cDDW/caSl 2015

Gastroenterology
PERSPECTIVES
CDDW/CASL 2015
Canadian Digestive Diseases Week/Canadian Association for the Study of the Liver
Conference Report on Gastroenterology & Liver Disease
Commentary and content provided by the CARE Gastroenterology and Liver Disease Faculties
Banff, Alberta - February 27-March 2, 2015
905 891 1900
www.CAREeducation.ca
[email protected]
Community Academic Research Education
@weareCARE
About the
Gastroenterology and Liver disease Faculties
The CARE (Community, Academic, Research, Education) Gastroenterology and Liver Disease Faculties
are a pan-Canadian group of leaders in their field who gather, discuss and address gaps in knowledge, to
develop education initiatives framing news from a Canadian perspective.
The vision of the CARE Gastroenterology and Liver Disease Faculties is to share opinions and update
Canadian specialists with news and developments from key conferences framed in a Canadian perspective.
The mission of the CARE Gastroenterology and Liver Disease Faculties is to enhance medical education
with the explicit goal of improving patient outcomes.
Gastroenterology
Liver
Disease
CDDW/CASL 2015 —
PERSPECTIVES — 1
PERSPECTIVES
CDDW/CASL 2015
Conference Report on Gastroenterology & Liver Disease
Highlights from CDDW/CASL 2015
Contents
Members of the CARE Gastroenterology Faculty recently met at the CDDW 2015 (Canadian
Digestive Diseases Week)/ CASL 2015 (Canadian Association for the Study of the Liver)
conference held in Banff, AB on February 27- March 2, 2014.
CARE Perspectives from CDDW/CASL 2015 provides a summary of the most compelling
abstracts and stories presented at this event, and is augmented with additional perspective
from the CARE Gastroenterology and Liver Disease Faculties. Also included in this report are
updates on the various CARE education initiatives currently underway in chronic constipation,
Crohn’s disease, hepatocellular carcinoma, and hepatitis C.
The following report has been produced in the language in which it was presented.
CARE Gastroenterology Faculty Contributing to this Report:
John Marshall, MD, FRCP(C), AGAF
Brian Bressler, MD, MS, FRCP(C)
McMaster University
University of British Columbia
CARE Liver Disease Faculty Contributing to this Report:
Hemant Shah, MD, MScCH, HPTE, FRCP(C)
Alnoor Ramji, MD FRCP(C)
Toronto Western Hospital
University of British Columbia
Gastroenterology
Irritable Bowel Disorders
Update on the CARE Crohn's Disease Tool
2
3
Chronic Constipation
4
Update on the CARE Chronic Conistipation Needs Assessment
5
Liver Disease
Hepatitis C Virus (HCV)
6
Hepatocellular Carcinoma (HCC)
7
Update on the CARE HCC Needs Assessment
CARE HCV CME Accredited Education Program
CARE at DDW 2015 Invitation
7
8
9
2 — CDDW/CASL 2015 —
PERSPECTIVES
Irritable Bowel Disorders
Ulcerative Colitis and Crohn’s Disease
Introduction
CAG Symposium: Ulcerative Colitis
Prognostic Factors in IBD
Co-Chairs: Edmond-Jean Bernard, Université de Montréal and
Brian Bressler, University of British Columbia
CDDW 2015 Abstract A129. Does Fecal Calprotectin Correlate
with Endoscopic Disease Activity, C Reactive Protein Levels, and
Disease Location in Patients with Inflammatory Bowel Disease?
The Canadian Association of Gastroenterology (CAG) held a symposium on the management of ulcerative colitis during the CDDW
2015 meeting. The learning objectives of this symposium included
understanding the definitions of various disease states and treatment responses for UC patients, why complete remission is a desirable outcome, the role of prognostic factors (ie. Fecal calprotectin
and histology) in managing patients, and the evidence supporting
therapeutic drug monitoring in the management of non-responders
to anti-TNF agents in UC.
