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Hepatocellular carcinoma prediction beyond year 5 of oral therapy in a large cohort of Caucasian patients with chronic hepatitis B☆
Journal Pre-proof Hepatocellular carcinoma prediction beyond year 5 of oral therapy in a large cohort of Caucasian patients with chronic hepatitis B George V. Papatheodoridis, Vana Sypsa, George N. Dalekos, Cihan Yurdaydin, Florian Van Boemmel, Maria Buti, Jose Luis Calleja, Heng Chi, John Goulis, Spilios Manolakopoulos, Alessandro Loglio, Theodoros Voulgaris, Nikolaos Gatselis, Onur Keskin, Rhea Veelken, Marta Lopez-Gomez, Bettina E. Hansen, Savvoula Savvidou, Anastasia Kourikou, John Vlachogiannakos, Kostas Galanis, Ramazan Idilman, Rafael Esteban, Harry LA. Janssen, Thomas Berg, Pietro Lampertico PII:
S0168-8278(20)30022-2
DOI:
https://doi.org/10.1016/j.jhep.2020.01.007
Reference:
JHEPAT 7592
To appear in:
Journal of Hepatology
Received Date: 24 April 2019 Revised Date:
27 November 2019
Accepted Date: 4 January 2020
Please cite this article as: Papatheodoridis GV, Sypsa V, Dalekos GN, Yurdaydin C, Van Boemmel F, Buti M, Calleja JL, Chi H, Goulis J, Manolakopoulos S, Loglio A, Voulgaris T, Gatselis N, Keskin O, Veelken R, Lopez-Gomez M, Hansen BE, Savvidou S, Kourikou A, Vlachogiannakos J, Galanis K, Idilman R, Esteban R, Janssen HL, Berg T, Lampertico P, Hepatocellular carcinoma prediction beyond year 5 of oral therapy in a large cohort of Caucasian patients with chronic hepatitis B, Journal of Hepatology (2020), doi: https://doi.org/10.1016/j.jhep.2020.01.007. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.
Risk scores for the prediction of hepatocellular carcinoma after 5 years of treatment with entecavir or tenofovir disoproxil fumarate in Caucasian chronic hepatitis B patients CAGE-B: Risk score based on year 5 and baseline variables (range: 0-16) Age at year 5, years 23-29: 0
Severity of fibrosis (baseline year 5)
Age at year 5, years
CAGE-B:0-5 CHB LSM<12 kPa: 0
23-29: 0
SAGE-B:0-5
CAGE-B:6-10
30-39: 2
SAGE-B:6-10
CAGE-B:11-16
40-49: 4
SAGE-B:11-15
30-39: 2
0.25
Cirrhosis LSM<12 kPa: 3
50-59: 6 60-69: 8
0.20
Cirrhosis LSM≥12 kPa: 6
≥70: 10 CAGE-B 11-16
0.15 0.10
P<0.001
0.05 CAGE-B 6-10 CAGE-B 0-5
0.00 0
1
2
3
4 5 6 7 8 9 Years since ETV/TDF initiation Number at risk 0-5 6-10 11-16
281 674 230
253 611 211
211 519 173
158 413 139
106 257 69
10
11
12
36 110 21
15 34 0
2 13 0
Cumulative probability of HCC
Cumulative probability of HCC
40-49: 4
SAGE-B: Risk score based on year 5 variables (range: 0-15)
0.25
Elastographic severity of fibrosis at year 5 LSM<12 kPa: 0
50-59: 6
LSM≥12 kPa: 5
60-69: 8
0.20
≥70: 10 SAGE-B 11-15
0.15 0.10
P<0.001 SAGE-B 6-10
0.05
SAGE-B 0-5
0.00 0
1
2
3
4 5 6 7 8 9 Years since ETV/TDF initiation Number at risk 0-5 6-10 11-15
308 815 88
CHB: chronic hepatitis B without cirrhosis, LSM: liver stiffness measurement
280 743 78
235 643 48
179 519 34
120 310 13
10
11
12
39 125 5
16 34 0
2 13 0
1
Hepatocellular carcinoma prediction beyond year 5 of oral therapy in a large cohort of Caucasian patients with chronic hepatitis B
George V. Papatheodoridis1, Vana Sypsa2, George N. Dalekos3, Cihan Yurdaydin4, Florian Van Boemmel5, Maria Buti6, Jose Luis Calleja7, Heng Chi8, John Goulis9, Spilios Manolakopoulos1,10, Alessandro Loglio11, Theodoros Voulgaris1, Nikolaos Gatselis3, Onur Keskin4, Rhea Veelken5, Marta LopezGomez7, Bettina E Hansen8,12, Savvoula Savvidou9, Anastasia Kourikou10, John
Vlachogiannakos1,
Kostas
Galanis3,
Ramazan
Idilman4,
Rafael
Esteban6, Harry LA Janssen12, Thomas Berg5, Pietro Lampertico11.
1
Department
of
Gastroenterology,
Medical
School
of
National
and
Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece; 2
Department of Hygiene, Epidemiology & Medical Statistics, Medical School of
National and Kapodistrian University of Athens, Athens, Greece; 3Department of
Internal
Medicine,
Thessalia
University
Medical
School,
Larissa,
Greece; 4Department of Gastroenterology, University of Ankara Medical School, Ankara, Turkey;
5
Division of Hepatology, Clinic and Polyclinic for
Gastroenterology, Hepatology, Infectiology and Pneumology, University Clinic Leipzig, Germany; 6Hospital General Universitario Valle Hebron and Ciberehd, Barcelona, Spain; 7Hospital U Puerta de Hierro, IDIPHIM CIBERehd, Madrid, Spain; 8Department of Gastroenterology & Hepatology, Erasmus MC, University Medical Center, Rotterdam, Netherlands;
9
4th Department of
Internal Medicine, Αristotle University of Thessaloniki Medical School,
2
Thessaloniki, Greece;
10
2nd Department of Internal Medicine, Medical School
of National and Kapodistrian University of Athens, Hippokratio General Hospital of Athens, Athens, Greece;
11
CRC “AM e A Migliavacca” Center for
Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milano, Italy; 12Liver Clinic, Toronto Western & General Hospital, University Health Network, Toronto, ON, Canada.
Corresponding author: George V. Papatheodoridis, MD, PhD. Director of Department
of
Gastroenterology,
School
of
Medicine,
National
and
Kapodistrian University of Athens, Laiko General Hospital of Athens, 17 Agiou Thoma street, 11527 Athens, Greece. Tel: +30 2132061115, Fax: +30 2107462601, email: [email protected]
Key words: cirrhosis; liver stiffness; entecavir; tenofovir
Word count: 6289 (including abstract, text, references, tables and figures legends). Tables: 4, Figures: 3, References: 26.
Conflict of interest - Financial support statement There has been no kind of support for this study by any source GV Papatheodoridis: advisor/lecturer for Abbvie, Bristol-Myers Squibb, Dicerna, Gilead, GlaxoSmithKline, Ipsen, Janssen, Merck Sharp & Dohme, Roche, Spring Bank; research grants Abbvie, Bristol- Myers Squibb, Gilead.
3
V Sypsa: advisor/lecturer for Abbvie, Gilead; research grants from Abbvie, Gilead. GN Dalekos: advisor/lecturer for Abbvie, Bayer, Genkyotex, Gilead, Ipsen, Janssen, Novartis, Pfizer, Roche; research grants from Abbvie, Gilead. C Yurdaydin: speaker's bureau and/or advisor for AbbVie, Bristol-Myers Squibb, Gilead, Merck, Roche; research grant from Bristol-Myers Squibb. F van Boemmel: advisor/lecturer for Abbvie, Bristol-Myers Squibb, Gilead, Janssen, Merck Sharp & Dohme, Novartis, Roche; research grants from Bristol- Myers Squibb, Gilead, Janssen, Roche, Siemens; consultant for Abbvie, Gilead, Roche. M Buti: advisor/lecturer for Abbvie, Arbutus, Bristol-Myers Squibb, Gilead, Glaxo Smith-Kleine, Merck, Roche, Spring Bank JL Calleja: advisor/lecturer for Abbvie , Bristol-Myers Squibb, Gilead, Janssen, Merck. H Chi: Nothing to declare. J Goulis: advisor/lecturer for Gilead, GlaxoSmithKline, Merck Sharp & Dohme, Roche; research grant from Gilead. S Manolakopoulos: advisor/lecturer for Abbvie, Gilead, GlaxoSmithKline, Ipsen, Merck Sharp & Dohme, Novartis, Roche; research grants from Abbvie, Gilead. A Loglio: advisor/lecturer for Gilead, MYR Pharma. T Voulgaris: Nothing to declare. N Gatselis: Nothing to declare. O Keskın: Nothing to declare. R Veelken: Nothing to declare
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M Lopez-Gomez: Nothing to declare BE Hansen: Nothing to declare. S Savvidou: Nothing to declare. A Kourikou: Nothing to declare. I Vlachogiannakos: advisor/lecturer for Abbvie, Bristol-Myers Squibb, Gilead, Merck Sharp & Dohme, Novartis, Roche. K Galanis: Nothing to declare. R Idilman: Nothing to declare. R Esteban: advisor/lecturer for Abbvie, Boehringer Ingelheim, Bristol-Myers Squibb, Gilead, GlaxoSmithKline, Janssen, Merck, Novartis. HLA Janssen: consultant for and grants from AbbVie, Arbutus, Bristol Myers Squibb, Enyo, Gilead Sciences, Janssen, Medimmune, Merck, Roche, Vir Biotechnology Inc., Viroclinics. T Berg: advisor/consultant/lecturer for Abbvie, Alexion, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Gilead, GlaxoSmithKline, Janssen, Merck Sharp & Dohme/Merck, Novartis, Roche, and Vertex; Research support from Abbvie, Bristol-Myers Squibb, Gilead, Janssen, Merck Sharp & Dohme/Merck, Novartis and Roche. P Lampertico: speaking bureau/advisor for Abbvie, Eiger, Bristol-Myers Squibb, Gilead, GlaxoSmithKline, Merck/ Merck Sharp & Dohme, MYR Pharma, Roche.
Author contributions
5
GV Papatheodoridis: Conception and design of the study; Assembly, analysis and interpretation of data; Drafting of the manuscript; Approval of the final version of the manuscript. V Sypsa: Statistical analysis and interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. G Dalekos: Design of the study; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. C Yurdaydin: Design of the study; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. F Van Boemmel: Data collection; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. M Buti: Conception and design of the study; Data collection; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. JL Calleja: Data collection; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. H Chi: Data collection; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. J Goulis: Design of the study; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. S Manolakopoulos: Design of the study; Data collection; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. A Loglio: Data collection; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript.
6
T Voulgaris: Data collection; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. N Gatselis: Data collection; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. O Keskın: Data collection; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. R Veelken: Data collection; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. ML-Gomez: Data collection; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. BE Hansen: Design of the study; Data collection; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. S Savvidou: Data collection; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. A Kourikou: Data collection; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. I Vlachogiannakos: Data collection; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. K Galanis: Data collection; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. R Idilman: Data collection; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. R Esteban: Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript.
7
HLA Janssen: Design of the study; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. T Berg: Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. P Lampertico: Conception and design of the study; Interpretation of data; Drafting of the manuscript; Approval of the final version of the manuscript.
8
ABSTRACT Background & Aims: Hepatocellular carcinoma (HCC) may develop in chronic hepatitis (CHB) patients even after 5 years of oral therapy and cannot be easily predicted. We assessed predictors and need for HCC surveillance in this setting. Methods: Of 1951 adult Caucasians with CHB included in the PAGE-B cohort, 1427 (73%) have completed follow-up >5 years under therapy without HCC until year 5. Median follow-up has been 8.4 years from treatment onset. Points-based risk scores were developed to predict HCC risk after year 5. Results: In years 5-12, HCC has been diagnosed in 33/1427 (2.3%) patients with cumulative incidence 2.4%, 3.2% and 3.8% at 8, 10 and 12 years, respectively. Older age or age >50 years, baseline cirrhosis and liver stiffness (LSM) ≥12 kPa at year 5 were independently associated with increased HCC risk. The HCC incidence was lower in non-cirrhotics than those with baseline cirrhosis and year-5 LSM <12 kPa than those with baseline cirrhosis and year5 LSM ≥12 kPa. CAGE-B score was based on age at year 5 and baseline cirrhosis in relation to LSM at year 5 and SAGE-B score was based only on age and LSM at year 5 (c-index=0.809-0.814, 0.805-0.806 after bootstrap validation). Both scores offered 100% negative predictive values for HCC development in their low risk groups. Conclusions: In Caucasians with CHB, the HCC risk after the first 5 years of antiviral therapy depends on age, baseline cirrhosis status and LSM at year 5. CAGE-B and particularly SAGE-B represent simple and reliable risk scores for HCC prediction and surveillance beyond year 5 of therapy. Electronic word count: 259
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Lay summary In Caucasians with chronic hepatitis B, the risk of hepatocellular carcinoma (HCC) after the first 5 years of entecavir or tenofovir therapy depends on age, baseline cirrhosis status and liver stiffness at year 5, which can provide simple and reliable risk scores for HCC prediction and surveillance beyond year 5. In patients with cirrhosis at baseline, liver stiffness <12 than ≥12 kPa at year 5 is associated with lower HCC risk, but surveillance may be still required.
