Commentary — November 2016
By Barbara J. Turner, MD; Barbara Riske; Laura L. Tenner, MD; and David L. Lakey, MD
Tex Med. 2016;112(11):13-14.
In the past two decades, cancer-related deaths in the United States have declined dramatically due to advances in prevention, early detection, and treatment. One notable exception, liver cancer, has had a 38-percent increase in incidence and a 56-percent increase in deaths in the past decade, according to the U.S. Centers for Disease Control and Prevention (CDC). Hepatitis C virus (HCV) infection is the leading cause of hepatocellular carcinoma (HCC), the most common type of primary liver cancer.
Death due to HCV is at an all-time high nationally, exceeding death rates from all other top-60 infectious diseases combined, including HIV and tuberculosis, according to CDC. Unless the nation takes swift action, liver cancer and other HCV-related complications such as cirrhosis will continue to increase rapidly because an estimated 3.5 million Americans are living with HCV, according to a 2005 study of Texas' prevalence of HCV infection. This threat is especially acute in Texas, where about 400,000 people are chronically infected with HCV, and the incidence of liver cancer is the second highest in the nation, according to a 2014 study published in The American Journal of Gastroenterology.
Most serious complications from HCV infection can be averted. A 2015 study published in Clinical Liver Disease shows more than 90 percent of chronically HCV-infected people can be cured, on average, within three months by treatment with new, direct-acting, all-oral anti-HCV drugs. A study published this year on HCV cirrhosis patients' survival in the Journal of Hepatology indicates cure with these medications has increased the life expectancy of patients with compensated cirrhosis, making it equivalent to that of the general population.
Yet CDC says roughly half of the millions of people with chronic HCV nationally are unaware they have this disease because it usually causes only vague symptoms until cirrhosis has occurred.
The U.S. Preventative Services Task Force (USPSTF) has endorsed one-time screening of all Americans born from 1945 to 1965 (baby boomers) for HCV because 75 percent of people living with HCV are in this age range. Most health insurers now cover HCV screening tests.
Implementation of USPSTF guidelines needs to be a priority. However, because studies show African-Americans have a higher risk of chronic HCV and Hispanics are more likely to have advanced HCV-related liver disease at diagnosis, health care professionals serving these populations are especially vital to assist with implementing HCV screening and coordinating care.
In Texas, the Center for Research to Advance Community Health (ReACH) at The University of Texas Health Science Center at San Antonio (UTHSCSA) has been developing universal baby-boomer HCV screening programs, especially those serving African-Americans and/or Hispanics, since 2012. A baby-boomer HCV screening and link-to-care project funded by CDC tested 4,582 (more than 90 percent) of eligible baby boomers admitted to University Hospital in San Antonio, of whom 175 (4 percent) were newly diagnosed with chronic HCV and the majority linked to outpatient care.
ReACH has three South Texas HCV projects that are multidisciplinary and multi-institutional and involve UTHSCSA, UT-Southwestern, and Parkland Health and Hospital System. These projects have produced methods for implementing HCV screening for baby boomers, including modification of the electronic health record to flag eligible patients, educational webinars, patient education materials on opt-out screening, and reflex testing to diagnose chronic HCV.
For those diagnosed with chronic HCV, ReACH has developed evaluation and treatment educational materials for patients and their physicians. These include a low literacy educational program, in English and Spanish, on a mobile device to teach patients about HCV and its treatment.
The mission of ReACH and its collaborators is to assist clinicians in Texas in reversing the significant health threats from HCV and HCC. We would be delighted to share our materials and methods to promote HCV screening and coordination of care for baby boomers.
Barbara J. Turner, MD, is the James D. and Ona I. Dye Professor of Medicine at UTHSCSA and is the director of UTHSCSA's ReACH.
Barbara Riske serves as a project coordinator at UTHSCSA's ReACH.
Laura L. Tenner, MD, is an associate professor in the division of hematology/oncology at UTHSCSA.
David L. Lakey, MD, is associate vice chancellor for population health and chief medical officer for The University of Texas System. He is chair of the Texas Medical Association Council on Science and Public Health.
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