Hepatitis C Screening and Treatment: A Public Health Priority for Texas

By Barbara J. Turner, MD, MSED, MA; Barbara R. Guerra, MS; and Laura Tenner, MD
Tuesday, November 15, 2016
Specialty: 

In the past two decades, cancer-related mortality in the U.S. has been greatly reduced due to advances in prevention, early detection and treatment. However, liver cancer is one of the few exceptions, with a 38 percent increase in the incidence rate and 56 percent increase in the death rate over the past decade.1

In 2016, It is estimated that more than 39,000 persons will be diagnosed with liver cancer and 27,000 persons will die of this disease.1 Hepatitis C virus infection is most common cause of liver cancer in the U.S. Deaths related to hepatitis C infection are at an all-time high in the U.S., exceeding deaths from all other top 60 infectious diseases combined, including HIV and tuberculosis.2 Unless action is taken quickly, the morbidity and mortality from liver cancer and other hepatitis C-related complications such as cirrhosis will continue to rise because an estimated 3.5 million Americans are living with hepatitis C.

Fortunately, the opportunity to avert serious complications from chronic hepatitis C has never been better. Over 90 percent of chronically infected persons can be cured by new direct-acting anti-hepatitis C drugs. This all-oral, well-tolerated treatment can generally be completed within three months. Research has shown that this treatment offers even persons with compensated hepatitis C-related cirrhosis a life expectancy similar to that of the general population.5 However, up to three in four of the persons with chronic hepatitis C infection in the U.S. are unaware that they have this insidious disease because it generally causes only vague symptoms until liver damage becomes severe.1 Waiting to diagnose chronic hepatitis C infection until symptoms appear may not offer the opportunity to avert liver failure and cancer.

ReACHing the At-risk Population

Approximately 75 percent of all persons living with hepatitis C in the U.S. were born from 1945 through 1965 (the baby boomer generation). Consequently, the United States Preventive Services Task Force (USPSTF) recommends that all baby boomers should be screened once for hepatitis C.4 Baby boomer screening is now covered by most insurers and is being implemented especially in primary care practices, emergency departments and substance abuse treatment settings.

Texas needs be at the forefront of hepatitis C screening and treatment in the nation. It has one of the highest incidence rates of liver cancer in the U.S., and an estimated 400,000 Texans are chronically infected with hepatitis C.5-7 Barbara J. Turner, MD, Director of the Center for Research to Advance Community Health (ReACH) at The University of Texas Health Science Centers at San Antonio (UTHSCSA), is leading several projects that support primary care practices in implementing baby boomer screening, evaluation and treatment with support from hepatologists. ReACH currently has three hepatitis C screening and linkage-to-care programs across the South Texas region, two of which are funded by the U.S. Centers for Medicare & Medicaid Services as part of a section 1115 Medicaid waiver, while the third receives support from the Cancer Prevention & Research Institute of Texas (CPRIT). These projects focus on screening underserved, primarily Hispanic and African-American patient populations, followed by education, evaluation and linkage to new, highly effective medications. African-Americans have a higher rate of chronic hepatitis C infection and Hispanics are more likely to have advanced hepatitis C-related liver disease at diagnosis.7-8

The CPRIT-funded program is titled: “STOP HCC (Screen, Treat or Prevent Hepatocellular Carcinoma),” and is being conducted by a multidisciplinary team at UTHSCSA, including its Cancer Therapy & Research Center, as well as The University of Texas Southwestern and Parkland Health and Hospital System. STOP HCC has been developing the infrastructure for hepatitis C screening, evaluation and treatment in 12 primary care clinics in Dallas and 18 primary care clinics across 14 South Texas counties. This project aims to test 20,000 patients for hepatitis C over a three-year period, facilitate access to care for those who test positive, and educate physicians, staff and communities throughout Texas about hepatitis C and liver cancer.

In May 2016, the ReACH Center was recognized for its work on hepatitis C in vulnerable populations by the White House and the U.S. Department of Health and Human Services at the National Hepatitis Testing Day observance in Washington, D.C. ReACH’s current outpatient primary care program builds on successes and lessons learned from a project funded by the CDC in which all baby boomers admitted to University Hospital were screened for hepatitis C. That program tested 4,582 (90 percent) of eligible baby boomers for hepatitis C, of whom 175 (4 percent of all tested patients) were newly diagnosed with chronic infection. Most of these patients subsequently received care for hepatitis C as outpatients and over one-third have received curative treatment for hepatitis C.