CARE Faculty member, Dr. John Marshall (McMaster University)
gave a presentation during this symposium on the recent CAG
clinical practice guidelines for moderate to severe UC. In his presentation, Dr. Marshall gave an overview of the guidelines and emphasized the importance/value of using these guidelines in Canadian
practice. Key highlights from the guidelines include:
• These are the only guidelines in the world that incorporate all
biologics currently available for UC
• Rectal OR oral OR combination of oral and rectal 5ASA are all
reasonable options for management of mild to moderate UC.
• Although data may point to combination therapy being the most
efficacious, other important factors such as cost and patient
preference were considered when putting all three choices as
reasonable options.
• Due to limited data supporting efficacy of azathioprine and
more recent data reinforcing the safety concern the use of this
medication alone to maintain remission in patients with UC,
azathioprine has a limited role.
• The definition of successful therapy is obtaining and keeping
patients in complete remission which includes both symptomatic
and endoscopic remission.
• The use of therapeutic drug monitoring is an important tool in
optimizing patients on anti-TNF agents who have lost response.
It is hypothesised that adherence to these guidelines will be a
main challenge, and that it will be important to continue education
on these guidelines and how to best integrate them into clinical
practice.
L. Kwapisz4 , M. Mosli1 , N. Chande1 , B. Yan 2 , M. Beaton 2 , J. Micsko1 , W. Barnett6 , K. Bax6 , T. Ponich 6 ,
J. Howard 6 , A. Tirolese1 , R. Lannigan 5 , J. Gregor3
1. LHSC-UWO, London, ON, Canada; 2. London Health Sciences Centre, London, ON, Canada; 3.
Los Alamos National Laboratory, London, ON, Canada; 4. UWO, Whitby, ON, Canada; 5. Western
University, London, ON, Canada; 6. Western University, London, ON, Canada.
Results: 126 patients, of whom 66 were females, were included
with a mean age of 44.4 years (+-16.7). Among these patients,
exactly 50% had known IBD prior to their endoscopy, whereas the
remaining patients had symptoms suggestive of IBD. FC levels were
subsequently measured and showed strong positive correlation
with endoscopically active disease using both the Mayo scoring
system and SES-CD (P=<0.0001). To better characterize the correlation between FC and CRP, simple linear regression was performed.
FC weakly but significantly positively correlated with CRP levels
(r=0.017, 95% CI: 0.006-0.03, p=0.003) and strongly positively
correlated with disease location (rho=0.5191, 95% CI: 0.006-0.03,
p=<0.00001) with colonic disease involvement by itself having the
strongest association.
Conclusions: FC is a useful test as an initial screening tool for patients
with active intestinal inflammation. It has a strong positive correlation with endoscopic disease activity. Furthermore, FC showed a
weak but positive correlation with CRP levels and a strong positive
correlation with disease location. Given its non-invasive nature, it
may yet prove to reduce the need for colonoscopy and be an added
tool in the diagnosis and management of IBD.
CDDW/CASL 2015 —
CDDW 2015 Abstract A127. The Correlation Between a Fecal
Calprotectin and a Clinical Index for Disease Activity for Crohn’s
Disease: A Prospective Cohort
S. Moosavi4 , O. Takach 3 , B. Bressler 1 , G. Rosenfeld 2
1. Pacific Gastroenterology Associates, Vancouver, BC, Canada; 2. UBC, Vancouver, BC, Canada; 3.
University of British Columbia, Burnaby, BC, Canada; 4. University of British Columbia, Vancouver,
BC, Canada.
Results: A total of 102 patients were enrolled in a prospective fashion.
78 patients with known Crohn's disease were eligible for this study.
These patients' HBI and FecalCal values were compared visually
using a scatter plot. Using Spearman's correlation coefficient, no
significant correlation was found between the HBI and FecalCal
levels, rs = - 0.070 (p = 0.484, .95 CI, -0.2664, 0.1319).
Conclusions: In this prospective study of patients previously diagnosed with Crohn's disease, no significant correlation was found
between FecalCal, an objection biomarker of disease activity and
a clinical index of disease activity, HBI. Although questionnaires,
such as HBI, are frequently used in clinical and research settings to
assess Crohn's disease activity, this study provides further evidence
that this approach may be unreliable. Further research is needed to
confirm the utility of FecalCal as a more appropriate and objective
measure of Crohn's disease active than indices such as the HBI.
