Periodic Liver Biopsy for Mild Hepatitis C

TO THE EDITOR:

The report by Wong and Koff (1), which advocates initial interferon-ribavirin therapy for mild chronic hepatitis C, seems flawed in several ways. First, it ignores reports (2, 3) that predict a significantly lower rate of progression to cirrhosis from chronic hepatitis C than the 27.5% or even 9.5% used in their study. Inclusion of these data would probably change the outcomes reported. The failure to even mention these and other similar reports showing a more favorable outcome of chronic hepatitis C is troubling. Second, in calculating costs for the group of patients with mild hepatitis, more than six liver biopsies were performed per lifetime followed. One questions the usefulness of performing a liver biopsy on a patient with mild, histologically unchanging, chronic hepatitis C after a decade of stability (proven by three biopsies). If three liver biopsies, rather than the six in the article, were used, the cost–benefit ratio would again significantly change to favor simple follow-up. Third, although Wong and Koff address the influence of patient nonadherence to follow-up for liver biopsy, they do not account for patient nonadherence to combination interferon-ribavirin therapy and the fate of those forced to discontinue it because of adverse effects. Conservatively, this would be 20% of those requiring 48 weeks of therapy (for the most common type of hepatitis C virus, genotype 1) and 8% for those needing 24 weeks of therapy (for the distinctly less common types 2 and 3) (4).