Blog | Monday, April 30, 2018

Hepatitis C - silent killer or innocent bystander?

For a few decades, I did not treat patients with hepatitis C (HCV) infection, despite aggressive marketing by the pharmaceutical companies and cheerleading by academics. I was an iconoclast as most of my gastroenterology colleagues were HCV treatment enthusiasts. They argued that if the virus could be eradicated, that there was evidence that these patients could avoid some horrendous HCV complications, such as cirrhosis, liver failure, and cancer of the liver.

I'm certainly against cancer and liver destruction, but I have thought that the evidence that HCV patients who vanquished the virus would be saved from these fates was somewhat murky. Treatment proponents would argue that the medical evidence for these claims is solid, but I wonder to what extent their favorable bias toward treatment influenced their judgment. We physicians know that a doctor or a drug company will seize on particularly studies that supports their views. Studies that challenge their beliefs may be criticized for study design flaws and other defects. I am generalizing here, but we all know how we tend to pursue confirmation bias, seeking out sources and opinions that support what we already think. This is not quite a pursuit of the truth.

Additionally, there is a well-known phenomenon called publication bias when favorable treatment results are more likely to be published than negative treatment results. In other words, a study that shows a drug is effective is more likely to be published than a study that shows a failed result. This means that physicians like me who read medical journals may receive an over optimistic view of drugs because of this cherry picking.

In my 30 years of practice, I have never had any of my untreated HCV patients develop any measurable deterioration of their liver status. In fact, nearly all of them were asymptomatic and felt entirely well.

Consider these facts:
• Most patients with HCV are not ill.
• HCV is not easily transmissible to other individuals. It is spread via contaminated blood, such as with sharing IV needles.
• The majority of HCV patients will never develop liver cancer or liver failure.
• The majority of HCV patient have had the infection for decades and remain well.
• Until recently, HCV medications had very limited efficacy and had numerous complications.

Like all of you, I harbor my own biases. I am a very conservative practitioner, as readers know well. I am never among the first to jump aboard the New Treatment Train.

Until groundbreaking HCV treatment emerged in recent years, I had been unable to convince myself, let alone my patients, that they should accept a complex medical regimen that included injections, that didn't work well and would make them feel sick.

While my academic colleagues would have accused me of nihilism, not a single HCV patient in my practice has seemingly progressed. (Of course, my academic friends would claim that many of my patients may have ‘silently progressed’ even though they still feel well.) There is always a medical argument a physician can wield to justify his or her recommendation or belief.

I'm not claiming that my view here is the only legitimate one. I do suggest that it deserves to be heard.

In an upcoming post, I will share why I have jumped, with some reluctance, into the HCV treatment arena.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.