CDDW 2015 Abstract A281. Predictive Value of Basal
Plasmacytosis on Clinical Relapse in Quiescent Ulcerative Colitis
C. Dargavel, D. Kevans, B. Kabakchiev, R. Riddell, R. Kirsch, M. Silverberg
Mount Sinai Hospital, Toronto, ON, Canada.
Results: This is a preliminary analysis of 62 [58% male, mean age
48.5 years] of an anticipated cohort of 86 patients. Average length
of follow-up was 72.6 months. On initial colonoscopy, 56.5% patients
had a Mayo 0 endoscopic subscore. At study entry, 67.7% were on
5ASA analogues, 27.4% were on immunomodulators, and 14.5%
were on biologicals. At 18 months, disease relapse occurred in 34%
of patients. Over the length of follow-up, disease relapse occurred
in 63% of patients at an average of 26.1 months from study entry.
Despite having quiescent disease, histological evaluation demonstrated the presence of BPC in 48%, active histology in 58%, and
eosinophils in 68% of subjects. Presence of BPC was associated with
a shorter time to disease relapse [median time to relapse 22 versus
46 months, p=0.035] and to corticosteroid prescription [median
time to relapse 38 versus 65 months, p=0.048]. Presence of BPC
trended towards being associated with disease relapse at 18 months
[p=0.071]. Histological evidence of eosinophils and active inflammation [GS ≥3.1] were not significantly associated with the primary
outcomes.
Conclusions: A significant proportion of UC patients with endoscopically quiescent UC experience disease relapse at 18 months. BPC is
an adjunctive histological marker associated with increased likelihood of disease relapse in this UC cohort. While prospective studies
are required, the presence of BPC should prompt consideration of
therapy optimization in UC patients.
PERSPECTIVES — 3
UPDATE:
Prognostic
Predictors
and Factors
for the Treatment of Crohn’s Disease
In fall of 2014, a CARE IBD needs assessment questionnaire
was sent to a pan-Canadian audience of gastroenterologists at both an academic and community level. Feedback
gathered from this needs assessment indicated a need
for more guidance on prognostic factors that should be
considered when deciding IBD therapy. For this reason, the
CARE Gastroenterology Faculty has developed a tool that
may help to assist in managing the treatment of Crohn’s
Disease.
This tool outlines factors that have both short- and longterm implications for patients suffering with Crohn’s
Disease. The aim of this tool is to aid in classifying patient
risk, and identifying the most appropriate treatment
options for each patient using case study examples from
clinical practice.
Please refer to the insert included along with this report for
more information.
4 — CDDW/CASL 2015 —
PERSPECTIVES
IBD Therapy
CDDW 2015 Abstract A148. The Introduction of Anti-TNF
Therapy in Edmonton to Treat Crohn’s Disease has Changed the
Demographics of Patients Undergoing Intestinal Resection
CDDW 2015 Abstract A290. Dissolution of Commercially
Available Canadian Mesalamine Formulations at Various PH Levels.
A. Dittrich, R. Fedorak, H. Wang, K. Kroeker
1. Shire, Wayne, PA; 2. Shire Canada, Montreal, QC, Canada.
University of Alberta, Edmonton, AB, Canada.
Results: To date, the charts of 250 of 1,650 patients undergoing
intestinal surgery have been reviewed. There was a trend for more
patients to undergo laparoscopic rather than open surgery after
1998 (18.1% v. 9.7%, p=0.10). In regards to medication use prior to
surgery, there was an increase in anti-TNF (0% v. 11.2%, p=0.003) and
immunosuppressive use (15.3% v. 28.1%, p=0.033) after 1998. While
5-ASA use was lower after 1998 (41.7% v. 19.7%, p<0.001) and steroid
use remained similar (56.9% v. 56.2%, p=0.912). No differences in
smoking status were found for patients undergoing surgery before
or after 1998 (smoker: 50.0% v. 43.4%, former: 8.6% vs. 18.3%, nonsmoker: 41.4% v. 38.3%, p=0.162).
