EASL Congress HCV Interview: Dr E. Lebovics
Posted on April 26, 2015
Regarding studies that are ongoing, what are you most excited about seeing at EASL? The results of which studies and what types of studies?
Dr. Lebovics: Well, now that we are able to eliminate hepatitis C with all oral regimens in about 95% of standard patients, one area of great interest is extending our currently available regimens to special populations, specifically those with decompensated cirrhosis, post-transplant and renal failure. Note that HIV co-infection is no longer considered a special population, as they respond just as well as mono-infected patients. For standard patients, the focus will be on new and upcoming agents that will be approved in the US in the near future including daclatasvir and the grazoprevir /elbasvir combination, as well as regimens that will shorten the duration of therapy. I think there will also be some interesting studies about hepatocellular carcinoma post-SVR, and the risk of re-infection in patients who were treated.
What are your thoughts about birth cohort screening for Hep C and should it be mandated by law?
Dr. Lebovics: I think that birth-cohort testing is important if we look at it on a national level. However, we have to recognize that in certain patient populations it’s not going to have as great a yield as in others and thereby may not be cost-effective across all groups. While legislation mandating a healthcare intervention is always controversial, it will definitely increase awareness among primary care providers, which is a major need with three quarters of hepatitis C patients in the US currently undiagnosed. On balance, I support it.
What challenges would you anticipate having to overcome in order to accommodate the anticipated increase in patient referrals due to birth cohort screening?
Dr. Lebovics: This question really depends on the region that you’re dealing with. In the major urban centers there are adequate numbers of specialists and facilities to accommodate increasing numbers of patients, especially now that anti-viral therapy has been simplified. In communities where access to specialists is not readily available, a system will have to be developed to allow either primary care physicians or physician extenders to evaluate and treat these patients under the general guidance of a specialist.
What issues do you encounter when attempting to provide timely and effective clinical care to HCV infected patients referred to you from the community?
Dr. Lebovics: Fortunately, we have a very effective infrastructure that includes physician assistants and nurses who dedicate most of their time to the management of Hepatitis C. We also have on our staff a person who will pursue the pre-authorizations for medications. So after I evaluate a patient and recommend a plan of action, the staff will ensure that patient is properly educated and will follow the patient to ensure adherence to the regimen. Management of side-effects has become much less of an issue with the use of interferon-free regimens. So we actually find that the current era is less challenging than the previous era, because the regimens are simpler and safer and no longer require close monitoring, dose adjustments, and frequent communication with the patient.
To what extent do you believe that community based healthcare providers should be treating Hepatitis C and why?
Dr. Lebovics: Well I think that there is no reason why physicians from the community should be excluded from treating hepatitis C if they can demonstrate that they had adequate training and supervision, much the same as any credentialing process. This could be achieved by a course followed by a period of treating under close communication with a specialist mentor. Perhaps the most challenging aspect for the primary care physician will not be the management of anti-viral therapy, but the assessment of chronic liver disease.
Is the higher cost of newer HCV regimens going to introduce socioeconomic and ethical considerations in the treatment of HCV and also, how do you think that the treatment of populations with limited resources will be affected?
Dr. Lebovics: I think that any hepatologist you ask will say that any hepatitis C virus infected patient who has a reasonable prognosis (ie, they don’t have a comorbidity that will imminently lead to their demise) should be offered treatment for hepatitis C. Yet we see particularly for indigent populations in the United States, treatment is being limited to those patients with more advanced disease, which I think is unfortunate. And you know, in other parts of the world, access is even more severely limited. There is no question that the price of therapy is having a significant impact on access and this raises the critical ethical issue of how scarce healthcare resources are to be distributed. You can have the same discussion about access to liver transplantation or expensive oncologic treatments. Whether healthcare is a right or a privilege is an issue that society has to grapple with.
What are your thoughts on restricting hepatitis C therapy to patients with advanced fibrosis or severe complications and/or symptoms?
Dr. Lebovics: I really think that it does not make medical sense to restrict therapy that way. Firstly, our ability to diagnose advanced fibrosis or cirrhosis is inexact, particularly by the non-invasive modalities we now use, so there may be many patients who will be falsely under-staged. We don’t know exactly when the risk of hepatocellular carcinoma will start to steeply increase, so while we’re waiting we may be exposing patients to a lifelong risk of cancer. And there’s mounting evidence of extra-hepatic ill-effects of hepatitis C in patients without significant fibrosis including cognitive effects. So I think that it’s really a “no-brainer” that anybody with hepatitis C would want to be treated. I recently asked a group of physicians at a symposium: if your family member has mild hepatitis C, would you want them to be treated? Of course, everybody said yes. I think restricting hepatitis C therapy to patients with cirrhosis is an indefensible position.
For more information on ILC-EASL 2015 Hepatitis abstracts and others to be presented at The International Liver Congress™, please click here to review the Congress abstract e-book.
Dr. Edward Lebovics is the Sarah C. Upham Professor of Gastroenterology at New York Medical College in Valhalla, New York.
Dr. Lebovics currently serves as the Director of the College’s Sarah C. Upham Division of Gastroenterology and Hepatobiliary Diseases. He is Chief of the Section of Gastroenterology and Hepatobiliary Diseases at Westchester Medical Center, which has become a leading liver transplant center. He has directed the College’s gastroenterology fellowship training program since 1997. Dr. Lebovics also serves on the Medical Advisory Boards of the New York Chapters of the American Liver Foundation and Crohn’s and Colitis Foundation of America.
Dr. Lebovics’ clinical expertise and research have made significant contributions in the fields of gastrointestinal and liver disease. His special interests include advanced therapeutic endoscopy, hepatitis C virus infection, chronic liver diseases, and inflammatory bowel disease. He has authored numerous articles and book chapters and delivered many invited lectures.
His achievements have been recognized by a Certificate of Special Congressional Recognition and by election to Fellowship at the American College of Physicians, American College of Gastroenterology and American Gastroenterological Association. He has been frequently listed amongst “Top Doctors” by New York Magazine and various other publications. Medical students and residents have also recognized his commitment to teaching through Excellence in Teaching Awards.