Alarmed by a near tripling of the number of veterans developing hepatocellular carcinoma (HCC) during the past five years, VA has strengthened its programs for the prevention, screening and treatment of veterans with hepatitis C (HCV), which is a major risk for developing the cancer. VA also is revamping practice guidelines for the use of promising new drugs.

The numbers paint a stark picture: According to Clinical Case Registry data, between 2000 and 2008, 287,410 veterans in VHA care screened positive for antibodies to HCV, and 189,065 of them were identified with chronic HCV infection. In fact, VHA is the largest single provider of HCV care in the United States.

More than 4,824 cases of HCC were diagnosed in veterans with chronic HCV infection during that time period, according to the report “State of Care for Veterans with Chronic Hepatitis C,” published in November 2010, “The incidence of HCC in the U.S. as well as in the VHA has been increasing, and this is likely due to the large pool of people with longstanding HCV infection. The cumulative number of new HCC diagnoses continues to increase at a rate that exceeds the increase in patients receiving ongoing care for their chronic HCV and HCC.”

That increase has been significant. “What we’ve seen over the last five years or so, as of the date of the report, is the total number of vets who had liver cancer has probably tripled in the last five years,” notes David Ross, MD, PhD, director of VA’s National Clinical Public Health Program. “The absolute numbers are not that high, but we’re concerned that they’ve been increasing.”

Those concerns are well warranted, given the prognosis for a veteran diagnosed with HCC. “Overall, the survival is quite low – an average of approximately eight months,” says Hashem B. El-Serag, MD, MPH, chief, Gastroenterology and Hepatology, at the Michael E DeBakey VA Medical Center in Houston, adding that more than 2,000 patients with HCC are seen annually in VA hospitals and that veterans are approximately three times more likely to have hepatitis C infection, compared with the general population.

Addressing Alcohol Use

Preventive programs instituted by VA include addressing lifestyle changes, such as reducing or eliminating use of alcohol and maintaining healthy body weight; HIV testing; cancer screenings; and antiviral treatment.

Most important, according to Ross, is for patients to stop or significantly decrease alcohol intake. “If you can do that, the risk goes way down.”

To address this problem, VA is using an approach called motivational interviewing. Launched in 2010, it has four key principles:

1) Resisting directing -- which stresses directing, lecturing, convincing and cajoling;

2) Understanding the person’s motivation -- by exploring their values, needs, aspirations, abilities and ideas;

3) Listening with empathy; and

4) Empowering -- by exploring the person’s past experience, setting achievable goals and problem-solving to overcome barriers to change.

“The more traditional approach – wagging your finger at someone and telling them to stop drinking – is as effective as telling a teenager not to drink,” noted Ross.

Motivational interviewing includes a three-question screening to gauge the level of the veteran’s drinking. Each answer is given a value, with a total score of 0-12, which in turn produces a color-coded risk pyramid. (Additional details of the program can be found at www.hepatitis.gov.)

Often, he noted, patients will perceive themselves to be “green,” when in fact their pyramid will be red, adding, “If you show them where they really are and tell them it’s ‘Based on data from vets just like you,’ it has a big impact over time.”

This low-cost tool takes about three to five minutes to implement. “We run the largest motivational training program within the VA on this,” according to Ross, with training programs being offered for providers twice a year.