10
Introduction Long-term monotherapy with one of the currently recommended nucleos(t)ide analogues (NAs), entecavir (ETV), tenofovir disoproxil fumarate (TDF) and tenofovir alafenamide, results in virological remission in almost all compliant chronic hepatitis B (CHB) patients and is associated with significant improvement of liver necroinflammation and fibrosis.1-3 CHB patients with or without compensated cirrhosis treated with ETV or TDF have also been shown to have excellent overall survival,4-6 similar to that of the general population.6 Hepatocellular carcinoma (HCC) remains the main challenge in the management of CHB patients nowadays, as it may occur even under effective antiviral therapy and is the only factor that affects liver-related mortality.6-9 Current antiviral agents decrease the HCC risk of CHB patients,7,8 who however remain at some risk for HCC development since HBV is not eradicated.8,10 Several groups have recently focused on the development of scores for the prediction of HCC in NA treated patients.11,12 However, most existing data on HCC prediction in NA treated CHB patients including all relevant data for Caucasians come from studies with mean/median treatment duration of <5 years.11,12 We recently showed that the incidence of HCC in Caucasian CHB patients is decreasing beyond year 5 of NA therapy, but HCC may still develop and cannot be accurately predicted by the existing risk scores including PAGE-B.13 Since the HCC incidence after 5 years of NA therapy is not high, large number of patients and long-term follow-up are required to efficiently assess potential predictors.
11
Having more extended follow-up of the PAGE-B cohort, this large, multicenter, ongoing cohort study aimed to assess predictors and need for HCC surveillance beyond year 5 of ETV/TDF in Caucasian CHB patients as well as to develop an accurate risk score for HCC prediction beyond year 5.
Patients and methods Patient population The PAGE-B ongoing cohort study included all (n=1951) CHB patients followed at the clinics of the 10 participating centers if they fulfilled the previously reported criteria.11 In summary, Caucasian adult CHB patients with ≥12-month ETV/TDF therapy started until December 2012 were included, while patients with decompensated cirrhosis, previously diagnosed HCC, coinfection(s) with hepatitis D, hepatitis C or human immunodeficiency virus and liver transplant were excluded. Of 1951 patients, 1427 (73%) have been followed for >5 years under ETV/TDF without HCC development within the first 5 years of therapy and represented this study population.
Follow-up-Definitions As previously reported,11 CHB was diagnosed in patients with positive HBsAg for ≥6 months, elevated ALT and serum HBV DNA >2000 IU/mL. The severity of liver disease before therapy was classified into CHB only (without cirrhosis) according to findings from liver biopsies and CHB with compensated cirrhosis according to histological, ultrasonographic and/or endoscopic findings. All patients were treated with ETV and/or TDF and followed at each centre according to international and/or national clinical practice guidelines. Clinical
12
examination and routine laboratory tests were performed every ≤6 months. Serum HBV DNA levels were determined every 6-12 months at the laboratory of each centre. Virological remission was considered to be present in case of HBV DNA <80 IU/mL that was maintained throughout ETV/TDF therapy. Cutoffs for upper limit of normal (ULN) of ALT proposed by different recommendations were considered: 30/19 IU/L for males/females (old AASLD-ULN),14 35/25 IU/L for males/females (new AASLD-ULN)2 and 40 IU/L for all patients (EASL-ULN).1 At year-5 of ETV/TDF, the severity of liver histological lesions and particularly of fibrosis was reassessed by transient elastography. Elastographic cirrhosis was considered to be present in cases with reliable liver stiffness measurements (LSM) of ≥12 kPa, which represents the lowest LSM cut-off for the diagnosis of cirrhosis according to the international guidelines.15 Ultrasonography, with or without alpha fetoprotein measurements, were performed every ≤6 months in cirrhotic and every ≤12 months in non-cirrhotic patients. HCC was diagnosed by standard histological and/or compatible radiological findings.16 Entry into this study (baseline) was defined as the onset of ETV/TDF. Followup was considered as the time interval between the study entry and the last available clinical information, while treatment duration was considered the time interval between the study entry until the end of therapy or the last ontherapy follow-up. Analysis time was the time interval between year 5 and HCC diagnosis or the end of follow-up in the absence of HCC development. The follow-up time was censored at 12 years.
13
Statistical analysis All data were analyzed using the statistical package Stata 13.0 (StataCorp LP, USA) and R (version 3.2.1). Continuous variables were summarised using median values and interquartile range or mean values and standard deviation. Categorical variables were summarized as frequencies and percentages. HCC incidence rates per 100 person-years were obtained using information on the number of new HCC diagnoses and the person-time at risk. KaplanMeier estimates of the cumulative probability of HCC occurrence in different subgroups were obtained and compared with the log-rank test. Cox proportional hazards regression models were used to estimate the effect of various variables on the hazard of HCC occurrence. Multivariable Cox proportional hazards models were used to identify independent prognostic factors. Hazard ratios (HR) and their 95% confidence intervals (CI) along with corresponding P values are presented. A prediction model was developed to predict the risk of HCC beyond year 5. We fitted univariable models and those variables that were found to be significant were then fitted together. Covariates which did not significantly increase the value of -2 log likelihood when they were omitted from the model were discarded. Variables that were not significant in the univariable analysis were added, one at time, to the model and the change in -2 log likelihood was assessed.17 As the model was intended for the prediction of HCC risk for those who are HCC-free at year 5, only variables measured at year 5 were used with the exception of liver disease severity. Thus, we assessed two models: a) a model with year-5 variables where information on the severity of liver disease at baseline (CHB or cirrhosis) and year 5 was combined, and b)
14
a model where only year 5 variables were considered. The latter was assessed as reliable information for the presence or absence of cirrhosis before the onset of therapy might not be available in clinical practice. To assess the discriminative performance of the resulting model, we used Harrell's c-index. We performed internal validation of the model using bootstrap. Bootstrap samples were random samples drawn with replacement from the original sample. We repeatedly fitted the model in 1000 bootstrap samples and evaluated its performance on the original sample. The next step was to develop a risk score based on a points system to simplify the computation of HCC risk estimate.18 We evaluated the agreement between risk estimates based on the points system and on the multivariable model (risk categories: <2%, 2%-8.9%, ≥9%) using weighted kappa. We assessed the discrimination and the calibration of the risk score by inspection of the KaplanMeier curves for risk groups stratified by the 25th and 75th percentiles of the risk score distribution. We estimated the sensitivity, specificity, positive predictive value and negative predictive value for various cut-offs of the risk score using appropriate methodology for censored data.19
Results Patient characteristics The main characteristics of the 1427 patients are shown in Table 1. The median duration of follow-up has been 8.4 years. At baseline and at year 5 of ETV/TDF, 805 (56.4%) and 992 (69.5%) patients were older than 50 years, respectively. Cirrhosis at baseline was present in 370 (26.6%) of 1393 patients with available histological data or in 16.3% (100/614) and 34.7%
15
(270/779) of patients ≤50 and >50 years old (P<0.001). At year 5, LSM ≥12 kPa (i.e. elastographic evidence for cirrhosis) was found in 96 (7.9%) of 1211 patients with available data or in 2.9% (10/339) and 9.9% (86/872) of patients ≤50 and >50 years old P<0.001). Of 315 patients with cirrhosis at baseline and available 5-year LSM, elastographic reversion of cirrhosis was considered to occur in 223 (70.8%) and maintenance of cirrhosis in 92 (29.2%) cases, while 3 (0.3%) of 873 patients without histological cirrhosis at baseline had LSM ≥12 kPa at year 5. One of the latter 3 patients was overweight and continued to drink alcohol (60-100 g daily), another patient was obese and developed radiological evidence of severe steatosis and signs of cirrhosis during on therapy follow-up and the third patient case was considered to have severe fibrosis (Ishak’s stage 4) at pretreatment liver biopsy and histological cirrhosis (Ishak’s stage 5) at a surgical liver biopsy during operation for colon cancer performed after two years of NA therapy.
HCC risk factors – Univariable analyses During years 5 to 12, HCC was diagnosed in 33 (2.3%) of the 1427 patients. The cumulative incidence of HCC development was 0.7%, 2.4%, 3.2% and 3.8% at 6, 8, 10 and 12 years, respectively (Figure 1). In univariable Cox regression models (Table 2), older age at either baseline or year 5 was a strong risk factor for HCC development (HR per year: 1.09, P<0.001). Age >50 years at ETV/TDF onset was also a significant predictor of HCC development (log-rank, P<0.001); HCC developed in 3.8% (32/838) and 0.2% (1/589) of patients >50 and ≤50 years old at ETV/TDF onset (P<0.001) as well as only in patients older than 50 years (33/992, 3.3%) and none of 435
16
cases ≤50 years old at year 5 of therapy (P<0.001). Gender did not affect the HCC incidence beyond year 5 (P=0.487). HCC during years 5 to 12 developed in 1.2% (12/1023) of patients without and 5.75 (21/370) of patients with cirrhosis at baseline (P<0.001) or in 1.0% (9/870) of patients without cirrhosis at baseline and LSM <12 kPa at year 5, 33.3% (1/3) of patients without cirrhosis at baseline and LSM ≥12 kPa at year 5 (the patient with Ishak’s stage 4 at baseline and 5 at two years of therapy), 4.9% (11/223) of patients with cirrhosis at baseline and LSM <12 kPa at year 5 and 9.8% (9/92) of patients with cirrhosis at baseline and LSM ≥12 kPa at year 5 (P<0.001). The 6, 8, 10, 12-year HCC incidence was lower in the 1023 patients without cirrhosis at baseline (0.5%, 1.2%, 1.7%, 1.7%) or the 870 patients without cirrhosis at baseline and LSM <12 kPa at year 5 (0.5%, 1.1%, 1.3%, 1.3%) compared to the 223 patients with elastographic reversion of cirrhosis (stiffness <12 kPa) at year 5 (0.9%, 3.6%, 6.2%, 10.7%; P<0.001) or the 92 patients who maintained cirrhosis (2.3%, 12.0%, 12.0%, 12.0%; P<0.001). Moreover, HCC incidence was lower in the 223 patients with elastographic reversion of cirrhosis than in the 92 patients who maintained cirrhosis at year 5 (P=0.019, log-rank test) (Figure 2). Liver stiffness ≥12 kPa at year 5, regardless of baseline cirrhosis, was also associated with higher HCC risk during years 5 to 12 (RH: 7.29, 95% CI: 3.40-15.66; P<0.001). HCC development was associated with lower platelet counts or platelets <150x109/L at baseline or year 5 as well as with platelets <100x109/L only at year 5 (Table 2). In patients >50 years old at year 5, the 6, 8 and 10-year HCC incidence was 1.3%, 5.0% and 8.9% in cases with platelets <150x109/L and 0.8%, 3.2% and 3.9% in cases with platelets ≥150x109/L (P=0.039).
17
Other patient characteristics associated with higher HCC incidence from year 5 to 12 were normal ALT by the old AASLD ULN at baseline, year 1 or year 5, lower or undetectable HBV DNA at baseline and prior use of NAs (Table 2).
Independent HCC risk factors – Multivariable analyses In multivariable Cox regression analysis including baseline parameters, older 3
3
age (HR per year: 1.08, P<0.001), low platelet count (≤150 x10 /mm ) (HR: 2.12, P=0.045] and presence of cirrhosis (HR: 2.61, P=0.016) were independently associated with higher HCC incidence from year 5 to 12 (Table 3). In a model including year-5 parameters, higher HCC incidence from year 5 to 12 was independently associated only with older age at year 5 (HR per year: 1.08, P<0.001) and liver stiffness ≥12 kPa (HR: 5.30, P<0.001). Moreover, HCC development was independently associated with older age and severity of liver elastography at year 5 in relation to baseline cirrhosis being lowest in patients without baseline cirrhosis and year-5 stiffness <12 kPa, intermediate in those with baseline cirrhosis and year-5 stiffness <12 kPa and highest in those with baseline cirrhosis and year-5 stiffness ≥12 kPa (Table 3).
Risk scores for prediction of HCC beyond year 5 Two risk scores were developed. In the first score, age and elastographic presence of cirrhosis at year 5 in relation to cirrhosis baseline status were retained to the final model. The c-index of the model was 0.814. After internal validation using bootstrap, the c-index was 0.806 and the calibration slope 0.962. The model score was simplified to an integer scoring system which
18
ranged from 0 to 16 [cirrhosis and age (CAGE-B) score] (Table 4). Higher score was associated with higher probability of HCC development beyond year 5 (HR per one unit increase: 1.47, 95% CI: 1.30-1.66; P<0.001). We further assessed the discriminative ability of the score by inspection of the Kaplan-Meier curves for risk groups stratified by the 25th and 75th percentiles of the score distribution (6 and 10 points). In patients with low (0-5), medium (6-10) and high (11-16) CAGE-B score, the 12-year cumulative HCC probability was 0%, 1.8% and 15.4% and HCC incidence was 0, 0.18 and 1.01 per 100 patient-years, respectively (Figure 3A). HCC developed only in patients with intermediate (10/674, 1.5%; incidence rate: 0.18 HCC/100 patient-years) or high score (19/230, 8.3%; incidence rate: 1.01 HCC/100 patient-years) versus none of 281 patients with low CAGE-B score (log-rank, P<0.001). In the second score, only age and elastographic presence of cirrhosis at year 5, regardless of cirrhosis baseline status, were retained to the final model. The c-index of the model was 0.809. After internal validation using bootstrap, the c-index was 0.805 and the calibration slope 0.995. The model score was simplified to an integer scoring system which ranged from 0 to 15 [stiffness and age (SAGE-B) score] (Table 4) (HR for HCC per one unit increase: 1.49, 95% CI: 1.32-1.68; P<0.001). We also assessed the discriminative ability of the SAGE-B score by inspection of the Kaplan-Meier curves for risk groups using the same cut-offs as in the previous score (6 and 10 points, respectively). In patients in the low (0-5), medium (6-10) and high (11-16) SAGE-B score, the 12-year cumulative HCC probability was 0%, 4.0% and 13.8% and the HCC incidence was 0, 0.29 and 1.51 per 100 patient-years,
19
respectively (Figure 3B). HCC developed only in patients with intermediate (21/815, 2.6%; incidence rate: 0.29 HCC/100 patient-years) or high score (10/88, 11.4%; incidence rate: 1.51 HCC/100 patient-years) versus none of 308 patients with low SAGE-B score (log-rank, P<0.001). There was very good agreement between the point system of both scores and the multivariable model (weighted kappa: 0.855 for CAGE-B and 0.875 for SAGE-B). The 12-year HCC risks according to the CAGE-B and SAGE-B scores are shown in Supplementary Figure 1. For both scores, the highest cut-off associated with 100% sensitivity and, as a result, 100% negative predictive value (NPV) was 6. In addition to the above models, we also assessed the predictability of lower LSM cut-offs (5, 6, 7, 8, 9, 10, 11 kPa) together with age (combined or not with baseline cirrhosis), which was similar or lower than that of the 12 kPa LSM cut-off (c-index: 0.769-0.819).
