Monitoring Disease Progression and Liver Cancer Risk in Hepatitis B

In "Monitoring Disease Progression and Liver Cancer Risk in Hepatitis B," our experts turn to how chronic hepatitis B silently raises liver cancer risk even without classic fibrosis.

Dr. Chung notes that liver disease progression in chronic hepatitis B is often heterogeneous and asks Dr. Dieterich to describe the stages of progression and how he monitors for them in practice.

Dr. Dieterich contrasts hepatitis B with hepatitis C, where fibrosis progresses fairly predictably over years due to ongoing inflammation. In hepatitis B, immune suppression driven by surface antigen excess often limits liver inflammation, so ALT and AST levels are frequently normal and only elevated in a small percentage of patients. As a result, fibrosis progression is not the primary concern.

Liver cancer is the greater worry, he explains, because hepatitis B, unlike hepatitis C, integrates directly into the hepatocyte genome. That integration can stimulate oncogenes and suppress tumor-suppressor genes, raising cancer risk even in patients without meaningful fibrosis. His practice performs yearly elastography to check for fibrosis and biannual hepatocellular carcinoma screening with AFP and ultrasound, escalating to more frequent screening for patients with advanced disease, significant fibrosis, or specific risk factors such as a first-degree relative with liver cancer or a basal core promoter mutation.

He describes one young patient with both a basal core promoter mutation and a brother diagnosed with liver cancer, for whom his team alternates MRI and ultrasound every year. He adds that suppressing the virus to an undetectable level, which is achievable with current tools, remains a central goal regardless of a patient's fibrosis stage. Dr. Chung closes by underscoring that because the disease can change unpredictably, longitudinal monitoring is essential at every stage, not just in patients who appear more advanced.

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