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With prof. Krzysztof Simon from the Department of Infectious Diseases, Liver Diseases and Acquired Immunodeficiencies of the Medical University of Wroclaw, Lower Silesian provincial consultant in the field of infectious diseases and president of the Polish Society of Epidemiologists and Doctors of Infectious Diseases, talks Mariola Marklowska-Dzierżak
According to the common opinion among patients, the liver is a very strong organ, resistant to poisoning and other unfavorable factors. What must happen for her to develop cancer?
It is not entirely true that the liver is a very powerful organ. It really has enormous regenerative potential after the action of various harmful factors that reach it most often through the blood, in addition to radiation with X-rays. These can be infectious and toxic factors, blood circulation disorders. It happens that they occur simultaneously and overlap. The consequence of their action are smaller or larger changes in the liver. The liver compensates for this in some way. However, when these factors are reproducible (e.g. alcoholism), there is a genetic error (e.g. hemochromatosis, iron storage, Wilson’s disease) or we are dealing with hepatotropic virus type B or C, various pathologies and the liver he is no longer able to compensate for it.
Is it true that B and C virus infections are the major causative agent of hepatocellular carcinoma?
As for the hepatitis B virus (HBV), it is a very potent carcinogen. In a person who is infected with it, cancer can develop even in an unchanged liver. Hepatitis C virus (HCV) is a less potent carcinogen and its cancer only develops in cirrhotic liver. Nevertheless, 50 percent of liver cancer cases in Poland are observed in patients with cirrhosis resulting from HCV infection. They are usually accompanied by metabolic disorders, alcoholism, chemical factors and many other co-occurring factors that are co-factors of cancer development. If we consider all causes of liver cancer, approximately 70-80 percent of them are infections with primary hepatotropic viruses, i.e. HBV or HCV.
It is worth adding that the problem of infections with B and C viruses of hepatitis affects probably one million citizens in our country.
We can get vaccinated against the virus that causes hepatitis B. And how can we protect ourselves from becoming infected with the C virus, against which a vaccine has not yet been invented?
The basic issue is hygiene and epidemiological standards as well as pro-health behavior, with which, fortunately, it is getting better in Poland. Compliance with these standards, sterilization of medical equipment in autoclaves, the use of disposable equipment, reducing the number of risky sexual contacts, and increasing awareness of the need to use condoms in risky situations, undoubtedly lead to a reduction in the number of new infections and the spread of viruses. This also applies to HBV.
It is true that there is no vaccine against hepatitis C. This is due to the nature of the virus, its complex structure and constant variability. But we have a therapy – pegylated interferon alpha2 with ribavirin – which inhibits viral replication in a large percentage of those treated, indirectly reducing the risk of spreading infections. Unfortunately, access to it in Poland is still a huge problem, e.g. in the Dolnośląskie Voivodeship you have to wait for it from 2,5 to 3 years!
So let’s talk about the treatment of hepatitis B and C viral infections. What is the availability of modern drugs in Poland? Does a Polish patient have the same treatment chances as patients in other European Union countries?
Comparing ourselves with Asian countries or countries located to the east of Poland, it can be said that it is not bad in our country. We look much worse than in Europe. The treatment of infections is reimbursed by the state, and it is doing it to an increasing extent. Despite this, in some provinces, such as mine, the queue of patients for treatment has been increasing over the years and we will not be able to discharge it quickly. It needs time. There is, however, a positive aspect – from April 1, access to modern drugs used in the treatment of HBV infections will be even more improved.
What are these infections treated with?
We have two groups of drugs at our disposal. In the case of hepatitis B, these are interferons, preferably pegylated (the only approved drug in this group is pegylated alpha2a) and nucleoside and nucleotide analogues. Two drugs dominate the world – entecavir and tenofovir, while in Poland we use effective, but ultimately anachronistic and resistance-generating lamivudine, which should already be eliminated from the market (it is extremely expensive and hinders further treatment of patients). When it comes to hepatitis C, we currently have state-funded, combined, extremely expensive therapy with pegylated interferon alfa 2a or alpha 2b administered with ribavirin, a nucleoside analogue. Such therapy is much more effective than monotherapy with each drug separately. According to the regulations, it may last 48 weeks. However, in many cases it should be extended to 72 weeks. However, there are no funds for this. If the patient wants to be treated well, he has to pay himself for the extended therapy.
