Challenges and Controversies

The first priority should be treatment of the HCC, which has good outcomes if early stage. In these individuals, I would delay starting DAA therapy for HCV until 4 to 6 months after initial therapy for hepatocellular carcinoma in order to maximize virologic response. In individuals with more advanced HCC, treating their HCV is also reasonable, but I would similarly delay starting therapy for 4-6 months after initial therapy for hepatocellular carcinoma in order to maximize virologic response. The exception would be patients with palliative goals of care, in which case treatment would not be warranted. If someone is undergoing liver transplantation as treatment for their HCC, then they could be treated either before or after transplantation, at the discretion of their transplant providers.

In this patient with HCV cirrhosis and new diagnosis of HCC, my first priority would be to appropriately stage and manage the HCC. The timing of DAA initiation would depend on the stage and treatment plan for his HCC. If this is a solitary and relatively small LIRAD 5 lesion, consistent with early HCC, I would wait to start SOF/VEL until after he has undergone locoregional therapy. The rationale for waiting in this case is that in a large systematic review and meta-analysis that included adults with HCV and HCC, higher SVR was noted in those with HCC who had received curative treatment versus those who had not (1). Although the ideal timing for starting DAAs after HCC treatment is unclear, I would not delay beyond ~4-6 months. If this patient\'s staging shows more advanced HCC, the HCC management plan again would take priority. After HCC treatment is initiated, I would start SOF/VEL recognizing that the likelihood of SVR is reduced in the setting of active HCC. The rationale for treating in this case is that the likelihood of SVR still remains high, and he has much to gain in terms of preventing further progression of his cirrhosis (2).