Discussion To our knowledge, this is the first study trying to accurately predict the development of HCC beyond year 5 of therapy with potent and high genetic barrier NAs, ETV and TDF, in Caucasian CHB patients, with or without compensated cirrhosis. We not only identified predictors of such late HCC development but also developed two simple HCC risk scores, CAGE-B and SAGE-B, which offer 100% NPV for HCC and therefore no need for HCC surveillance beyond year 5 in their low risk groups. Older age and presence of cirrhosis at baseline and/or elastographic presence of cirrhosis at year 5 represented the most important factors for late
20
HCC development. Older age is a well established risk factor for HCC development in CHB patients.20 An interesting finding of our study was that late HCC developed exclusively in patients older than 50 years at year 5 of therapy, which further supports that the residual HCC risk after several years of suppression of HBV replication may be related to longer duration of chronic HBV infection and/or hepatocyte senescence which are both linked to older age.21,22 Although the HCC risk is decreasing after 5 years of ETV/TDF therapy in Caucasian patients with CHB and compensated cirrhosis, it still remains higher than in patients without cirrhosis at baseline.13 Presence of cirrhosis at ETV/TDF onset was a significant risk factor for HCC development even after 5 years of therapy. Long-term histological data in patients treated with ETV or mostly TDF have shown that cirrhosis reversion can be achieved in approximately 75% of patients with baseline cirrhosis,3,23 but whether such a histological change is associated with decreased subsequent HCC risk is currently
unknown.
Potential
cirrhosis
reversion
estimated
by
liver
elastography (LSM <12 kPa) was observed in a similar proportion of our patients (71%) after 5 years of ETV/TDF therapy. Although liver elastography may not reliably determine the presence or absence of cirrhosis in patients with previous cirrhosis who maintain inactivity of their liver disease for some years, it is the most commonly used method which can easily and noninvasively offer relevant information in routine clinical practice. Our data show for the first time that patients with reversion of baseline cirrhosis, as assessed by liver elastography, have a significantly lower HCC risk after 5 years of therapy, compared to patients with cirrhosis at baseline
21
and no elastographic reversion of cirrhosis after 5 years of therapy. Such a reduction of the HCC risk is quite interesting, but LSM <12 kPa at year 5 alone cannot modify the need for HCC surveillance, as the mean annual HCC incidence from year 5 to 10 was greater than 0.2%, the threshold that has been considered to make HCC surveillance cost-effective,20 in both subgroups of our patients with cirrhosis at baseline and even in patients with CHB only. Thus, additional characteristics are required in order to identify patients who may not require HCC surveillance during NA therapy beyond year 5. Compared to the 12 kPa cut-off, lower LSM cut-offs combined with age were found to offer similar HCC predictability after year 5, but they could classify less patients into the low risk group. In the future, biological markers could be used to refine the diagnosis of cirrhosis and possibly improve the accuracy of fibrosis severity for HCC prediction in CHB patients. CAGE-B and SAGE-B scores are both simple and easy to use in routine clinical practice, as they are based on only two variables, age and presence or absence of cirrhosis. In fact, SAGE-B is simpler as, in addition to age at year 5, requires only liver stiffness at year 5 as a qualitative variable (≥12 or <12 kPa), while CAGE-B also requires knowledge of cirrhosis status at baseline. It is reassuring that the 12-year cumulative probability of HCC was 0% in the low risk groups of both scores, which included approximately 20% of our patients. Thus, the cut-off point of 6 in both scores offered 100% sensitivity and NPV for HCC prediction beyond year 5. If these findings are confirmed in other cohorts, it would mean that HCC surveillance can be avoided in patients with liver stiffness <12 kPa at year 5 who are younger than 40 years regardless of baseline fibrosis severity as well as in patients with liver stiffness
22
<12 kPa at year 5 who are 40-49 years old especially if they had no cirrhosis at baseline (Table 4). It should be noted however, that were rather few patients with baseline cirrhosis who were younger than 40 years and therefore strong conclusions cannot be drawn for this particular subgroup. Interestingly, two factors, gender and platelets, which have been associated with the HCC risk during the first 5 years of therapy,11 had no independent association with HCC development beyond year 5. The lack of association between gender and late HCC development cannot be easily explained, but a reasonable hypothesis might be that the protective effects of estrogens on hepatocarcinogenesis weaken in post-menopausal females who represented the majority of female patients in this cohort (median age: 58 years).25 Platelet counts at both baseline and year 5 were associated with the HCC incidence from year 5 to 12 only in univariable analyses and could not identify any patient subgroup with low HCC risk that would not justify HCC surveillance. Additional factors found initially to be associated with HCC incidence beyond year 5, like ALT, baseline HBV DNA and prior use of NAs, did not maintain their associations in multivariable analyses. Our study has a few limitations. First, HCC surveillance was based on ultrasonography
performed
by
different
radiologists
or
gastroenterologists/hepatologists, whereas the compliance may have varied across the centers and even among the patients of the same center. Thus, the diagnosis of HCC could have been delayed in some cases. Such problems, however, reflect the daily clinical practice and exist in all large cohort studies and even in carefully designed prospective large studies. In addition, as recently suggested, prompt HCC diagnosis seems to be increasing in recent
23
years at least in patients who remain under follow-up in specialized centers.24 Thus, given the natural course of HCC and the long-term follow-up of our patients in clinics of tertiary expert centers, we believe that delays in HCC diagnosis cannot substantially affect the validity of our findings. Second, since all our patients were Caucasians, it is unclear whether these findings are valid in NA treated CHB patients of different origin and perhaps infected with different HBV genotypes. Third, our study had only internal but lacked external validation, which is critical for any risk score,26 and therefore the proposed scores should be further tested in other cohorts before it can be considered for use in clinical practice. In particular, CAGE-B and SAGE-B scores should be first validated in at least one large independent cohort of Caucasian CHB patients and perhaps in Asian cohorts of CHB patients as well. In conclusion, in a large cohort of Caucasian CHB patients with or without compensated cirrhosis, HCC after the first 5 years of ETV/TDF therapy seems to develop exclusively in patients older than 50 years at year 5. In patients with cirrhosis before therapy, elastographic reversion at 5 years of therapy defined by LSM <12 kPa seems to significantly decrease the subsequent HCC risk. However, LSM at 5 years of therapy alone cannot identify patients who will not benefit from continued HCC surveillance. Thus, HCC surveillance should continue in all patients older than 50 years and probably in the few cirrhotics ≤50 years old. CAGE-B, which is based on age and LSM at year 5 and presence of baseline cirrhosis, and particularly SAGE-B, which is based on only age and LSM at year 5, represent two simple and reliable risk scores for HCC prediction and surveillance beyond year 5 of therapy offering 100% negative predictive values for HCC development in their low risk groups
24
including all patients with liver stiffness <12 kPa at year 5 who are less than 40 years old and probably 40-49 years old particularly if the latter had no cirrhosis at baseline. CAGE-B and SAGE-B scores should now be further validated in an independent large Caucasian cohort before definitive use for HCC surveillance in clinical practice.
25
References 1. European Association for the Study of the Liver. EASL 2017 Clinical Practice Guidelines on the management of hepatitis B virus infection. J Hepatol 2017;67:370-398. 2. Terrault NA, Lok ASF, McMahon BJ et al. Update on prevention, diagnosis, and treatment of chronic hepatitis B: AASLD 2018 hepatitis B guidance. Hepatology 2018;67:1560-1599. 3. Marcellin P, Gane E, Buti M et al. Regression of cirrhosis during treatment with tenofovir disoproxil fumarate for chronic hepatitis B: a 5year open-label follow-up study. Lancet 2013;381:468-475. 4. Wong GL, Chan HL, Mak CW et al. Entecavir treatment reduces hepatic events and deaths in chronic hepatitis B patients with liver cirrhosis. Hepatology 2013;58:1537-1547. 5. Lim YS, Han S, Heo NY et al. Mortality, liver transplantation, and hepatocellular carcinoma among patients with chronic hepatitis B treated with entecavir vs lamivudine. Gastroenterology 2014;147:152161. 6. Papatheodoridis GV, Sypsa V, Dalekos G et al. Eight-year survival in chronic hepatitis B patients under long-term entecavir or tenofovir therapy is similar to the general population. J Hepatol 2018;66:11291136. 7. Papatheodoridis GV, Lampertico P, Manolakopoulos S et al. Incidence of hepatocellular carcinoma in chronic hepatitis B patients receiving nucleos(t)ide therapy: a systematic review. J Hepatol 2010;53:348-356.
26
8. Papatheodoridis GV, Chan HL, Hansen BE et al. Risk of hepatocellular carcinoma in chronic hepatitis B: Assessment and modification with current antiviral therapy. J Hepatol 2015;62:956-967. 9. Vlachogiannakos J, Papatheodoridis G. Hepatocellular carcinoma in chronic hepatitis B patients under antiviral therapy. World J Gastroenterol 2013;19:8822-8830. 10. Lampertico P, Maini M, Papatheodoridis G. Optimal management of hepatitis B virus infection - EASL Special Conference. J Hepatol 2015;63:1238-1253. 11. Papatheodoridis G, Dalekos G, Sypsa V et al. PAGE-B predicts the risk of developing hepatocellular carcinoma in Caucasians with chronic hepatitis B on 5-year antiviral therapy. J Hepatol 2016;64:800-806. 12. Wong VWS, Janssen HLA. Can we use HCC risk scores to individualize surveillance in chronic hepatitis B infection? J Hepatol 2015;63:722-732. 13. Papatheodoridis G, Idilman R, Dalekos G et al. The risk of hepatocellular carcinoma decreases after the first 5 years of entecavir or tenofovir in Caucasians with chronic hepatitis B. Hepatology 2017;66:1444-1453. 14. Terrault NA, Bzowej NH, Chang KM et al. AASLD guidelines for treatment of chronic hepatitis B. Hepatology 2016;63:261-283. 15. European Association for the Study of the Liver, Asociacion Latinoamericana para el Estudio del Higado. EASL-ALEH Clinical Practice Guidelines: Non-invasive tests for evaluation of liver disease severity and prognosis. J Hepatol 2015;63:237-264.
27
16. European
Association
for
the
Study
of
the
Liver,
European
Organisation for Research and Treatment of Cancer. EASL-EORTC Clinical Practice Guidelines: Management of hepatocellular carcinoma. J Hepatol 2012;56:908-943. 17. Collett D. Modelling Survival Data in Medical Research. Boca Raton, FL: CRC Press, 2014. 18. Sullivan LM, Massaro JM, D'Agostino RB, Sr. Presentation of multivariate data for clinical use: The Framingham Study risk score functions. Stat Med 2004;23:1631-1660. 19. Heagerty PJ, Lumley T, Pepe MS. Time-dependent ROC curves for censored
survival
data
and
a
diagnostic
marker.
Biometrics
2000;56:337-344. 20. European Association for the Study of the Liver. EASL Clinical Practice Guidelines: Management of hepatocellular carcinoma. J Hepatol 2018;69:182-236. 21. Hadziyannis SJ, Papatheodoridis GV. Hepatitis Be antigen negative chronic hepatitis B – natural history and treatment. Semin Liver Dis 2006;26:130-141. 22. Wiemann SU, Satyanarayana A, Tsahuridu M et al. Hepatocyte telomere shortening and senescence are general markers of human liver cirrhosis. FASEB J 2002;16:935-942. 23. Chang TT, Liaw YF, Wu SS et al. Long-term entecavir therapy results in the reversal of fibrosis/cirrhosis and continued histological improvement in patients with chronic hepatitis B. Hepatology 2010;52:886-893.
28
24. Samji H, Yu A, Kuo M et al. Late hepatitis B and C diagnosis in relation to
disease
decompensation
and
hepatocellular
carcinoma
development. J Hepatol 2017;67:909-917. 25.
Ruggieri A, Gagliardi MC, Anticoli S. Sex-dependent outcome of hepatitis B and C viruses infections: synergy of sex hormones and immune responses? Front Immunol 2018;9:2302.
26.
Sherman M. HCC risk scores: useful or not? Semin Liver Dis 2017;37:287-295.