It is this combination therapy that in some regions there are over two-year queues?
In some provinces they are shorter, in others they are longer. Resources for treating hepatitis C infection are generally insufficient.
How is hepatocellular carcinoma treated?
As I mentioned, in Polish conditions, viruses are responsible for the development of hepatocellular carcinoma in 80%, of which 70% is the fault of the C virus and 30% of the B virus. In Poland, unlike in other countries, this cancer is diagnosed very late. which determines the method and possibilities of therapeutic treatment. It is best removed by surgical methods – by resection or liver transplant. There are also indirect techniques, such as thermoablation or cryotherapy, but they affect a small percentage of patients. In others, neither of these methods can be used because the cancer is diagnosed too late or is multifocal, has a bad localization, or the patient is burdened with additional diseases that make surgery impossible. For such patients, new therapies with the use of drugs blocking signaling pathways reaching the neoplastic cell are proposed, only entering clinical practice. Such a drug is sorafenib. Therapy with this drug is very expensive, effective in a limited percentage of patients, but often extends life by two or three years. This is huge progress. Of course, antiviral therapy must not be forgotten.
What access to these modern drugs do Polish patients have?
Very limited. This is due to, inter alia, from the fact that oncologists have a monopoly on the treatment of liver cancer, while decisions on the treatment of a patient with diagnosed hepatocellular carcinoma should, in my opinion, and this is the case in the world, be taken by a commission composed of a radiologist, surgeon, infectious agent, oncologist and possibly a gastroenterologist . It is a cancer different from the rest. As I mentioned, 80 percent of it is caused by infectious agents – viruses. Removing the tumor itself does not change much. Comprehensive treatment is needed, because in the liver, with the active replication of the virus, several thousand potential neoplastic outbreaks can arise simultaneously. Without antiviral treatment, there is no point in treating hepatocellular carcinoma.
In addition, there are also problems related to the coexistence of cirrhosis of the liver. Cirrhosis is portal hypertension, bleeding from esophageal and rectal varices, gastropathy, ascites, hepatocardial syndromes and many other diseases. Hepatocellular carcinoma must therefore be treated in the context of infection and liver dysfunction, and thus of many very different comorbid disease entities. Only such a comprehensive procedure promises a chance for therapeutic success, i.e. extending the patient’s life.
Why is liver cancer diagnosed so late in Poland? Is it because it does not cause any symptoms and does not hurt for many years?
For many reasons. Firstly, patients ignore the problem of B and C infection. Secondly, cancer rarely shows any symptoms at the beginning, they usually appear only in advanced forms of the disease. Third, screening is not normally performed in patients with cirrhosis. As a result, patients who should have a six-month an ultrasound scan, or a determined concentration of AFP (alpha-phetoprotein), and the National Health Fund will not refund it to them, they simply do not perform it. As a consequence, there are paradoxical situations where the cancer is inoperable at the moment of diagnosis.
How can we prevent hepatitis and hepatitis cancer?
If someone is not infected with the B or C virus, the first thing they should do is get vaccinated against hepatitis B. The person who is vaccinated should check whether they have a protective antibody title and make sure that they do not become superinfected. It could have happened that the vaccination was ineffective. It turns out no one is doing it, and that’s a mistake. Another thing – you need to be treated in hygienic facilities, avoid risky sexual contact, and if anything, use condoms to reduce the risk of infection. It is also important for health professionals to follow procedures. It goes, among others for washing hands or changing gloves during minor surgical procedures, because they are changed with large ones. Many things are done mechanically, unnecessarily putting yourself and the patient at risk of infection.
Mariola Marklowska-Dzierżak