ReACH has developed several tools to assist primary care practices to implement hepatitis C screening and would be happy to share these approaches to promote hepatitis C and liver cancer prevention in Texas. Through programs to increase screening and treatment of hepatitis C such as ours and others nationally, it will be possible to reverse the significant health threat from of hepatitis C-related disease.



Laura Tenner, MD

Laura L. Tenner, MD, is a faculty member at The University of Texas Health Science Center San Antonio, Cancer Therapy and Research Center and a board-certified gastroenterologist and medical oncologist who has special training in population research and clinical ethics. Dr. Tenner treats hepatocellular carcinoma, or liver cancer, as well as cancers of the stomach, esophagus, colon, rectum, small bowel, anus, pancreas, gallbladder and neuroendocrine system. Her area of research includes cancer prevention and access to care. She is a board member for the American Society of Clinical Oncology Ethics Committee as well as the American Society of Clinical Oncology Cancer Prevention Committee.


Barbara J. Turner, MD, MSED, MA

Barbara J. Turner MD, MSED, MA, MACP, is the James D. and Ona I. Dye Professor of Medicine at the UT Health Science Center San Antonio and founding Director of the Center for Research to Advance Community Health (ReACH), a joint initiative with UT School of Public Health to advance health in South Texas in partnership with the community. She was formerly the executive deputy editor of the Annals of Internal Medicine and a professor of medicine at the University of Pennsylvania. She is a practicing general internist and author of over 175 peer-reviewed publications on diverse research topics addressing opportunities to improve prevention and outcomes of chronic disease as well as reduce health disparities. She is currently leading several research projects to implement new national guidelines for hepatitis C virus screening of all baby boomers and treat chronically infected patients. In May of 2016, Dr. Turner was honored with the U.S. Department of Health and Human Services’ Viral Hepatitis Testing Recognition Award for her efforts in implementing viral hepatitis testing in alignment with the goals of the Action Plan for the Prevention and Treatment of Viral Hepatitis.


Barbara R. Guerra, MS

Barbara Riske Guerra serves as a Project Coordinator for STOP HCC, a Cancer Prevention Research Institute of Texas Hepatitis C screening project across multiple primary care clinic systems in the South Texas region. She oversees day-to-day tasks associated with the project, maintains ongoing communication with clinics and project staff, and ensures that project activities are completed within the appropriate timeline and budget. Riske previously worked as a project manager and data manager in the area of substance abuse and mental health. She received her MS in psychology from The University of Texas at San Antonio.

For more information, please contact Guerra at Riske@uthscsa.edu.

References:

  1. Liver Cancer. Center for Disease Control and Prevention. http://www.cdc.gov/cancer/liver. Published March 9, 2016. Accessed June 6, 2016.
  2. Highleyman L. Hepatitis C kills more people than any other infectious disease in US, CDC says. http://www.aidsmap.com/Hepatitis-C-kills-more-people-than-any-other-infe.... Published May 6, 2016. Accessed June 6, 2016.
  3. Ly KN, Hughes EM, Jiles RB, Holmberg SD. Rising mortality associated with hepatitis C virus in the United States, 2003-2013. Clin Infect Dis. 2016;62(10):1287-1288.
  4. U.S. Preventive Services Task Force. Hepatitis C: Screening. http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummary.... Published June 2013. Accessed June 6, 2013.
  5. Bruno S, Di Marco V, Iavarone M, et al. Survival of patients with HCV cirrhosis and sustained virologic response is similar to the general population. J Hepatol. 2016;64(6):1217-23.
  6. Hepatocellular Carcinoma-United States, 2001 – 2006. Centers for Disease Control and Prevention. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5917a3.htm. Published May 7, 2010. Accessed October 31, 2016.
  7. Yalamanchili K, Saadeh S, Lepe R, Davis GL. The prevalence of hepatitis C virus infection in Texas: implications for future health care. Proc (Bayl Univ Med Cent). 2005;18(1):3-6.
  8. Saab S, Jackson C, Nieto J, Francois F. Hepatitis C in African Americans. Am J Gastroenterol. 2014;109(10):1576-84.
  9. Turner BJ, Taylor BS, Hanson JT, et al. High priority for hepatitis C screening in safety net hospitals: Results from a prospective cohort of 4582 hospitalized baby boomers. Hepatology. 2015;62(5):1388-95.