Conclusions: After the introduction of anti-TNF therapy for Crohn's
disease in 1998, we can see a trend toward older age and longer
disease duration at the time of surgery. There was both an increase
in anti-TNF and immunosuppressive use, while 5-ASA use declined.
The proportion of women undergoing intestinal resection after 1998
increased. Data collection is still in progress.
CDDW 2015 Abstract A159. The Non-Use of IBD-Specific
Medications in Patients with IBD
S. Bhasin1 , C. Bernstein1 , H. Singh1 , L. Targownik 1 , E. Israeli2
1.University of Manitoba, Winnipeg, MB, Canada; 2.Hadassah-Hebrew University Hospital,Jerusalem, Israel
Results: 552 CD patients and 299 UC patients were identified. This
equated to 1218 CD visits and 662 UC visits. 215 CD patients were
non-users (39%) vs 62 UC patients (20.7%) (p<0.001). There were
396 CD visits with no med use (32.4%) vs 139 UC vists with no med
use (21%, p<0.001). The mean age of CD non med users in years was
45.3 and was 40.5 in med users (p<0.0007). Conversely in UC, Mean
age in years of non-users was 40.3, and in users was 43.1 (p<0.01).
Top reasons for non-drug use in CD visits were disease remission
(46.1%), recent diagnosis/change in clinical condition -or in need
of treatment or planning to start meds (17.8%), and post-operative
state (13%). In UC visits, the top reasons for non-drug use were
disease remission (49%), non-adherence (22%), and recent diagnosis/change in clinical condition - or in need of treatment and planning
to start meds (12%). Patients who had multiple visits were more likely
to be on medications at every visit if they had UC (70%) vs CD (9%).
Conclusions: About one third of IBD patients presenting to a specialty referral clinic were not using IBD-specific drugs. This was
more likely in CD than UC. Close to half of all IBD patients who were
non-drug users were in disease remission and deemed suitable to
be off IBD-specific medications by the physician. There appears to
be more non-adherence in UC patients as compared to CD patients
in this study population. Of persons with multiple visits, CD patients
had a higher inconsistency of medication use than UC patients.
A. Abinusawa1 , S. Tenjarla1 , S. Schaffer 2
Results: The dissolution profiles for each formulation at pH 6.8 are
shown in the Figure 1. At pH 1, <1% 5-ASA release was observed
for all formulations except for PENTASA 500mg and PENTASA 1g,
which released 65% and 58%, respectively. At pH 6.0, ASACOL,
MEZAVANT, and NOVO-5 ASA formulations exhibited <1% 5-ASA
release, while cumulative 5-ASA release for SALOFALK 500mg,
PENTASA 500mg, and PENTASA 1g tablets were 73%, 72%, and
68%, respectively. At pH 6.8, the remainder of 5-ASA was released
for SALOFALK (~27%) and NOVO-5 ASA (~99%) in <30 min. For both
PENTASA 500mg and PENTASA 1g, ≥85% of 5-ASA was released
after 2h at pH 6.8. For ASACOL and MEZAVANT, >85% of 5-ASA
was released by 3.5h and 6.5h at pH 6.8, respectively. Pill-to-pill variability in 5-ASA release within a particular formulation also differed
between formulations. Similar results (not shown) were observed
for all mesalamine formulations at pH 7.2 following exposure to pH
1.0 and pH 6.0.
Conclusions: Differences in 5-ASA release were observed between
tested mesalamine formulations exposed to physiologically relevant
pH levels.
CARE Faculty Perspective: Various release mechanisms ensure
that the drug is released in the colon where the disease is active.
This, as well as other factors such as patient adherence need to be
considered when deciding on mesalamine formulations.
Online resources are available to help answer common questions
and provide in depth information to IBD patients. These types of
resources that provide this level of support outside of the clinic
are important to help address and minimize issues like adherence
to therapy.
Figure 1.
CDDW/CASL 2015 —
PERSPECTIVES — 5
CDDW 2015 Abstract A339. Validating the Use of Constipation
Symptoms to Predict Functional Defecation Disorder using a
Pruned Tree Analysis
C. Parker 1 , G. Tomlinson 2 , A. Correia 3 , L. Liu 1
1. Department of Medicine, University of Toronto, Toronto, ON, Canada; 2. Toronto General Hospital
Research Institute, Toronto, ON, Canada; 3. Credit Valley Hospital, Mississauga, ON, Canada.