29
Table 1. Main characteristics of 1427 Caucasian patients with chronic hepatitis B (CHB), with or without compensated cirrhosis, treated with entecavir (ETV) or tenofovir disoproxil fumarate (TDF) for at least 5 years without development of hepatocellular carcinoma within the first 5 years of therapy. All patients’ characteristics were assessed at the onset of ETV/TDF, unless stated otherwise. Age, years
52.1±13.1
Male gender, n (%)
992 (69.5)
Body mass index1, kg/m2
26.0±4.8
Current alcohol use, n/N (%) None/Mild (<20/<10 g daily for M/F)
850/997 (85.3)
Moderate (20-60/10-40 g daily for M/F)
130/997 (13.0)
Abuse (>60/40 g daily for M/F)
17/997 (1.7)
Diabetes mellitus, n/N (%)
83/1008 (8.2)
Family history of HCC, n/N (%)
51/990 (5.2)
HBeAg positive patients, n/N (%) HBeAg positive patients at 5 years of ETV/TDF, n/N (%)
261/1422 (18.4) 73/1384 (5.4)
ALT ≤40 IU/L, n/N (%)
676/1366 (49.5)
ALT ≤35/25 IU/L for males/females (M/F), n/N (%)
539/1366 (39.5)
ALT ≤30/19 IU/L for M/F, n/N (%)
416/1366 (30.5)
ALT in patients with ALT >40 IU/L, IU/L
84 (54, 150)
ALT ≤40 IU/L at year 1 of ETV/TDF, n/N (%)
1055/1236 (85.4)
ALT ≤35/25 IU/L for M/F at year 1 of ETV/TDF, n/N (%)
874/1236 (70.7)
ALT ≤30/19 IU/L for M/F at year 1 of ETV/TDF, n/N (%)
683/1236 (55.3)
ALT ≤40 IU/L at year 5 of ETV/TDF, n/N (%)
1216/1341 (90.7)
30
ALT ≤35/25 IU/L for M/F at year 5 of ETV/TDF, n/N (%)
1091/1341 (81.4)
ALT ≤30/19 IU/L for M/F at year 5 of ETV/TDF, n/N (%)
886/1341 (66.1)
3
3
Platelet counts x10 /mm
194±63
Platelet counts, n/N (%) 3
3
1091/1393 (78.3)
>150 x10 /mm 3
3
100-150 x10 /mm 3
234/1393 (16.8) 68/1393 (4.9)
3
<100 x10 /mm Platelet counts at 5 years of ETV/TDF, n/N (%) 3
3
956/1159 (82.5)
>150 x10 /mm 3
3
100-150 x10 /mm 3
3
158/1159 (13.6) 45/1159 (3.9)
<100 x10 /mm HBV DNA <80 IU/mL, n/N (%) HBV DNA in cases with HBV DNA ≥80 IU/mL, log10 IU/ml
404/1358 (29.8) 5.6±1.9
HBV DNA <80 IU/mL at 5 years of ETV/TDF, n/N (%)
1378/1411 (97.7)
(Pegylated-)interferon-alfa in the past, n (%)
358/1427 (25.1)
Nucleos(t)ide analogue(s) before ETV/TDF, n (%)
642/1427 (45.0)
Disease severity, n (%) CHB without cirrhosis
1023 (71.7)
Compensated cirrhosis
370 (25.9)
Unknown
34 (2.4)
Elastographic disease severity at 5 years of ETV/TDF, n (%) CHB without cirrhosis (liver stiffness <12 kPa) Compensated cirrhosis (liver stiffness ≥12 kPa) Unknown
1115 (78.1) 96 (6.7) 216 (15.1)
31
Initial antiviral therapy, n (%) ETV monotherapy
515 (36.1)
ETV and adefovir
10 (0.7)
ETV and TDF
20 (1.4)
TDF monotherapy
609 (42.7)
TDF and lamivudine
268 (18.8)
TDF and telbivudine
5 (0.3)
Follow-up under therapy, months
101 (81, 111)
Quantitative variables are expressed as mean±standard deviation or median (25th, 75th) values; M/F: male/female; 1Body mass index was available in 1259 patients.
32
Table 2. Effects of patient characteristics on the incidence of hepatocellular carcinoma (HCC) within 5-12 years of entecavir (ETV) and/or tenofovir disoproxil fumarate (TDF) therapy in 1427 chronic hepatitis B patients, with or without compensated cirrhosis, without HCC within the first 5 years (univariable analyses). Baseline characteristics are those at the onset of ETV/TDF therapy. Characteristics at baseline
Hazard ratio (95% CI)
P
Age (per year increase)
1.09 (1.05, 1.13)
<0.001
Age (>50 vs ≤50 years old)
7.42 (2.26, 24.32)
0.001
Gender [male (M) vs female (F)]
1.33 (0.60, 2.94)
0.487
Body mass index (per kg/m2)
1.04 (0.99, 1.09)
0.154
Alcohol use (no/mild vs moderate vs abuse)
1.26 (0.54, 2.99)
0.593
Diabetes mellitus (yes vs no)
2.02 (0.70, 5.84)
0.196
Family history of HCC (yes vs no)
2.01 (0.59, 6.93)
0.268
HBeAg status (negative vs positive)
1.17 (0.45, 3.04)
0.743
ALT (per IU/L)
0.99 (0.98, 1.00)
0.109
ALT (>40 vs ≤40 IU/L)
0.52 (0.26, 1.08)
0.078
ALT (>35/25 vs ≤35/25 IU/L for M/F)
0.51 (0.26, 1.02)
0.056
ALT (>30/19 vs ≤30/19 IU/L for M/F)
0.34 (0.17, 0.68)
0.002
0.99 (0.98, 1.00)
0.013
3.09 (1.54, 6.22)
0.002
Platelets (≤100 vs >100 x10 /mm )
1.57 (0.37, 6.57)
0.540
Serum HBV DNA (per log10 IU/ml)
0.73 (0.61, 0.87)
0.001
Serum HBV DNA (≥80 vs <80 IU/mL)
0.26 (0.13, 0.52)
<0.001
3
3
Platelets (per 10 /mm ) 3
3
Platelets (≤150 vs >150 x10 /mm ) 3
3
33
(Peg-)IFNa in the past (yes vs no)
0.48 (0.19, 1.25)
0.133
NA(s) before ETV/TDF (yes vs no)
2.94 (1.39, 6.18)
0.005
Cirrhosis (yes vs no)
4.81 (2.36, 9.79)
<0.001
Initial antiviral regimen (TDF vs ETV)
1.24 (0.61, 2.53)
0.559
Hazard ratio (95% CI)
P
ALT (>40 vs ≤40 IU/L)
0.75 (0.23, 2.47)
0.635
ALT (>35/25 vs ≤35/25 IU/L for M/F)
0.53 (0.20, 1.39)
0.198
ALT (>30/19 vs ≤30/19 IU/L for M/F)
0.42 (0.18, 0.97)
0.043
Characteristics at year 5
Hazard ratio (95% CI)
P
Age (per year increase)
1.09 (1.05, 1.13)
<0.001
HBeAg status (negative vs positive)
0.59 (0.18, 1.93)
0.386
ALT (>40 vs ≤40 IU/L)
0.33 (0.05, 2.42)
0.277
ALT (>35/25 vs ≤35/25 IU/L for M/F)
0.65 (0.23, 1.86)
0.424
ALT (>30/19 vs ≤30/19 IU/L for M/F)
0.46 (0.19, 1.12)
0.087
Platelets (≤100 vs >100 x10 /mm )
7.50 (3.07, 18.33)
<0.001
HBV DNA (≥80 vs <80 IU/mL)
0.88 (0.33, 2.36)
0.805
Liver stiffness ≥12 kPa (yes vs no)
7.30 (3.40, 15.66)
<0.001
Liver stiffness (per kPa)
1.08 (1.06, 1.11)
<0.001
ALT at year 1
3
3
(Peg-)IFNa: pegylated interferon-alfa, NA(s): nucleos(t)ide analogue(s). Hazard ratio (95% CI [confidence interval]) from Cox regression analyses.
34
Table 3. Independent effects of patient characteristics on the incidence of hepatocellular carcinoma (HCC) within 5-12 years of entecavir (ETV) and/or tenofovir disoproxil fumarate (TDF) therapy in 1427 chronic hepatitis B patients without HCC within the first 5 years of therapy. Characteristics at baseline (onset of ETV/TDF)
Adjusted HR (95% CI)
P
Age (per year increase)
1.08 (1.04, 1.12)
<0.001
ALT (>30/19 vs ≤30/19 IU/L for M/F)
0.96 (0.41, 2.23)
0.923
Platelets (≤150 vs >150 x10 /mm )
2.12 (1.02, 4.43)
0.045
Serum HBV DNA (per log10 IU/ml)
0.82 (0.62, 1.07)
0.140
NA(s) before ETV/TDF (yes vs no)
1.00 (0.84, 1.19)
0.986
Cirrhosis (yes vs no)
2.61 (1.19, 5.70)
0.016
Adjusted HR (95% CI)
P
Age (per year increase)
1.08 (1.04, 1.12)
<0.001
ALT (>30/19 vs ≤30/19 IU/L for M/F)
0.57 (0.21, 1.51)
0.256
Platelets (≤150 vs >150 x10 /mm )
1.63 (0.72, 3.67)
0.239
Liver stiffness (≥12 vs <12 kPa)
5.30 (2.38, 11.80)
<0.001
Adjusted HR (95% CI)
P
Age at year 5 (per year increase)
1.08 (1.04, 1.12)
<0.001
ALT at year 5 (>30/19 vs ≤30/19 IU/L for M/F)
0.60 (0.23, 1.61)
0.310
1.43 (0.63, 3.25)
0.396
3
3
Characteristics at year 5 of ETV/TDF therapy
3
3
Characteristics at year 5 & baseline cirrhosis
3
3
Platelets at year 5 (≤150 vs >150 x10 /mm ) Fibrosis severity at baseline and year 5 - Baseline cirrhosis & stiffness <12 kPa at year 5
1
- Baseline CHB & stiffness <12 kPa at year 5
0.34 (0.14, 0.87)
0.024
- Baseline cirrhosis & stiffness ≥12 kPa at year 5
2.82 (1.15, 6.91)
0.024
35
NA(s): nucleos(t)ide analogue(s), CHB: chronic hepatitis B (without cirrhosis). HR [hazard ratio] (95% CI [confidence interval]) from multivariable Cox regression analyses.
36
Table 4. Risk scores for the prediction of hepatocellular carcinoma after 5 years of treatment with entecavir or tenofovir disoproxil fumarate in Caucasian chronic hepatitis B patients CAGE-B: Risk score based on year 5 SAGE-B: Risk score based on and baseline variables (range: 0-16)
year 5 variables (range: 0-15)
Age*,
Severity of fibrosis
Age*,
Elastographic severity
years
(baseline year 5)
years
of fibrosis at year 5
CHB LSM<12 kPa: 0 23-29: 0
LSM<12 kPa: 0
30-39: 2 Cirrhosis LSM<12 kPa: 3 30-39: 2
LSM≥12 kPa: 5
23-29: 0
40-49: 4 Cirrhosis LSM≥12 kPa: 6 40-49: 4 50-59: 6
50-59: 6
60-69: 8
60-69: 8
≥70: 10
≥70: 10
CAGE-B: cirrhosis and age, SAGE-B: stiffness and age, CHB: chronic hepatitis B without cirrhosis, LSM: liver stiffness measurement; *Age at year 5.
37
FIGURE LEGENDS Figure 1. Cumulative probability of hepatocellular carcinoma (HCC) beyond year 5 of therapy with entecavir or tenofovir disoproxil fumarate in Caucasian chronic hepatitis B patients (dashed lines: 95% confidence intervals). Figure 2. Cumulative probability of hepatocellular carcinoma (HCC) beyond year 5 of therapy with entecavir or tenofovir disoproxil fumarate in Caucasian chronic hepatitis B patients in relation to their cirrhosis (Ci) status at baseline (A) or to their cirrhosis (Ci) status at baseline and the elastographic presence or absence of cirrhosis [liver stiffness (LS) <12 or ≥12 kPa) at year 5 (B). CHB: chronic hepatitis B without cirrhosis. P values by log-rank tests from Kaplan-Meier analyses. Figure 3. Cumulative probability of hepatocellular carcinoma (HCC) beyond year 5 of therapy with entecavir or tenofovir disoproxil fumarate in Caucasian chronic hepatitis B patients according to the CAGE-B (A) and the SAGE-B score (B) risk groups. P values by log-rank tests from Kaplan-Meier analyses.
Cumulative probability of HCC
.2
.15
.1
.05
0 0
1
2
3
4 5 6 7 8 Years since ETV/TDF initiation Number at risk 1427
Fig. 1
1252
1007
777
9
10
11
12
460
178
52
16
Cumulative probability of HCC
0.16 0.14 0.12
Ci
0.10 0.08 0.06
p<0.001
0.04 CHB 0.02 0.00 0
1
2
3
4 5 6 7 8 9 Years since ETV/TDF initiation Number at risk CHB Ci
Fig. 2A
1023 370
888 333
715 264
541 210
340 107
10
11
12
144 31
50 1
16 0
Cumulative probability of HCC
0.16 0.14 Ci-Ci
0.12
p=0.019
0.10 0.08 Ci-CHB 0.06 p<0.001
0.04 0.02
CHB-CHB
0.00 0
1
2
3
4 5 6 7 8 9 Years since ETV/TDF initiation Number at risk Ci-CHB CHB-CHB Ci-Ci
Fig. 2B
223 870 92
212 781 82
193 658 52
164 510 36
89 328 15
10
11
12
23 138 6
0 49 0
0 15 0
CAGE-B:0-5 CAGE-B:6-10
Cumulative probability of HCC
CAGE-B:11-16
0.25 0.20
P<0.001 CAGE-B 11-16
0.15 0.10 0.05
CAGE-B 6-10 CAGE-B 0-5
0.00 0
1
2
3
4 5 6 7 8 9 Years since ETV/TDF initiation Number at risk 0-5 6-10 11-16
Fig. 3A
281 674 230
253 611 211
211 519 173
158 413 139
106 257 69
10
11
12
36 110 21
15 34 0
2 13 0
SAGE-B:0-5 SAGE-B:6-10
Cumulative probability of HCC
SAGE-B:11-15
0.25 0.20
P<0.001
0.15
SAGE-B 11-15
0.10 0.05
SAGE-B 6-10 SAGE-B 0-5
0.00 0
1
2
3
4 5 6 7 8 9 Years since ETV/TDF initiation Number at risk 0-5 6-10 11-15
Fig. 3B
308 815 88
280 743 78
235 643 48
179 519 34
120 310 13
10
11
12
39 125 5
16 34 0
2 13 0
Highlights • In Caucasians with chronic hepatitis B, age >50 years, baseline cirrhosis and liver stiffness (LSM) ≥12 kPa at year 5 are independently associated with increased risk of hepatocellular carcinoma (HCC) after the first 5 years of entecavir or tenofovir therapy • In patients with cirrhosis at baseline, liver stiffness <12 than ≥12 kPa at year 5 is associated with lower HCC risk, but surveillance may be still required. • CAGE-B score based on age at year 5 and baseline cirrhosis in relation to LSM at year 5 and SAGE-B score based only on age and LSM at year 5 represent simple and reliable risk scores for HCC prediction and surveillance beyond year 5 of therapy
S0168-8278(20)30022-2
DOI:
https://doi.org/10.1016/j.jhep.2020.01.007
Reference:
JHEPAT 7592
To appear in:
Journal of Hepatology
Received Date: 24 April 2019 Revised Date:
27 November 2019
Accepted Date: 4 January 2020
Please cite this article as: Papatheodoridis GV, Sypsa V, Dalekos GN, Yurdaydin C, Van Boemmel F, Buti M, Calleja JL, Chi H, Goulis J, Manolakopoulos S, Loglio A, Voulgaris T, Gatselis N, Keskin O, Veelken R, Lopez-Gomez M, Hansen BE, Savvidou S, Kourikou A, Vlachogiannakos J, Galanis K, Idilman R, Esteban R, Janssen HL, Berg T, Lampertico P, Hepatocellular carcinoma prediction beyond year 5 of oral therapy in a large cohort of Caucasian patients with chronic hepatitis B, Journal of Hepatology (2020), doi: https://doi.org/10.1016/j.jhep.2020.01.007. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.
