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June 9, 1999

Cost-effectiveness of Interferon Treatment for Hepatitis C

Author Affiliations

Margaret A.WinkerMD, Deputy EditorIndividualAuthorPhil B.FontanarosaMD, Interim CoeditorIndividualAuthor

JAMA. 1999;281(22):2083-2084. doi:10-1001/pubs.JAMA-ISSN-0098-7484-281-22-jbk0609

To the Editor: Dr Wong and colleagues1 conclude that "routine liver biopsy prior to interferon therapy increases the managing costs without improving health outcome." Their conclusions unintentionally are prone to be misunderstood by physicians, patients, and insurance carriers. A biopsy can be helpful to decide whether, and how urgently, treatment should be given. Patients with slightly elevated transaminase levels may have minor inflammatory activity on liver biopsy or full-blown cirrhosis. Patients with normal transaminase levels tend to have minimal inflammatory activity and, as a rule, are neither treated nor undergo biopsy. However, elevated transaminase levels are less predictive of the severity of disease (inflammation or fibrosis).2 Therefore, the consequence of biopsy may be to defer therapy in certain patients. However, this probably should not be done in patients with more severe disease. Patients with cirrhosis may benefit earlier than any other patient category. Cirrhosis also may be missed on cross-sectional imaging and is a risk factor for hepatocellular carcinoma. Therefore, this diagnosis could have further implications for long-term management, including screening for varices and hepatocellular carcinoma. Most patients without cirrhosis, on the other hand, currently receive costly therapy in the hopes of preventing long-term (10-20 years) complications of the disease.