Chronic Constipation
CDDW 2015 Abstract A331. Efficacy of Linaclotide in the
Treatment of Chronic Constipation: A Systematic Review of
Randomized Controlled Trials.
T. Poon 2 , A. Rezaie1 , B. Chang 1 , E. Cheng 2
1. Cedars-Sinai Medical Center, Los Angeles, CA; 2. University of Calgary, Calgary, AB, Canada.
Results: There were 150 papers on linaclotide identified, four of
which were RCTs. Three of these RCTs were included based on their
use of a primary end point of ≥ 3 spontaneous bowel movements
per week and an increase of ≥ 1 spontaneous bowel movements per
week. There were 1586 patients randomized to once daily linaclotide
145 mcg, 150 mcg, 290 mcg, or 300 mcg versus placebo. Duration of
intervention was 4 to 12 weeks. Low dose linaclotide (145 or 150 mcg)
versus placebo was found to have a pooled RR of 3.80 (95% CI 2.20
6.55) for the primary end point and a response rate of 16%-26.8%.
High dose linaclotide (290 or 300 mcg) versus placebo pooled RR
was 4.26 (95% CI 2.80 6.47) for the primary end point and had
a response rate of 19.4%-29.0%. Other end points analyzed also
showed improvement with low dose linaclotide. These included
improved abdominal discomfort (RR 1.57, 95% CI 1.26 1.97), adequate
relief response (RR 2.50, 95% CI 1.87 3.34), decreased bloating which
was defined as a score of ≥ 0.5 for 75% of treatment time (RR 1.97,
95% CI 1.44 2.69), and health related quality of life improvement
shown by an increase of ≥ 1 point on the Patient Assessment of
Constipation Quality of Life instrument (RR 1.83, 95% CI 1.34 2.50).
Conclusions: Linaclotide at low and high doses is more effective
than placebo in the treatment of chronic constipation. This was
found in the primary endpoint of improved bowel function and also
in secondary end points such as adequate relief response, bloating,
and health related quality of life.
CARE Faculty Perspective: Linaclotide is an agonist of the
guanylate cyclase C receptor on the luminal surface of intestinal
enterocytes. In phase III trials, linaclotide has shown to improve
abdominal pain and stool frequency and was well tolerated for
IBS-C patients. This agent was approved by Health Canada in
late 2014 and was included in the recent ACG/AGA guidelines
on constipation management and should begin to be included in
clinical practice across Canada.
Results: 163 (79.8% female, age 50.1 (18-90) yr) completed the questionnaire. DD was diagnosed in 87 (53.4%) patients. The pruned tree
analysis identified that need to strain, duration of strain and sense
of incomplete evacuation are likely the best variables to predict the
presence of DD (Figure 1).
Conclusions: The pruned tree analysis independently determined
that the symptoms of the need to strain and straining duration >2
minutes increase the likelihood of the presence of DD in patients
with CC. This automatic objective analysis increases the confidence
in our previous results that the straining duration in patient's bowel
symptoms help to differentiate the presence of DD. In addition, this
analysis indicates that a sense of incomplete evaluation may also be
a useful symptom to predict patients with DD.
UPDATE:
CHRONIC
CONSTIPATION
NEEDS ASSESSMENT Program
A CARE Needs Assessment, led by Dr. Louis Liu (UHN), was
sent out earlier this year with the aim of identifying clinical
practice patterns in Canada, especially since the updated ACG/
AGA guidelines became available. A publication containing the
responder feedback from this needs assessment is in development and will be distributed in late-spring, 2015.
6 — CDDW/CASL 2015 —
PERSPECTIVES
Hepatitis C Virus (HCV).