Risk scores for the prediction of hepatocellular carcinoma after 5 years of treatment with entecavir or tenofovir disoproxil fumarate in Caucasian chronic hepatitis B patients CAGE-B: Risk score based on year 5 and baseline variables (range: 0-16) Age at year 5, years 23-29: 0
Severity of fibrosis (baseline year 5)
Age at year 5, years
CAGE-B:0-5 CHB LSM<12 kPa: 0
23-29: 0
SAGE-B:0-5
CAGE-B:6-10
30-39: 2
SAGE-B:6-10
CAGE-B:11-16
40-49: 4
SAGE-B:11-15
30-39: 2
0.25
Cirrhosis LSM<12 kPa: 3
50-59: 6 60-69: 8
0.20
Cirrhosis LSM≥12 kPa: 6
≥70: 10 CAGE-B 11-16
0.15 0.10
P<0.001
0.05 CAGE-B 6-10 CAGE-B 0-5
0.00 0
1
2
3
4 5 6 7 8 9 Years since ETV/TDF initiation Number at risk 0-5 6-10 11-16
281 674 230
253 611 211
211 519 173
158 413 139
106 257 69
10
11
12
36 110 21
15 34 0
2 13 0
Cumulative probability of HCC
Cumulative probability of HCC
40-49: 4
SAGE-B: Risk score based on year 5 variables (range: 0-15)
0.25
Elastographic severity of fibrosis at year 5 LSM<12 kPa: 0
50-59: 6
LSM≥12 kPa: 5
60-69: 8
0.20
≥70: 10 SAGE-B 11-15
0.15 0.10
P<0.001 SAGE-B 6-10
0.05
SAGE-B 0-5
0.00 0
1
2
3
4 5 6 7 8 9 Years since ETV/TDF initiation Number at risk 0-5 6-10 11-15
308 815 88
CHB: chronic hepatitis B without cirrhosis, LSM: liver stiffness measurement
280 743 78
235 643 48
179 519 34
120 310 13
10
11
12
39 125 5
16 34 0
2 13 0
1
Hepatocellular carcinoma prediction beyond year 5 of oral therapy in a large cohort of Caucasian patients with chronic hepatitis B
George V. Papatheodoridis1, Vana Sypsa2, George N. Dalekos3, Cihan Yurdaydin4, Florian Van Boemmel5, Maria Buti6, Jose Luis Calleja7, Heng Chi8, John Goulis9, Spilios Manolakopoulos1,10, Alessandro Loglio11, Theodoros Voulgaris1, Nikolaos Gatselis3, Onur Keskin4, Rhea Veelken5, Marta LopezGomez7, Bettina E Hansen8,12, Savvoula Savvidou9, Anastasia Kourikou10, John
Vlachogiannakos1,
Kostas
Galanis3,
Ramazan
Idilman4,
Rafael
Esteban6, Harry LA Janssen12, Thomas Berg5, Pietro Lampertico11.
1
Department
of
Gastroenterology,
Medical
School
of
National
and
Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece; 2
Department of Hygiene, Epidemiology & Medical Statistics, Medical School of
National and Kapodistrian University of Athens, Athens, Greece; 3Department of
Internal
Medicine,
Thessalia
University
Medical
School,
Larissa,
Greece; 4Department of Gastroenterology, University of Ankara Medical School, Ankara, Turkey;
5
Division of Hepatology, Clinic and Polyclinic for
Gastroenterology, Hepatology, Infectiology and Pneumology, University Clinic Leipzig, Germany; 6Hospital General Universitario Valle Hebron and Ciberehd, Barcelona, Spain; 7Hospital U Puerta de Hierro, IDIPHIM CIBERehd, Madrid, Spain; 8Department of Gastroenterology & Hepatology, Erasmus MC, University Medical Center, Rotterdam, Netherlands;
9
4th Department of
Internal Medicine, Αristotle University of Thessaloniki Medical School,
2
Thessaloniki, Greece;
10
2nd Department of Internal Medicine, Medical School
of National and Kapodistrian University of Athens, Hippokratio General Hospital of Athens, Athens, Greece;
11
CRC “AM e A Migliavacca” Center for
Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milano, Italy; 12Liver Clinic, Toronto Western & General Hospital, University Health Network, Toronto, ON, Canada.
Corresponding author: George V. Papatheodoridis, MD, PhD. Director of Department
of
Gastroenterology,
School
of
Medicine,
National
and
Kapodistrian University of Athens, Laiko General Hospital of Athens, 17 Agiou Thoma street, 11527 Athens, Greece. Tel: +30 2132061115, Fax: +30 2107462601, email: [email protected]
Key words: cirrhosis; liver stiffness; entecavir; tenofovir
Word count: 6289 (including abstract, text, references, tables and figures legends). Tables: 4, Figures: 3, References: 26.
Conflict of interest - Financial support statement There has been no kind of support for this study by any source GV Papatheodoridis: advisor/lecturer for Abbvie, Bristol-Myers Squibb, Dicerna, Gilead, GlaxoSmithKline, Ipsen, Janssen, Merck Sharp & Dohme, Roche, Spring Bank; research grants Abbvie, Bristol- Myers Squibb, Gilead.
3
V Sypsa: advisor/lecturer for Abbvie, Gilead; research grants from Abbvie, Gilead. GN Dalekos: advisor/lecturer for Abbvie, Bayer, Genkyotex, Gilead, Ipsen, Janssen, Novartis, Pfizer, Roche; research grants from Abbvie, Gilead. C Yurdaydin: speaker's bureau and/or advisor for AbbVie, Bristol-Myers Squibb, Gilead, Merck, Roche; research grant from Bristol-Myers Squibb. F van Boemmel: advisor/lecturer for Abbvie, Bristol-Myers Squibb, Gilead, Janssen, Merck Sharp & Dohme, Novartis, Roche; research grants from Bristol- Myers Squibb, Gilead, Janssen, Roche, Siemens; consultant for Abbvie, Gilead, Roche. M Buti: advisor/lecturer for Abbvie, Arbutus, Bristol-Myers Squibb, Gilead, Glaxo Smith-Kleine, Merck, Roche, Spring Bank JL Calleja: advisor/lecturer for Abbvie , Bristol-Myers Squibb, Gilead, Janssen, Merck. H Chi: Nothing to declare. J Goulis: advisor/lecturer for Gilead, GlaxoSmithKline, Merck Sharp & Dohme, Roche; research grant from Gilead. S Manolakopoulos: advisor/lecturer for Abbvie, Gilead, GlaxoSmithKline, Ipsen, Merck Sharp & Dohme, Novartis, Roche; research grants from Abbvie, Gilead. A Loglio: advisor/lecturer for Gilead, MYR Pharma. T Voulgaris: Nothing to declare. N Gatselis: Nothing to declare. O Keskın: Nothing to declare. R Veelken: Nothing to declare
4
M Lopez-Gomez: Nothing to declare BE Hansen: Nothing to declare. S Savvidou: Nothing to declare. A Kourikou: Nothing to declare. I Vlachogiannakos: advisor/lecturer for Abbvie, Bristol-Myers Squibb, Gilead, Merck Sharp & Dohme, Novartis, Roche. K Galanis: Nothing to declare. R Idilman: Nothing to declare. R Esteban: advisor/lecturer for Abbvie, Boehringer Ingelheim, Bristol-Myers Squibb, Gilead, GlaxoSmithKline, Janssen, Merck, Novartis. HLA Janssen: consultant for and grants from AbbVie, Arbutus, Bristol Myers Squibb, Enyo, Gilead Sciences, Janssen, Medimmune, Merck, Roche, Vir Biotechnology Inc., Viroclinics. T Berg: advisor/consultant/lecturer for Abbvie, Alexion, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Gilead, GlaxoSmithKline, Janssen, Merck Sharp & Dohme/Merck, Novartis, Roche, and Vertex; Research support from Abbvie, Bristol-Myers Squibb, Gilead, Janssen, Merck Sharp & Dohme/Merck, Novartis and Roche. P Lampertico: speaking bureau/advisor for Abbvie, Eiger, Bristol-Myers Squibb, Gilead, GlaxoSmithKline, Merck/ Merck Sharp & Dohme, MYR Pharma, Roche.
Author contributions
5
GV Papatheodoridis: Conception and design of the study; Assembly, analysis and interpretation of data; Drafting of the manuscript; Approval of the final version of the manuscript. V Sypsa: Statistical analysis and interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. G Dalekos: Design of the study; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. C Yurdaydin: Design of the study; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. F Van Boemmel: Data collection; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. M Buti: Conception and design of the study; Data collection; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. JL Calleja: Data collection; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. H Chi: Data collection; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. J Goulis: Design of the study; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. S Manolakopoulos: Design of the study; Data collection; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. A Loglio: Data collection; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript.
6
T Voulgaris: Data collection; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. N Gatselis: Data collection; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. O Keskın: Data collection; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. R Veelken: Data collection; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. ML-Gomez: Data collection; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. BE Hansen: Design of the study; Data collection; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. S Savvidou: Data collection; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. A Kourikou: Data collection; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. I Vlachogiannakos: Data collection; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. K Galanis: Data collection; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. R Idilman: Data collection; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. R Esteban: Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript.
7
HLA Janssen: Design of the study; Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. T Berg: Interpretation of data; Revision of the manuscript; Approval of the final version of the manuscript. P Lampertico: Conception and design of the study; Interpretation of data; Drafting of the manuscript; Approval of the final version of the manuscript.
8
ABSTRACT Background & Aims: Hepatocellular carcinoma (HCC) may develop in chronic hepatitis (CHB) patients even after 5 years of oral therapy and cannot be easily predicted. We assessed predictors and need for HCC surveillance in this setting. Methods: Of 1951 adult Caucasians with CHB included in the PAGE-B cohort, 1427 (73%) have completed follow-up >5 years under therapy without HCC until year 5. Median follow-up has been 8.4 years from treatment onset. Points-based risk scores were developed to predict HCC risk after year 5. Results: In years 5-12, HCC has been diagnosed in 33/1427 (2.3%) patients with cumulative incidence 2.4%, 3.2% and 3.8% at 8, 10 and 12 years, respectively. Older age or age >50 years, baseline cirrhosis and liver stiffness (LSM) ≥12 kPa at year 5 were independently associated with increased HCC risk. The HCC incidence was lower in non-cirrhotics than those with baseline cirrhosis and year-5 LSM <12 kPa than those with baseline cirrhosis and year5 LSM ≥12 kPa. CAGE-B score was based on age at year 5 and baseline cirrhosis in relation to LSM at year 5 and SAGE-B score was based only on age and LSM at year 5 (c-index=0.809-0.814, 0.805-0.806 after bootstrap validation). Both scores offered 100% negative predictive values for HCC development in their low risk groups. Conclusions: In Caucasians with CHB, the HCC risk after the first 5 years of antiviral therapy depends on age, baseline cirrhosis status and LSM at year 5. CAGE-B and particularly SAGE-B represent simple and reliable risk scores for HCC prediction and surveillance beyond year 5 of therapy. Electronic word count: 259
9
Lay summary In Caucasians with chronic hepatitis B, the risk of hepatocellular carcinoma (HCC) after the first 5 years of entecavir or tenofovir therapy depends on age, baseline cirrhosis status and liver stiffness at year 5, which can provide simple and reliable risk scores for HCC prediction and surveillance beyond year 5. In patients with cirrhosis at baseline, liver stiffness <12 than ≥12 kPa at year 5 is associated with lower HCC risk, but surveillance may be still required.
10
Introduction Long-term monotherapy with one of the currently recommended nucleos(t)ide analogues (NAs), entecavir (ETV), tenofovir disoproxil fumarate (TDF) and tenofovir alafenamide, results in virological remission in almost all compliant chronic hepatitis B (CHB) patients and is associated with significant improvement of liver necroinflammation and fibrosis.1-3 CHB patients with or without compensated cirrhosis treated with ETV or TDF have also been shown to have excellent overall survival,4-6 similar to that of the general population.6 Hepatocellular carcinoma (HCC) remains the main challenge in the management of CHB patients nowadays, as it may occur even under effective antiviral therapy and is the only factor that affects liver-related mortality.6-9 Current antiviral agents decrease the HCC risk of CHB patients,7,8 who however remain at some risk for HCC development since HBV is not eradicated.8,10 Several groups have recently focused on the development of scores for the prediction of HCC in NA treated patients.11,12 However, most existing data on HCC prediction in NA treated CHB patients including all relevant data for Caucasians come from studies with mean/median treatment duration of <5 years.11,12 We recently showed that the incidence of HCC in Caucasian CHB patients is decreasing beyond year 5 of NA therapy, but HCC may still develop and cannot be accurately predicted by the existing risk scores including PAGE-B.13 Since the HCC incidence after 5 years of NA therapy is not high, large number of patients and long-term follow-up are required to efficiently assess potential predictors.
