EASL Pre-Congress HCV Interview: Dr R. Brown

Posted on April 20, 2015

Is there any data that is going to be presented at EASL that you’re really excited about? Are there any research studies that are going on right now that you’re really excited about?

Dr. Brown: Right now we have two excellent FDA approved options for our genotype 1 Hepatitis C patient, but we have issues with patients who are not genotype 1, or those who have other extenuating circumstances or special populations, for whom we don’t know what the ideal treatment is.  We also don’t know which patients we need ribavirin for. And for some patients, we need better treatments altogether. This would include patients with end-stage renal disease, those with decompensated cirrhosis, and patients who have genotypes other than 1. So, I’m hoping that we’re going to see some good data on those patient populations. We also may see data that may further allow us to refine treatment duration so that we can find the most cost-effective treatment management strategy for all of our patients, because the high cost of medicines has led to lower access.

What are your thoughts on birth cohort screening for hepatitis C? Should it be mandated by law? 

Dr. Brown: I think that birth-cohort screening is the best way to identify the 75% of hepatitis C positive patients that remain undiagnosed, as risk-factor based screening has clearly failed. However, it hasn’t been widely implemented, either through the CDC recommendations, or by mandate. In New York State, for instance, it is a law. So though you would think that having it be mandated by law would be a step forward, it hasn’t done much.  A better step forward would be meaningful use, because if health care providers have financial incentives and disincentives, then they will screen.

In New York State, do you think that PCPs know that this is the law?

Dr. Brown: I don’t know whether they know the law, I doubt it.  What I do know is that they don’t really screen for HCV to any appreciable degree.

What challenges would you anticipate having to overcome in order to accommodate the anticipated increase in HCV patient referrals due to birth cohort screening?

Dr. Brown: I think that right now, the major issue is not managing the treatment. Managing the treatment is easy. The difficulty is managing the insurance approval process. I could easily treat more people if the process of getting drugs approved by the insurers was simplified.

What issues do you commonly encounter when attempting to provide timely and effective clinical care to HCV-infected patients referred to you from the community?

Dr. Brown: Our major barrier in providing timely and effective clinical care is that we find good candidates for treatment who have difficulty getting treatments approved by their insurers. That to me is the major barrier, that and screening in the general population to find the hepatitis C positive people. Those are the two major barriers in the community in terms of having a positive impact in hepatitis C patients’ lives right now.

To what extent do you believe that community based healthcare providers should be treating hepatitis C, and why?

Dr. Brown: I think that we are certainly going to need community-based treatment. It can’t all be done in specialized centers. It does require knowledge of the clinical protocols. But anyone that does sees an adequate volume and is willing to learn can do it, certainly any experienced gastroenterologist, should be able to do this. 

In your opinion, is the cost of newer oral HCV regimens going to introduce socioeconomic and ethical considerations into the treatment of HCV? How do you think the treatment of populations with limited resources will be affected?

Dr. Brown: I think that there are going to be, unless we take steps to make access to medications more available for patients.  The key to improving access includes both decreases in the cost of medicine, and public advocacy to get coverage for what is clearly an effective, lifesaving treatment.

What are your thoughts on targeting access to newer oral HCV regimens to specific populations such as active injection users or incarcerated individuals?

Dr. Brown: Those are two different things. I don’t think incarcerated individuals should be denied care, whereas people who are still actively using IV drugs can get re-infected (and that was seen in a trial of HIV-co-infected individuals). So I think that for people who are still actively using IV drugs, our first effort should be drug rehabilitation. But once they receive drug rehabilitation, treating hepatitis C and preventing its ill effects should be as important as in people who are not using IV drugs.  If people get re-infected, treating hepatitis to have a short hiatus virus free would not be beneficial to them.

 What are your thoughts on restricting hepatitis C therapy to patients with advanced fibrosis or severe complications and/or symptoms?

Dr. Brown: Once patients develop cirrhosis, they are at risk for liver cancer even if we cure them. If we are making people wait until the end, then the risk of liver cancer does not disappear if they are cured. So the idea that we make people wait until they are at risk for liver cancer, and then use a treatment regimen that often requires a longer duration with increased cost and lower cure rates makes no sense to me.

It’s been shown that there are benefits in terms of survival both to patients with advanced fibrosis and those with milder fibrosis. And you know, a lot of the insurance companies are trying to create a panic by making it seem like we’re going to treat all 4 million people with Hepatitis C in the next 1-2 years and drive the healthcare system broke. It’s clear that, for one, we haven’t identified the vast majority of people with Hepatitis C, so we can’t treat them because we don’t know where they are. Although the patients with advanced fibrosis and cirrhosis do need treatment the most, we should be trying to cure Hepatitis C and eliminate Hepatitis C for all of our patients. This involves treating any and all patients that we find.

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.

Robert S. Brown, Jr., MD, MPH is the Frank Cardile Professor of Medicine and Medical Director of the Transplantation Initiative at Columbia University College of Physicians and Surgeons in New York, New York. He also holds appointments in the Departments of Surgery and Pediatrics at Columbia and the Department of Medicine at Weill Cornell School of Medicine. Dr. Brown is the Director of the Center for Liver Disease and Transplantation at NewYork-Presbyterian Hospital in New York.

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