CASL 2015 Abstract A22. Feasibility of Hepatitis C Virus Disease
Elimination in Canada Within Two Decades
R. Myers10 , M. Krajden 4 , A. Ramji 5 , K. Peltekian 6 , K. Kaita7, P. Marotta 8 , S. Borgia 2 , S. Shafran 9 , M.
CASL 2015 Abstract A168. Safety and Efficacy of OmbitasvirABT-450/R and Dasabuvir ± RBV in HCV Genotype 1-Infected
Canadian Patients: Results from Phase 3 Trials
Bilodeau 1 , M. Swain10 , H. Shah 3 , J. Feld3 , C. Estes11 , H. Razavi11 , M. Sherman 3
J. Feld 1 , E. Yoshida 2 , A. Ramji2 , E. Tam 3 , V. Bain 4 , N. Ackad 5 , J. Baloukas 5 , N. Shulman 6 , C. Cooper7
1. CRCHUM, Montréal, QC, Canada; 2. McMaster, Hamilton, ON, Canada; 3. University of Toronto,
Toronto, ON, Canada; 4. BCCDC, Vancouver, BC, Canada; 5. GIRI, Vancouver, BC, Canada; 6.
Dalhousie, Halifax, NS, Canada; 7. University of Manitoba, Winnipeg, MB, Canada; 8. UWO, London,
ON, Canada; 9. University of Alberta, Edmonton, AB, Canada; 10. University of Calgary, Calgary, AB,
Canada; 11. CDA, Louisville, CO.
1. Toronto Centre for Liver Disease, University of Toronto, Toronto, ON, Canada; 2. University of British
Columbia, Vancouver, BC, Canada; 3. LAIR Centre, Vancouver, BC, Canada; 4. University of Alberta,
Edmonton, AB, Canada; 5. AbbVie Canada, Saint-Laurent, QC, Canada; 6. AbbVie Inc., North Chicago,
IL; 7. University of Ottawa, Ottawa, ON, Canada.
Results: In 2014, we estimated 250,859 HCV-infected cases in
Canada including 2,171 with decompensated cirrhosis, 802 with
HCC and 824 liver-related deaths. In the base case, 174,941 viremic
cases will remain in 2035 (30% decline from 2014), but increases in
decompensated cirrhosis (32% [n=2,866]), HCC (108% [n=1,667])
and liver-related deaths (84% [n=1,516]) will be observed. The five
selected strategies of increased Rx uptake could eliminate HCVrelated complications by 2035; to achieve a dramatic decline in HCV
prevalence, strategies limiting fibrosis restrictions would be needed.
However, the ‘progressive strategy', treating those with more severe
liver disease first, was most efficient in achieving elimination of infections and complications. Above 10,800 patients/yr, all Rx scenarios
resulted in similar declines in morbidity and mortality by 2035.
Conclusions: With the availability of novel antiviral regimens, elimination of HCV infections and hepatic complications from Canada
within two decades are achievable.
CARE Faculty Perspective: This study is incredibly important
Canadian work. Treating HCV in small numbers will not impact the
overall public health burden of the disease according to several
analyses, but how much HCV we should be treating in Canada
is unknown. This paper provides practical policy approaches
to possibly eliminate HCV from Canada, with the best approach
being one that treats patients with more advanced fibrosis today,
then expanding to patients with less advanced disease. Coupled
with creative methods to amortize the costs of HCV meds,
this strategy really could work. Of course, HCV will never be
eliminated with treatment alone, but a sizeable advance could be
made in reducing the complications of this curable infection with
a ‘progressive strategy’.
Results:
n/N(%)
Overall
GT1a
GT1b
Treatment
naïve
Treatment Experienced
Relapse
All patients
SAPPHIRE-I
SAPPHIRE-II
PEARL-IV
TURQUOISE-II
Partial
Null
Response Response
114/117
91/94
23/23
82/85
7/7
10/10
15/15
(97.4)
(96.8)
(100)
(96.5)
(100)
(100)
(100)
NA
NA
NA
4/4 (100)
9/9 (100)
NA
NA
33/34
25/26
8/8
33/34
(97.1)
(96.2)
(100)
(97.1)
18/18
13/13
5/5
(100)
(100)
(100)
30/31
30/31
(96.8)
(96.8)
NA
33/34
23/24
10/10
(97.1)
(95.8)
(100)
NA
30/31
(96.8)
19/20 (95)
5/5
(100)
NA
2/2
6/6
6/6
(100)
(100)
(100)
Conclusions: Canadian patients enrolled in phase 3 trials of 3D±RBV
achieved similar SVR12 rates to the overall study populations.