11
Having more extended follow-up of the PAGE-B cohort, this large, multicenter, ongoing cohort study aimed to assess predictors and need for HCC surveillance beyond year 5 of ETV/TDF in Caucasian CHB patients as well as to develop an accurate risk score for HCC prediction beyond year 5.
Patients and methods Patient population The PAGE-B ongoing cohort study included all (n=1951) CHB patients followed at the clinics of the 10 participating centers if they fulfilled the previously reported criteria.11 In summary, Caucasian adult CHB patients with ≥12-month ETV/TDF therapy started until December 2012 were included, while patients with decompensated cirrhosis, previously diagnosed HCC, coinfection(s) with hepatitis D, hepatitis C or human immunodeficiency virus and liver transplant were excluded. Of 1951 patients, 1427 (73%) have been followed for >5 years under ETV/TDF without HCC development within the first 5 years of therapy and represented this study population.
Follow-up-Definitions As previously reported,11 CHB was diagnosed in patients with positive HBsAg for ≥6 months, elevated ALT and serum HBV DNA >2000 IU/mL. The severity of liver disease before therapy was classified into CHB only (without cirrhosis) according to findings from liver biopsies and CHB with compensated cirrhosis according to histological, ultrasonographic and/or endoscopic findings. All patients were treated with ETV and/or TDF and followed at each centre according to international and/or national clinical practice guidelines. Clinical
12
examination and routine laboratory tests were performed every ≤6 months. Serum HBV DNA levels were determined every 6-12 months at the laboratory of each centre. Virological remission was considered to be present in case of HBV DNA <80 IU/mL that was maintained throughout ETV/TDF therapy. Cutoffs for upper limit of normal (ULN) of ALT proposed by different recommendations were considered: 30/19 IU/L for males/females (old AASLD-ULN),14 35/25 IU/L for males/females (new AASLD-ULN)2 and 40 IU/L for all patients (EASL-ULN).1 At year-5 of ETV/TDF, the severity of liver histological lesions and particularly of fibrosis was reassessed by transient elastography. Elastographic cirrhosis was considered to be present in cases with reliable liver stiffness measurements (LSM) of ≥12 kPa, which represents the lowest LSM cut-off for the diagnosis of cirrhosis according to the international guidelines.15 Ultrasonography, with or without alpha fetoprotein measurements, were performed every ≤6 months in cirrhotic and every ≤12 months in non-cirrhotic patients. HCC was diagnosed by standard histological and/or compatible radiological findings.16 Entry into this study (baseline) was defined as the onset of ETV/TDF. Followup was considered as the time interval between the study entry and the last available clinical information, while treatment duration was considered the time interval between the study entry until the end of therapy or the last ontherapy follow-up. Analysis time was the time interval between year 5 and HCC diagnosis or the end of follow-up in the absence of HCC development. The follow-up time was censored at 12 years.
13
Statistical analysis All data were analyzed using the statistical package Stata 13.0 (StataCorp LP, USA) and R (version 3.2.1). Continuous variables were summarised using median values and interquartile range or mean values and standard deviation. Categorical variables were summarized as frequencies and percentages. HCC incidence rates per 100 person-years were obtained using information on the number of new HCC diagnoses and the person-time at risk. KaplanMeier estimates of the cumulative probability of HCC occurrence in different subgroups were obtained and compared with the log-rank test. Cox proportional hazards regression models were used to estimate the effect of various variables on the hazard of HCC occurrence. Multivariable Cox proportional hazards models were used to identify independent prognostic factors. Hazard ratios (HR) and their 95% confidence intervals (CI) along with corresponding P values are presented. A prediction model was developed to predict the risk of HCC beyond year 5. We fitted univariable models and those variables that were found to be significant were then fitted together. Covariates which did not significantly increase the value of -2 log likelihood when they were omitted from the model were discarded. Variables that were not significant in the univariable analysis were added, one at time, to the model and the change in -2 log likelihood was assessed.17 As the model was intended for the prediction of HCC risk for those who are HCC-free at year 5, only variables measured at year 5 were used with the exception of liver disease severity. Thus, we assessed two models: a) a model with year-5 variables where information on the severity of liver disease at baseline (CHB or cirrhosis) and year 5 was combined, and b)
14
a model where only year 5 variables were considered. The latter was assessed as reliable information for the presence or absence of cirrhosis before the onset of therapy might not be available in clinical practice. To assess the discriminative performance of the resulting model, we used Harrell's c-index. We performed internal validation of the model using bootstrap. Bootstrap samples were random samples drawn with replacement from the original sample. We repeatedly fitted the model in 1000 bootstrap samples and evaluated its performance on the original sample. The next step was to develop a risk score based on a points system to simplify the computation of HCC risk estimate.18 We evaluated the agreement between risk estimates based on the points system and on the multivariable model (risk categories: <2%, 2%-8.9%, ≥9%) using weighted kappa. We assessed the discrimination and the calibration of the risk score by inspection of the KaplanMeier curves for risk groups stratified by the 25th and 75th percentiles of the risk score distribution. We estimated the sensitivity, specificity, positive predictive value and negative predictive value for various cut-offs of the risk score using appropriate methodology for censored data.19
Results Patient characteristics The main characteristics of the 1427 patients are shown in Table 1. The median duration of follow-up has been 8.4 years. At baseline and at year 5 of ETV/TDF, 805 (56.4%) and 992 (69.5%) patients were older than 50 years, respectively. Cirrhosis at baseline was present in 370 (26.6%) of 1393 patients with available histological data or in 16.3% (100/614) and 34.7%
15
(270/779) of patients ≤50 and >50 years old (P<0.001). At year 5, LSM ≥12 kPa (i.e. elastographic evidence for cirrhosis) was found in 96 (7.9%) of 1211 patients with available data or in 2.9% (10/339) and 9.9% (86/872) of patients ≤50 and >50 years old P<0.001). Of 315 patients with cirrhosis at baseline and available 5-year LSM, elastographic reversion of cirrhosis was considered to occur in 223 (70.8%) and maintenance of cirrhosis in 92 (29.2%) cases, while 3 (0.3%) of 873 patients without histological cirrhosis at baseline had LSM ≥12 kPa at year 5. One of the latter 3 patients was overweight and continued to drink alcohol (60-100 g daily), another patient was obese and developed radiological evidence of severe steatosis and signs of cirrhosis during on therapy follow-up and the third patient case was considered to have severe fibrosis (Ishak’s stage 4) at pretreatment liver biopsy and histological cirrhosis (Ishak’s stage 5) at a surgical liver biopsy during operation for colon cancer performed after two years of NA therapy.
HCC risk factors – Univariable analyses During years 5 to 12, HCC was diagnosed in 33 (2.3%) of the 1427 patients. The cumulative incidence of HCC development was 0.7%, 2.4%, 3.2% and 3.8% at 6, 8, 10 and 12 years, respectively (Figure 1). In univariable Cox regression models (Table 2), older age at either baseline or year 5 was a strong risk factor for HCC development (HR per year: 1.09, P<0.001). Age >50 years at ETV/TDF onset was also a significant predictor of HCC development (log-rank, P<0.001); HCC developed in 3.8% (32/838) and 0.2% (1/589) of patients >50 and ≤50 years old at ETV/TDF onset (P<0.001) as well as only in patients older than 50 years (33/992, 3.3%) and none of 435
16
cases ≤50 years old at year 5 of therapy (P<0.001). Gender did not affect the HCC incidence beyond year 5 (P=0.487). HCC during years 5 to 12 developed in 1.2% (12/1023) of patients without and 5.75 (21/370) of patients with cirrhosis at baseline (P<0.001) or in 1.0% (9/870) of patients without cirrhosis at baseline and LSM <12 kPa at year 5, 33.3% (1/3) of patients without cirrhosis at baseline and LSM ≥12 kPa at year 5 (the patient with Ishak’s stage 4 at baseline and 5 at two years of therapy), 4.9% (11/223) of patients with cirrhosis at baseline and LSM <12 kPa at year 5 and 9.8% (9/92) of patients with cirrhosis at baseline and LSM ≥12 kPa at year 5 (P<0.001). The 6, 8, 10, 12-year HCC incidence was lower in the 1023 patients without cirrhosis at baseline (0.5%, 1.2%, 1.7%, 1.7%) or the 870 patients without cirrhosis at baseline and LSM <12 kPa at year 5 (0.5%, 1.1%, 1.3%, 1.3%) compared to the 223 patients with elastographic reversion of cirrhosis (stiffness <12 kPa) at year 5 (0.9%, 3.6%, 6.2%, 10.7%; P<0.001) or the 92 patients who maintained cirrhosis (2.3%, 12.0%, 12.0%, 12.0%; P<0.001). Moreover, HCC incidence was lower in the 223 patients with elastographic reversion of cirrhosis than in the 92 patients who maintained cirrhosis at year 5 (P=0.019, log-rank test) (Figure 2). Liver stiffness ≥12 kPa at year 5, regardless of baseline cirrhosis, was also associated with higher HCC risk during years 5 to 12 (RH: 7.29, 95% CI: 3.40-15.66; P<0.001). HCC development was associated with lower platelet counts or platelets <150x109/L at baseline or year 5 as well as with platelets <100x109/L only at year 5 (Table 2). In patients >50 years old at year 5, the 6, 8 and 10-year HCC incidence was 1.3%, 5.0% and 8.9% in cases with platelets <150x109/L and 0.8%, 3.2% and 3.9% in cases with platelets ≥150x109/L (P=0.039).
17
Other patient characteristics associated with higher HCC incidence from year 5 to 12 were normal ALT by the old AASLD ULN at baseline, year 1 or year 5, lower or undetectable HBV DNA at baseline and prior use of NAs (Table 2).
Independent HCC risk factors – Multivariable analyses In multivariable Cox regression analysis including baseline parameters, older 3
3
age (HR per year: 1.08, P<0.001), low platelet count (≤150 x10 /mm ) (HR: 2.12, P=0.045] and presence of cirrhosis (HR: 2.61, P=0.016) were independently associated with higher HCC incidence from year 5 to 12 (Table 3). In a model including year-5 parameters, higher HCC incidence from year 5 to 12 was independently associated only with older age at year 5 (HR per year: 1.08, P<0.001) and liver stiffness ≥12 kPa (HR: 5.30, P<0.001). Moreover, HCC development was independently associated with older age and severity of liver elastography at year 5 in relation to baseline cirrhosis being lowest in patients without baseline cirrhosis and year-5 stiffness <12 kPa, intermediate in those with baseline cirrhosis and year-5 stiffness <12 kPa and highest in those with baseline cirrhosis and year-5 stiffness ≥12 kPa (Table 3).
Risk scores for prediction of HCC beyond year 5 Two risk scores were developed. In the first score, age and elastographic presence of cirrhosis at year 5 in relation to cirrhosis baseline status were retained to the final model. The c-index of the model was 0.814. After internal validation using bootstrap, the c-index was 0.806 and the calibration slope 0.962. The model score was simplified to an integer scoring system which
18
ranged from 0 to 16 [cirrhosis and age (CAGE-B) score] (Table 4). Higher score was associated with higher probability of HCC development beyond year 5 (HR per one unit increase: 1.47, 95% CI: 1.30-1.66; P<0.001). We further assessed the discriminative ability of the score by inspection of the Kaplan-Meier curves for risk groups stratified by the 25th and 75th percentiles of the score distribution (6 and 10 points). In patients with low (0-5), medium (6-10) and high (11-16) CAGE-B score, the 12-year cumulative HCC probability was 0%, 1.8% and 15.4% and HCC incidence was 0, 0.18 and 1.01 per 100 patient-years, respectively (Figure 3A). HCC developed only in patients with intermediate (10/674, 1.5%; incidence rate: 0.18 HCC/100 patient-years) or high score (19/230, 8.3%; incidence rate: 1.01 HCC/100 patient-years) versus none of 281 patients with low CAGE-B score (log-rank, P<0.001). In the second score, only age and elastographic presence of cirrhosis at year 5, regardless of cirrhosis baseline status, were retained to the final model. The c-index of the model was 0.809. After internal validation using bootstrap, the c-index was 0.805 and the calibration slope 0.995. The model score was simplified to an integer scoring system which ranged from 0 to 15 [stiffness and age (SAGE-B) score] (Table 4) (HR for HCC per one unit increase: 1.49, 95% CI: 1.32-1.68; P<0.001). We also assessed the discriminative ability of the SAGE-B score by inspection of the Kaplan-Meier curves for risk groups using the same cut-offs as in the previous score (6 and 10 points, respectively). In patients in the low (0-5), medium (6-10) and high (11-16) SAGE-B score, the 12-year cumulative HCC probability was 0%, 4.0% and 13.8% and the HCC incidence was 0, 0.29 and 1.51 per 100 patient-years,
19
respectively (Figure 3B). HCC developed only in patients with intermediate (21/815, 2.6%; incidence rate: 0.29 HCC/100 patient-years) or high score (10/88, 11.4%; incidence rate: 1.51 HCC/100 patient-years) versus none of 308 patients with low SAGE-B score (log-rank, P<0.001). There was very good agreement between the point system of both scores and the multivariable model (weighted kappa: 0.855 for CAGE-B and 0.875 for SAGE-B). The 12-year HCC risks according to the CAGE-B and SAGE-B scores are shown in Supplementary Figure 1. For both scores, the highest cut-off associated with 100% sensitivity and, as a result, 100% negative predictive value (NPV) was 6. In addition to the above models, we also assessed the predictability of lower LSM cut-offs (5, 6, 7, 8, 9, 10, 11 kPa) together with age (combined or not with baseline cirrhosis), which was similar or lower than that of the 12 kPa LSM cut-off (c-index: 0.769-0.819).
