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Chronic hepatitis B virus (HBV) infection is a serious public health problem, leading to cirrhosis, hepatocellular carcinoma (HCC) and liver failure. In highly endemic areas and among immigrants from these areas, most cases of chronic hepatitis B are due to HBV infection at birth or during the first year of life. Cirrhosis and HCC may occur at any age, but infections early in life are typically asymptomatic for the first few decades. Sharp rises in the incidence of fibrosis, cirrhosis and HCC generally do not appear until after the age of 30, the incidence of HCC showing a sharp rise after the age of 40. Approximately 50% of deaths in HBV carriers may be due to either chronic liver disease or HCC. Cirrhosis is a consequence of hepatocyte death and chronic inflammation in the liver, while HCC, like many cancers, probably results from a combination of initiation (hepatocyte mutation) and promotion (liver regeneration). Symptoms are often not apparent until a patient has terminal liver disease, and better approaches are needed to create public awareness and demand for early screening. With the availability of new antiviral drugs, a change in treatment guidelines may also be warranted. As discussed here, there are reasons to believe earlier treatment may decrease the risk of HCC.
Hepatocellular carcinoma (HCC) is generally, but not always, seen on a background of cirrhosis. Since antiviral therapy with nucleoside(tide) analogues (NAs) slows or prevents cirrhosis and reduces the incidence of HCC, its benefits are obvious. Indeed, it is widely assumed that withholding antiviral therapy until the appearance of clinically active liver disease and fibrotic lesions is an adequate standard of care. Guidelines from international liver associations have mainly recommended that antiviral therapy be initiated if patients show signs of …