CARE Faculty Perspective: This abstract represents all the
Canadian sites and patients who participated in the phase-3
program evaluating the Abbvie 3D regimen that has recently
received Health Canada approval. The results reveal excellent
SVR-12 rates overall of 97%, including in persons with cirrhosis
and prior treatment experienced (Peg-INF + RBV only) patients.
It is notable that the Genotype 1b persons had a 100% SVR. The
regimen was well tolerated with only 1% requiring RBV dose
modification. Overall, the SVR and tolerance of Canadian patients
is similar to that of the overall phase 3 program of this regimen.
CDDW/CASL 2015 —
PERSPECTIVES — 7
UPDATE:
Hepatocellular Carcinoma
CASL 2015 Abstract A236. Hepatocellular Carcinoma Screening:
Quality Assurance Project
J. Kiberd 1 , C. Burgess 2 , G. Hirsch2 , M. Laryea2 , K. Peltekian3
1. Dalhousie University, Halifax, NS, Canada; 2. Queen Elizabeth II Health Sciences Center, Halifax, NS,
Canada; 3. Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada.
Results: 481 patients underwent surveillance at our center. Patients
with prior HCC, cancer, or transplant recipients were excluded.
The remaining 404 (84%) patients were included in the incidence
analysis. HCC was detected in 29 (7.2%) patients with a median
follow-up of 5.8 years (IQR 0.8 to 7.5 years) with a rate of 1.4 cancers
per 100 patient years. Sixty-four percent were male with average
age 54.7 years (SD 9.33). Disease etiologies were: HCV 223(55%),
HBV 23(6%), NASH 66(16%), Alcoholic Steatohepatitis 38(9%), PBC
28(7%), AIH 20(5%), Hemochromatosis 13(3%), and Cryptogenic
cirrhosis 10(2%). Those who developed HCC were HCV 20 (69%),
Alcoholic Steatohepatitis 6(21%) and NASH 3(10%). Cumulative
incidence among etiologies were ASH (16%), HCV (9%), and NASH
(4%). Average tumor size by ultrasound was 2.25cm (95%CI: 1.722.78cm). Mean time from last normal scan to diagnosis of HCC was
11.0 months (95%CI: 8.3-13.7months). Mean time from ultrasound to
diagnostic MRI was 4.1 months (95%CI: 2.6-5.6months). Average size
of HCC by MRI was 2.47cm (95%CI: 1.94-2.99cm). Tumor size was not
significantly different between ultrasound and MRI.
Conclusions: Overall incidence of HCC was 1.4% per year, which
is in range of what has been reported in the literature. Our center
adheres to recommended guidelines performing ultrasounds every
six months among patients with suspected cirrhosis.
HCc NEEDS
ASSESSMENT
Program
Further education on the referral process and management
strategies of HCC are warranted. This has been a topic of interest for the CARE Liver Disease, Interventional Radiology, and
Medical Oncology Faculties. For this reason, a needs assessment,
focused on the identification and management of hepatocellular carcinoma (HCC) was developed by medical oncologist, Dr.
Winson Cheung (BCCA). This questionnaire was distributed to
Canadian hepatologists to gain their insights on HCC. The goal
was to promote a shared understanding of the range of issues,
perspectives, and developments related to these issues, framed
from a Canadian perspective.
Key takeaways from the responder feedback include:
» Everyone monitors patients ‘at-risk’ for HCC
» The most commonly used HCC guidelines are from the American Association
for the Study of Liver Disease
» Surgery and Radio Frequency Ablation are typically the preferred curative
first-line therapy for most patients, followed by TACE.
» It is often unclear when TACE becomes unsuitable, however, for those in
academic centres it is much better understood.
» Systemic therapy is the most common treatment regimen after TACE
If you would like more information on this project, or would like
the full details of the needs assessment feedback please email
your request to [email protected].