Discussion To our knowledge, this is the first study trying to accurately predict the development of HCC beyond year 5 of therapy with potent and high genetic barrier NAs, ETV and TDF, in Caucasian CHB patients, with or without compensated cirrhosis. We not only identified predictors of such late HCC development but also developed two simple HCC risk scores, CAGE-B and SAGE-B, which offer 100% NPV for HCC and therefore no need for HCC surveillance beyond year 5 in their low risk groups. Older age and presence of cirrhosis at baseline and/or elastographic presence of cirrhosis at year 5 represented the most important factors for late
20
HCC development. Older age is a well established risk factor for HCC development in CHB patients.20 An interesting finding of our study was that late HCC developed exclusively in patients older than 50 years at year 5 of therapy, which further supports that the residual HCC risk after several years of suppression of HBV replication may be related to longer duration of chronic HBV infection and/or hepatocyte senescence which are both linked to older age.21,22 Although the HCC risk is decreasing after 5 years of ETV/TDF therapy in Caucasian patients with CHB and compensated cirrhosis, it still remains higher than in patients without cirrhosis at baseline.13 Presence of cirrhosis at ETV/TDF onset was a significant risk factor for HCC development even after 5 years of therapy. Long-term histological data in patients treated with ETV or mostly TDF have shown that cirrhosis reversion can be achieved in approximately 75% of patients with baseline cirrhosis,3,23 but whether such a histological change is associated with decreased subsequent HCC risk is currently
unknown.
Potential
cirrhosis
reversion
estimated
by
liver
elastography (LSM <12 kPa) was observed in a similar proportion of our patients (71%) after 5 years of ETV/TDF therapy. Although liver elastography may not reliably determine the presence or absence of cirrhosis in patients with previous cirrhosis who maintain inactivity of their liver disease for some years, it is the most commonly used method which can easily and noninvasively offer relevant information in routine clinical practice. Our data show for the first time that patients with reversion of baseline cirrhosis, as assessed by liver elastography, have a significantly lower HCC risk after 5 years of therapy, compared to patients with cirrhosis at baseline
21
and no elastographic reversion of cirrhosis after 5 years of therapy. Such a reduction of the HCC risk is quite interesting, but LSM <12 kPa at year 5 alone cannot modify the need for HCC surveillance, as the mean annual HCC incidence from year 5 to 10 was greater than 0.2%, the threshold that has been considered to make HCC surveillance cost-effective,20 in both subgroups of our patients with cirrhosis at baseline and even in patients with CHB only. Thus, additional characteristics are required in order to identify patients who may not require HCC surveillance during NA therapy beyond year 5. Compared to the 12 kPa cut-off, lower LSM cut-offs combined with age were found to offer similar HCC predictability after year 5, but they could classify less patients into the low risk group. In the future, biological markers could be used to refine the diagnosis of cirrhosis and possibly improve the accuracy of fibrosis severity for HCC prediction in CHB patients. CAGE-B and SAGE-B scores are both simple and easy to use in routine clinical practice, as they are based on only two variables, age and presence or absence of cirrhosis. In fact, SAGE-B is simpler as, in addition to age at year 5, requires only liver stiffness at year 5 as a qualitative variable (≥12 or <12 kPa), while CAGE-B also requires knowledge of cirrhosis status at baseline. It is reassuring that the 12-year cumulative probability of HCC was 0% in the low risk groups of both scores, which included approximately 20% of our patients. Thus, the cut-off point of 6 in both scores offered 100% sensitivity and NPV for HCC prediction beyond year 5. If these findings are confirmed in other cohorts, it would mean that HCC surveillance can be avoided in patients with liver stiffness <12 kPa at year 5 who are younger than 40 years regardless of baseline fibrosis severity as well as in patients with liver stiffness
22
<12 kPa at year 5 who are 40-49 years old especially if they had no cirrhosis at baseline (Table 4). It should be noted however, that were rather few patients with baseline cirrhosis who were younger than 40 years and therefore strong conclusions cannot be drawn for this particular subgroup. Interestingly, two factors, gender and platelets, which have been associated with the HCC risk during the first 5 years of therapy,11 had no independent association with HCC development beyond year 5. The lack of association between gender and late HCC development cannot be easily explained, but a reasonable hypothesis might be that the protective effects of estrogens on hepatocarcinogenesis weaken in post-menopausal females who represented the majority of female patients in this cohort (median age: 58 years).25 Platelet counts at both baseline and year 5 were associated with the HCC incidence from year 5 to 12 only in univariable analyses and could not identify any patient subgroup with low HCC risk that would not justify HCC surveillance. Additional factors found initially to be associated with HCC incidence beyond year 5, like ALT, baseline HBV DNA and prior use of NAs, did not maintain their associations in multivariable analyses. Our study has a few limitations. First, HCC surveillance was based on ultrasonography
performed
by
different
radiologists
or
gastroenterologists/hepatologists, whereas the compliance may have varied across the centers and even among the patients of the same center. Thus, the diagnosis of HCC could have been delayed in some cases. Such problems, however, reflect the daily clinical practice and exist in all large cohort studies and even in carefully designed prospective large studies. In addition, as recently suggested, prompt HCC diagnosis seems to be increasing in recent
23
years at least in patients who remain under follow-up in specialized centers.24 Thus, given the natural course of HCC and the long-term follow-up of our patients in clinics of tertiary expert centers, we believe that delays in HCC diagnosis cannot substantially affect the validity of our findings. Second, since all our patients were Caucasians, it is unclear whether these findings are valid in NA treated CHB patients of different origin and perhaps infected with different HBV genotypes. Third, our study had only internal but lacked external validation, which is critical for any risk score,26 and therefore the proposed scores should be further tested in other cohorts before it can be considered for use in clinical practice. In particular, CAGE-B and SAGE-B scores should be first validated in at least one large independent cohort of Caucasian CHB patients and perhaps in Asian cohorts of CHB patients as well. In conclusion, in a large cohort of Caucasian CHB patients with or without compensated cirrhosis, HCC after the first 5 years of ETV/TDF therapy seems to develop exclusively in patients older than 50 years at year 5. In patients with cirrhosis before therapy, elastographic reversion at 5 years of therapy defined by LSM <12 kPa seems to significantly decrease the subsequent HCC risk. However, LSM at 5 years of therapy alone cannot identify patients who will not benefit from continued HCC surveillance. Thus, HCC surveillance should continue in all patients older than 50 years and probably in the few cirrhotics ≤50 years old. CAGE-B, which is based on age and LSM at year 5 and presence of baseline cirrhosis, and particularly SAGE-B, which is based on only age and LSM at year 5, represent two simple and reliable risk scores for HCC prediction and surveillance beyond year 5 of therapy offering 100% negative predictive values for HCC development in their low risk groups
24
including all patients with liver stiffness <12 kPa at year 5 who are less than 40 years old and probably 40-49 years old particularly if the latter had no cirrhosis at baseline. CAGE-B and SAGE-B scores should now be further validated in an independent large Caucasian cohort before definitive use for HCC surveillance in clinical practice.
25
References 1. European Association for the Study of the Liver. EASL 2017 Clinical Practice Guidelines on the management of hepatitis B virus infection. J Hepatol 2017;67:370-398. 2. Terrault NA, Lok ASF, McMahon BJ et al. Update on prevention, diagnosis, and treatment of chronic hepatitis B: AASLD 2018 hepatitis B guidance. Hepatology 2018;67:1560-1599. 3. Marcellin P, Gane E, Buti M et al. Regression of cirrhosis during treatment with tenofovir disoproxil fumarate for chronic hepatitis B: a 5year open-label follow-up study. Lancet 2013;381:468-475. 4. Wong GL, Chan HL, Mak CW et al. Entecavir treatment reduces hepatic events and deaths in chronic hepatitis B patients with liver cirrhosis. Hepatology 2013;58:1537-1547. 5. Lim YS, Han S, Heo NY et al. Mortality, liver transplantation, and hepatocellular carcinoma among patients with chronic hepatitis B treated with entecavir vs lamivudine. Gastroenterology 2014;147:152161. 6. Papatheodoridis GV, Sypsa V, Dalekos G et al. Eight-year survival in chronic hepatitis B patients under long-term entecavir or tenofovir therapy is similar to the general population. J Hepatol 2018;66:11291136. 7. Papatheodoridis GV, Lampertico P, Manolakopoulos S et al. Incidence of hepatocellular carcinoma in chronic hepatitis B patients receiving nucleos(t)ide therapy: a systematic review. J Hepatol 2010;53:348-356.
26
8. Papatheodoridis GV, Chan HL, Hansen BE et al. Risk of hepatocellular carcinoma in chronic hepatitis B: Assessment and modification with current antiviral therapy. J Hepatol 2015;62:956-967. 9. Vlachogiannakos J, Papatheodoridis G. Hepatocellular carcinoma in chronic hepatitis B patients under antiviral therapy. World J Gastroenterol 2013;19:8822-8830. 10. Lampertico P, Maini M, Papatheodoridis G. Optimal management of hepatitis B virus infection - EASL Special Conference. J Hepatol 2015;63:1238-1253. 11. Papatheodoridis G, Dalekos G, Sypsa V et al. PAGE-B predicts the risk of developing hepatocellular carcinoma in Caucasians with chronic hepatitis B on 5-year antiviral therapy. J Hepatol 2016;64:800-806. 12. Wong VWS, Janssen HLA. Can we use HCC risk scores to individualize surveillance in chronic hepatitis B infection? J Hepatol 2015;63:722-732. 13. Papatheodoridis G, Idilman R, Dalekos G et al. The risk of hepatocellular carcinoma decreases after the first 5 years of entecavir or tenofovir in Caucasians with chronic hepatitis B. Hepatology 2017;66:1444-1453. 14. Terrault NA, Bzowej NH, Chang KM et al. AASLD guidelines for treatment of chronic hepatitis B. Hepatology 2016;63:261-283. 15. European Association for the Study of the Liver, Asociacion Latinoamericana para el Estudio del Higado. EASL-ALEH Clinical Practice Guidelines: Non-invasive tests for evaluation of liver disease severity and prognosis. J Hepatol 2015;63:237-264.
27
16. European
Association
for
the
Study
of
the
Liver,
European
Organisation for Research and Treatment of Cancer. EASL-EORTC Clinical Practice Guidelines: Management of hepatocellular carcinoma. J Hepatol 2012;56:908-943. 17. Collett D. Modelling Survival Data in Medical Research. Boca Raton, FL: CRC Press, 2014. 18. Sullivan LM, Massaro JM, D'Agostino RB, Sr. Presentation of multivariate data for clinical use: The Framingham Study risk score functions. Stat Med 2004;23:1631-1660. 19. Heagerty PJ, Lumley T, Pepe MS. Time-dependent ROC curves for censored
survival
data
and
a
diagnostic
marker.
Biometrics
2000;56:337-344. 20. European Association for the Study of the Liver. EASL Clinical Practice Guidelines: Management of hepatocellular carcinoma. J Hepatol 2018;69:182-236. 21. Hadziyannis SJ, Papatheodoridis GV. Hepatitis Be antigen negative chronic hepatitis B – natural history and treatment. Semin Liver Dis 2006;26:130-141. 22. Wiemann SU, Satyanarayana A, Tsahuridu M et al. Hepatocyte telomere shortening and senescence are general markers of human liver cirrhosis. FASEB J 2002;16:935-942. 23. Chang TT, Liaw YF, Wu SS et al. Long-term entecavir therapy results in the reversal of fibrosis/cirrhosis and continued histological improvement in patients with chronic hepatitis B. Hepatology 2010;52:886-893.
28
24. Samji H, Yu A, Kuo M et al. Late hepatitis B and C diagnosis in relation to
disease
decompensation
and
hepatocellular
carcinoma
development. J Hepatol 2017;67:909-917. 25.
Ruggieri A, Gagliardi MC, Anticoli S. Sex-dependent outcome of hepatitis B and C viruses infections: synergy of sex hormones and immune responses? Front Immunol 2018;9:2302.
26.
Sherman M. HCC risk scores: useful or not? Semin Liver Dis 2017;37:287-295.
