefit among patients with HCC. In addition, patients with HCV infection who achieve SVR have an OS benefit over patients unable to achieve SVR. The type of treatment, DAA vs IFN-based regimen, did not show significant survival benefit.