8 — CDDW/CASL 2015 —
PERSPECTIVES
HCV
CME Accredited
Education Program
DDW 2015
Friday May 15, 2015
Washington, DC
FREE REGISTRATION AT:
www.CAREeducation.ca/ddw2015
Dinner included after the session
Starting at AASLD 2013, the CARE Liver Disease Faculty began development
of a CARE Liver Disease Education Program. Focused in HCV, this program
can be utilized by specialists across Canada for education/training and can
update physicians on recent developments in the screening, treatment and
management of HCV.
This program has now been accredited through the University of Calgary.
Chapters in this program include content on the following:
» Section One: Review
» Section Two: Screening
» Section Three: Assessment
» Section Four: Treatment
» Section Five: Self-Assessment Checklist
The CARE Faculty is pleased to announce that the first CME accredited event
will be held in conjunction with this year’s CARE at DDW 2015 Community
and Trainee Education Program.
HCV CME Accredited Meeting Chair:
» Dr. Hemant Shah (Toronto Western Hospital)
For additional details, or if you would like to register for this event please visit
the CARE education website: www.careeducation.ca/ddw2015 or contact
CARE at: [email protected]
CDDW/CASL 2015 —
PERSPECTIVES — 9
DDW
2015
D
DDW 2015
@ DDW 2015
FRIDAY MAY 15, 2015
CARE @ DDW 2015, held in Washington, DC, will provide community and trainee gastroenterologists and
hepatologists an opportunity to explore news and developments from DDW within a Canadian context. The
program will also allow participants to network with peers and engage in lively discussion with other conference
attendees. The program, led by CARE faculty member Dr. John Marshall (McMaster University), will take place
on Friday, May 15, 2015. This year the program includes a CME-accredited HCV program prior to the networking
dinner. Both gastroenterologists and hepatologists are welcome to attend all sessions.
WASHINGTON, DC
The objective of this meeting is to discuss recent advances, research, treatment options, and fellowship/career
opportunities in gastroenterology and hepatology.
Paris Meeting Room
Sofitel Washington DC Lafayette
Square
5:00pm HCV Education Session (CME-Accredited)
Friday May 15, 2015
Shah, MD, Toronto Western Hospital
806 15th St NW, Washington,Hemant
DC 20005
Washington, DC
6:10pm
+1 202-730-8800
FREE REGISTRATION AT:
6:45pm
www.CAREeducation.ca/ddw2015
Networking Dinner
Opening Remarks
John Marshall, MD, McMaster University
Liver Disease
FOR INFORMATION &
REGISTRATION
6:55pm
Hemant Shah, MD, Toronto Western Hospital
Dinner included after
thecontact
[email protected]
Please
P: 905-891-9000
ext. 200Ulcerative Colitis and Crohn’s Disease
7:20pm
F: 905-891-9015
Alain Bitton, MD, McGill University
or visit www.CAREeducation.ca/DDW2015
Paris Meeting Room
7:45pm
Break
Sofitel Washington DC Lafayette Square
8:00pm
IBD Guidelines
Brian Bressler, MD, University of British Columbia
8:25pm
Functional GI Disorders
Louis Liu, MD, University Health Network
8:50pm
Closing Remarks
John Marshall, MD, McMaster University
806 15th St NW, Washington, DC 20005
+1 202-730-8800
FR
W
This CARE PUBLICATION provides educational updates on current trends in medicine. Views expressed in this report are those of the faculty. All information is
provided for general informational purposes only, on an “as is” basis, without any representations, warranties or conditions, whether express or implied, statutory or
otherwise, including, without limitation, any representations, warranties or conditions as to quality, accuracy, completeness, currency, reliability, efficacy, or fitness
for a particular purpose. This information is not a substitute for informed medical advice. Support for the distribution of this report was provided by Shire Pharma
Canada ULC, Janssen Inc. and Actavis Canada. Copyright © 2015 by CARE. All rights reserved. This publication or any portion thereof, in print, electronic copy or any
other form, cannot be reproduced without the express written consent of CARE. Any information, data, analysis, or results reproduced from another source remains
the property of its authors.