29
Table 1. Main characteristics of 1427 Caucasian patients with chronic hepatitis B (CHB), with or without compensated cirrhosis, treated with entecavir (ETV) or tenofovir disoproxil fumarate (TDF) for at least 5 years without development of hepatocellular carcinoma within the first 5 years of therapy. All patients’ characteristics were assessed at the onset of ETV/TDF, unless stated otherwise. Age, years
52.1±13.1
Male gender, n (%)
992 (69.5)
Body mass index1, kg/m2
26.0±4.8
Current alcohol use, n/N (%) None/Mild (<20/<10 g daily for M/F)
850/997 (85.3)
Moderate (20-60/10-40 g daily for M/F)
130/997 (13.0)
Abuse (>60/40 g daily for M/F)
17/997 (1.7)
Diabetes mellitus, n/N (%)
83/1008 (8.2)
Family history of HCC, n/N (%)
51/990 (5.2)
HBeAg positive patients, n/N (%) HBeAg positive patients at 5 years of ETV/TDF, n/N (%)
261/1422 (18.4) 73/1384 (5.4)
ALT ≤40 IU/L, n/N (%)
676/1366 (49.5)
ALT ≤35/25 IU/L for males/females (M/F), n/N (%)
539/1366 (39.5)
ALT ≤30/19 IU/L for M/F, n/N (%)
416/1366 (30.5)
ALT in patients with ALT >40 IU/L, IU/L
84 (54, 150)
ALT ≤40 IU/L at year 1 of ETV/TDF, n/N (%)
1055/1236 (85.4)
ALT ≤35/25 IU/L for M/F at year 1 of ETV/TDF, n/N (%)
874/1236 (70.7)
ALT ≤30/19 IU/L for M/F at year 1 of ETV/TDF, n/N (%)
683/1236 (55.3)
ALT ≤40 IU/L at year 5 of ETV/TDF, n/N (%)
1216/1341 (90.7)
30
ALT ≤35/25 IU/L for M/F at year 5 of ETV/TDF, n/N (%)
1091/1341 (81.4)
ALT ≤30/19 IU/L for M/F at year 5 of ETV/TDF, n/N (%)
886/1341 (66.1)
3
3
Platelet counts x10 /mm
194±63
Platelet counts, n/N (%) 3
3
1091/1393 (78.3)
>150 x10 /mm 3
3
100-150 x10 /mm 3
234/1393 (16.8) 68/1393 (4.9)
3
<100 x10 /mm Platelet counts at 5 years of ETV/TDF, n/N (%) 3
3
956/1159 (82.5)
>150 x10 /mm 3
3
100-150 x10 /mm 3
3
158/1159 (13.6) 45/1159 (3.9)
<100 x10 /mm HBV DNA <80 IU/mL, n/N (%) HBV DNA in cases with HBV DNA ≥80 IU/mL, log10 IU/ml
404/1358 (29.8) 5.6±1.9
HBV DNA <80 IU/mL at 5 years of ETV/TDF, n/N (%)
1378/1411 (97.7)
(Pegylated-)interferon-alfa in the past, n (%)
358/1427 (25.1)
Nucleos(t)ide analogue(s) before ETV/TDF, n (%)
642/1427 (45.0)
Disease severity, n (%) CHB without cirrhosis
1023 (71.7)
Compensated cirrhosis
370 (25.9)
Unknown
34 (2.4)
Elastographic disease severity at 5 years of ETV/TDF, n (%) CHB without cirrhosis (liver stiffness <12 kPa) Compensated cirrhosis (liver stiffness ≥12 kPa) Unknown
1115 (78.1) 96 (6.7) 216 (15.1)
31
Initial antiviral therapy, n (%) ETV monotherapy
515 (36.1)
ETV and adefovir
10 (0.7)
ETV and TDF
20 (1.4)
TDF monotherapy
609 (42.7)
TDF and lamivudine
268 (18.8)
TDF and telbivudine
5 (0.3)
Follow-up under therapy, months
101 (81, 111)
Quantitative variables are expressed as mean±standard deviation or median (25th, 75th) values; M/F: male/female; 1Body mass index was available in 1259 patients.
32
Table 2. Effects of patient characteristics on the incidence of hepatocellular carcinoma (HCC) within 5-12 years of entecavir (ETV) and/or tenofovir disoproxil fumarate (TDF) therapy in 1427 chronic hepatitis B patients, with or without compensated cirrhosis, without HCC within the first 5 years (univariable analyses). Baseline characteristics are those at the onset of ETV/TDF therapy. Characteristics at baseline
Hazard ratio (95% CI)
P
Age (per year increase)
1.09 (1.05, 1.13)
<0.001
Age (>50 vs ≤50 years old)
7.42 (2.26, 24.32)
0.001
Gender [male (M) vs female (F)]
1.33 (0.60, 2.94)
0.487
Body mass index (per kg/m2)
1.04 (0.99, 1.09)
0.154
Alcohol use (no/mild vs moderate vs abuse)
1.26 (0.54, 2.99)
0.593
Diabetes mellitus (yes vs no)
2.02 (0.70, 5.84)
0.196
Family history of HCC (yes vs no)
2.01 (0.59, 6.93)
0.268
HBeAg status (negative vs positive)
1.17 (0.45, 3.04)
0.743
ALT (per IU/L)
0.99 (0.98, 1.00)
0.109
ALT (>40 vs ≤40 IU/L)
0.52 (0.26, 1.08)
0.078
ALT (>35/25 vs ≤35/25 IU/L for M/F)
0.51 (0.26, 1.02)
0.056
ALT (>30/19 vs ≤30/19 IU/L for M/F)
0.34 (0.17, 0.68)
0.002
0.99 (0.98, 1.00)
0.013
3.09 (1.54, 6.22)
0.002
Platelets (≤100 vs >100 x10 /mm )
1.57 (0.37, 6.57)
0.540
Serum HBV DNA (per log10 IU/ml)
0.73 (0.61, 0.87)
0.001
Serum HBV DNA (≥80 vs <80 IU/mL)
0.26 (0.13, 0.52)
<0.001
3
3
Platelets (per 10 /mm ) 3
3
Platelets (≤150 vs >150 x10 /mm ) 3
3
33
(Peg-)IFNa in the past (yes vs no)
0.48 (0.19, 1.25)
0.133
NA(s) before ETV/TDF (yes vs no)
2.94 (1.39, 6.18)
0.005
Cirrhosis (yes vs no)
4.81 (2.36, 9.79)
<0.001
Initial antiviral regimen (TDF vs ETV)
1.24 (0.61, 2.53)
0.559
Hazard ratio (95% CI)
P
ALT (>40 vs ≤40 IU/L)
0.75 (0.23, 2.47)
0.635
ALT (>35/25 vs ≤35/25 IU/L for M/F)
0.53 (0.20, 1.39)
0.198
ALT (>30/19 vs ≤30/19 IU/L for M/F)
0.42 (0.18, 0.97)
0.043
Characteristics at year 5
Hazard ratio (95% CI)
P
Age (per year increase)
1.09 (1.05, 1.13)
<0.001
HBeAg status (negative vs positive)
0.59 (0.18, 1.93)
0.386
ALT (>40 vs ≤40 IU/L)
0.33 (0.05, 2.42)
0.277
ALT (>35/25 vs ≤35/25 IU/L for M/F)
0.65 (0.23, 1.86)
0.424
ALT (>30/19 vs ≤30/19 IU/L for M/F)
0.46 (0.19, 1.12)
0.087
Platelets (≤100 vs >100 x10 /mm )
7.50 (3.07, 18.33)
<0.001
HBV DNA (≥80 vs <80 IU/mL)
0.88 (0.33, 2.36)
0.805
Liver stiffness ≥12 kPa (yes vs no)
7.30 (3.40, 15.66)
<0.001
Liver stiffness (per kPa)
1.08 (1.06, 1.11)
<0.001
ALT at year 1
3
3
(Peg-)IFNa: pegylated interferon-alfa, NA(s): nucleos(t)ide analogue(s). Hazard ratio (95% CI [confidence interval]) from Cox regression analyses.
34
Table 3. Independent effects of patient characteristics on the incidence of hepatocellular carcinoma (HCC) within 5-12 years of entecavir (ETV) and/or tenofovir disoproxil fumarate (TDF) therapy in 1427 chronic hepatitis B patients without HCC within the first 5 years of therapy. Characteristics at baseline (onset of ETV/TDF)
Adjusted HR (95% CI)
P
Age (per year increase)
1.08 (1.04, 1.12)
<0.001
ALT (>30/19 vs ≤30/19 IU/L for M/F)
0.96 (0.41, 2.23)
0.923
Platelets (≤150 vs >150 x10 /mm )
2.12 (1.02, 4.43)
0.045
Serum HBV DNA (per log10 IU/ml)
0.82 (0.62, 1.07)
0.140
NA(s) before ETV/TDF (yes vs no)
1.00 (0.84, 1.19)
0.986
Cirrhosis (yes vs no)
2.61 (1.19, 5.70)
0.016
Adjusted HR (95% CI)
P
Age (per year increase)
1.08 (1.04, 1.12)
<0.001
ALT (>30/19 vs ≤30/19 IU/L for M/F)
0.57 (0.21, 1.51)
0.256
Platelets (≤150 vs >150 x10 /mm )
1.63 (0.72, 3.67)
0.239
Liver stiffness (≥12 vs <12 kPa)
5.30 (2.38, 11.80)
<0.001
Adjusted HR (95% CI)
P
Age at year 5 (per year increase)
1.08 (1.04, 1.12)
<0.001
ALT at year 5 (>30/19 vs ≤30/19 IU/L for M/F)
0.60 (0.23, 1.61)
0.310
1.43 (0.63, 3.25)
0.396
3
3
Characteristics at year 5 of ETV/TDF therapy
3
3
Characteristics at year 5 & baseline cirrhosis
3
3
Platelets at year 5 (≤150 vs >150 x10 /mm ) Fibrosis severity at baseline and year 5 - Baseline cirrhosis & stiffness <12 kPa at year 5
1
- Baseline CHB & stiffness <12 kPa at year 5
0.34 (0.14, 0.87)
0.024
- Baseline cirrhosis & stiffness ≥12 kPa at year 5
2.82 (1.15, 6.91)
0.024
35
NA(s): nucleos(t)ide analogue(s), CHB: chronic hepatitis B (without cirrhosis). HR [hazard ratio] (95% CI [confidence interval]) from multivariable Cox regression analyses.
36
Table 4. Risk scores for the prediction of hepatocellular carcinoma after 5 years of treatment with entecavir or tenofovir disoproxil fumarate in Caucasian chronic hepatitis B patients CAGE-B: Risk score based on year 5 SAGE-B: Risk score based on and baseline variables (range: 0-16)
year 5 variables (range: 0-15)
Age*,
Severity of fibrosis
Age*,
Elastographic severity
years
(baseline year 5)
years
of fibrosis at year 5
CHB LSM<12 kPa: 0 23-29: 0
LSM<12 kPa: 0
30-39: 2 Cirrhosis LSM<12 kPa: 3 30-39: 2
LSM≥12 kPa: 5
23-29: 0
40-49: 4 Cirrhosis LSM≥12 kPa: 6 40-49: 4 50-59: 6
50-59: 6
60-69: 8
60-69: 8
≥70: 10
≥70: 10
CAGE-B: cirrhosis and age, SAGE-B: stiffness and age, CHB: chronic hepatitis B without cirrhosis, LSM: liver stiffness measurement; *Age at year 5.
37
FIGURE LEGENDS Figure 1. Cumulative probability of hepatocellular carcinoma (HCC) beyond year 5 of therapy with entecavir or tenofovir disoproxil fumarate in Caucasian chronic hepatitis B patients (dashed lines: 95% confidence intervals). Figure 2. Cumulative probability of hepatocellular carcinoma (HCC) beyond year 5 of therapy with entecavir or tenofovir disoproxil fumarate in Caucasian chronic hepatitis B patients in relation to their cirrhosis (Ci) status at baseline (A) or to their cirrhosis (Ci) status at baseline and the elastographic presence or absence of cirrhosis [liver stiffness (LS) <12 or ≥12 kPa) at year 5 (B). CHB: chronic hepatitis B without cirrhosis. P values by log-rank tests from Kaplan-Meier analyses. Figure 3. Cumulative probability of hepatocellular carcinoma (HCC) beyond year 5 of therapy with entecavir or tenofovir disoproxil fumarate in Caucasian chronic hepatitis B patients according to the CAGE-B (A) and the SAGE-B score (B) risk groups. P values by log-rank tests from Kaplan-Meier analyses.
Cumulative probability of HCC
.2
.15
.1
.05
0 0
1
2
3
4 5 6 7 8 Years since ETV/TDF initiation Number at risk 1427
Fig. 1
1252
1007
777
9
10
11
12
460
178
52
16
Cumulative probability of HCC
0.16 0.14 0.12
Ci
0.10 0.08 0.06
p<0.001
0.04 CHB 0.02 0.00 0
1
2
3
4 5 6 7 8 9 Years since ETV/TDF initiation Number at risk CHB Ci
Fig. 2A
1023 370
888 333
715 264
541 210
340 107
10
11
12
144 31
50 1
16 0
Cumulative probability of HCC
0.16 0.14 Ci-Ci
0.12
p=0.019
0.10 0.08 Ci-CHB 0.06 p<0.001
0.04 0.02
CHB-CHB
0.00 0
1
2
3
4 5 6 7 8 9 Years since ETV/TDF initiation Number at risk Ci-CHB CHB-CHB Ci-Ci
Fig. 2B
223 870 92
212 781 82
193 658 52
164 510 36
89 328 15
10
11
12
23 138 6
0 49 0
0 15 0
CAGE-B:0-5 CAGE-B:6-10
Cumulative probability of HCC
CAGE-B:11-16
0.25 0.20
P<0.001 CAGE-B 11-16
0.15 0.10 0.05
CAGE-B 6-10 CAGE-B 0-5
0.00 0
1
2
3
4 5 6 7 8 9 Years since ETV/TDF initiation Number at risk 0-5 6-10 11-16
Fig. 3A
281 674 230
253 611 211
211 519 173
158 413 139
106 257 69
10
11
12
36 110 21
15 34 0
2 13 0
SAGE-B:0-5 SAGE-B:6-10
Cumulative probability of HCC
SAGE-B:11-15
0.25 0.20
P<0.001
0.15
SAGE-B 11-15
0.10 0.05
SAGE-B 6-10 SAGE-B 0-5
0.00 0
1
2
3
4 5 6 7 8 9 Years since ETV/TDF initiation Number at risk 0-5 6-10 11-15
Fig. 3B
308 815 88
280 743 78
235 643 48
179 519 34
120 310 13
10
11
12
39 125 5
16 34 0
2 13 0
Highlights • In Caucasians with chronic hepatitis B, age >50 years, baseline cirrhosis and liver stiffness (LSM) ≥12 kPa at year 5 are independently associated with increased risk of hepatocellular carcinoma (HCC) after the first 5 years of entecavir or tenofovir therapy • In patients with cirrhosis at baseline, liver stiffness <12 than ≥12 kPa at year 5 is associated with lower HCC risk, but surveillance may be still required. • CAGE-B score based on age at year 5 and baseline cirrhosis in relation to LSM at year 5 and SAGE-B score based only on age and LSM at year 5 represent simple and reliable risk scores for HCC prediction and surveillance beyond year 5 of therapy