Wednesday, January 6, 2016

Persistent unanswered questions in screening for hepatitis C

About a year ago, I co-authored an analysis in BMJ with Ronald Koretz, John Ioannidis, and Jeanne Lenzer that challenged the growing consensus about the value of routine, rather than risk-based, screening for hepatitis C virus in the "baby boomer" generation (the cohort of persons born from 1945 to 1965). We called for a point-of-entry randomized trial to test the hypothesis that screening the 60 million Americans in this age group and treating those who test positive for HCV will reduce deaths from liver disease and hepatocellular carcinoma. To my knowledge, no health agency or other organization has stepped forward to support such a trial, which leaves unanswered the critical question of whether the hundreds of billions of dollars that will ultimately be spent on $1000 antiviral pills as a result of widespread screening for hepatitis C (Medicare spent $9.2 billion on hepatitis C drugs in 2015) will lead to more population health benefits than harms.

In a recent editorial in American Family Physician, I explained why I continue to feel that family physicians should not be required to institute routine birth cohort screening for hepatitis C. Please read the whole piece if you can, but if you don't have a personal or institutional subscription to the journal, here is the bottom line:

In summary, recent innovations in identification and management of patients with HCV infection have left family physicians facing important unanswered questions. Is it worthwhile to modify practice workflows to prioritize screening for HCV in middle-aged and older adults without any known risk factors, who are more likely to be at risk of cardiovascular disease and cancer than HCV infection? In persons who test positive for HCV, who should be treated or referred for treatment, knowing that many will not benefit?

Given current scientific uncertainties, limited resources, and evolving guidelines, a reasonable middle ground would be for family physicians to collaborate with subspecialty colleagues and focus HCV testing and therapy on patients who are most likely to have long-term complications from the infection, such as those with human immunodeficiency virus infection or type 2 diabetes mellitus, rather than instituting more broad screening and treating everyone who tests positive.