Low incidence of HCC in chronic hepatitis C patients with pretreatment liver stiffness measurements below 17.5 kilopascal who achieve SVR following DAAs

Jacob Søholm; Janne Fuglsang Hansen; Belinda Mössner; Birgit Thorup Røge; Alex Lauersen; Jesper Bach Hansen; Nina Weis; Toke Seierøe Barfod; Suzanne Lunding; Anne Øvrehus; Rajesh Mohey; Peter Thielsen; Peer Brehm Christensen

doi:10.1371/journal.pone.0243725

Peer Review History

Original SubmissionAugust 5, 2020
19 Aug 2020 Decision Letter - Pavel Strnad, Editor PONE-D-20-23907 Low incidence of HCC in chronic hepatitis C patients with pretreatment liver stiffness measurements below 17.5 kilopascal who achieve SVR following DAAs PLOS ONE Dear Dr. Søholm, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. As you can see, both reviewers appreciated your work, but also raised a couple of important issues. Most importantly, the low number of events greatly limits the power of the study and this limitation needs to be clearly highlighted. Along the same lines, some of the conclusions should probably be softened a bit. Please submit your revised manuscript by Oct 03 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. 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The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2.We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. In your revised cover letter, please address the following prompts: a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). 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The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: I Don't Know Reviewer #2: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Jacob Søholm et al. Investigated if liver stiffness measurement (LSM) could predict the risk of HCC, decompensation and all-cause mortality in patients with SVR after DAA treatment. This is a retrospective study of 773 patients. The authors suggest that Patients after HCV cure by DAA therapy with a pretreatment LSM <17.5 kPa appear not to benefit from HCC surveillance for the first 3 years after treatment. Several other studies have performed similar studies. Comments: „We did not find a significantly higher risk of developing HCC in patients with a pLSM of 10-17.4 kPa compared to patients with a pLSM <10 kPa“ LSM is influenced by several factors, e.g. it has been shown that values can be higher in patients that have had a meal withing the last 2 hours prior to the investigation. This needs to be considered. In addition, pretreatment LSM can be influenced by the ALT value (inflammation). Ideally, a cut-off at the end of the treatment could be more accurate? (i.e. Clin Infect Dis. 2019 Nov 22;ciz1140.) Only 11 patients in that cohort developed HCC. 9/11 patients could be identified by the cut-off of 17.5 kPa. The authors mentioned that LSM >17.5 kPA was associated with age, male sex and diabetes. All these factors have been associated with HCC risk. Were the other 2 patients male, had older age and diabetes? Are these factors (in combination) more relevant than LSM? I wonder if the authors would not perform HCC surveillance in a male patient, with LSM of 14 kPA and diabetes mellitus? Thus, in my view the concluison is too stroing in my view based on the 11 patients with HCC. LSM may not be available in all settings. Other easier to use parameter may be more valuable. Several studies have investigated albumin (J Hepatol. 2020 Mar;72(3):472-480) or FIB-4 (e.g. Gastroenterology. 2019 Nov;157(5):1264-1278.e4.) as predictive marker. FIB-4 data could improve the study. Reviewer #2: Soholm et al performed a retrospective analysis of about 800 patients to predict HCC, complications and mortality depending on the liver stiffness in patients after successful (SVR) DAA therapy. They could identify 17.5 kPA as LSM cut-off with a NPV for any complication >95% suggesting that in those patients closed surveillance after SVR is not required. Although novelty is limited, data analysis and the study design are of good quality. I have just some minor comments: A valid LSM <2 years before treatment with DAA which is the index day might be quite long and might include a selection bias – subgroup analysis or time between LSM and index date as confounder in the multivariate would be important to show As the primary outcome was HCC but more patient died than developing HCC during follow, authors should state and discuss how they dealt with competing risk (death before HCC). The figures show cumulative incidences which suggest that this was considered during analysis. Multivariate data might be over fitted as incidence of 11 (HCC), 14 (dec. cirrhosis) and 38 for death restrict the number of confounder to maximum of four when calculating the risk of death and even 1-2 for the other endpoints. ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0243725.r001
Revision 1
8 Oct 2020 Author Response Response to Reviewers We would like to thank the academic editor and the reviewers for their comments. We have addressed the queries in order below Response to the academic editor 1: Editor’s comment: Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. Author’s reply: We have tried to adhere to the PLOS ONE’s style requirements. 2: Editor’s comment: We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. Author’s reply: We have addressed the issue of data access in the cover letter. Response to reviewer 1: 1: reviewer’s comment: „We did not find a significantly higher risk of developing HCC in patients with a pLSM of 10-17.4 kPa compared to patients with a pLSM <10 kPa“. LSM is influenced by several factors, e.g. it has been shown that values can be higher in patients that have had a meal withing the last 2 hours prior to the investigation. This needs to be considered. In addition, pretreatment LSM can be influenced by the ALT value (inflammation). Ideally, a cut-off at the end of the treatment could be more accurate? (i.e. Clin Infect Dis. 2019 Nov 22;ciz1140.) Authors’s reply: We have discussed the first point in the discussion: Thirdly, we did not have data on whether pLSM were performed with the patients fasting. As LSM can be falsely elevated if the patient is not fasting this could have caused an overestimation of the LSM cutoffs in the study. However, patients in Denmark are instructed to be fasting when having LSM performed and as almost all patients had at least one LSM prior to the pLSM, most would be expected to have been fasting at the time of the pLSM. We also agree that also having a LSM at end of treatment or SVR would have been preferable, but unfortunately, it was not available in most patients. We have added the following to the discussion: It would have been preferable to also have LSM at end of treatment (EOT) or at SVR as the inflammation caused by CHC can cause an elevation of LSM, regardless of fibrosis and LSM at SVR could be more accurate at predicting outcomes after DAA treatment [38]. However, LSM at EOT or SVR was not available in most patients. Furthermore, a significant part of patients in treatment for CHC are lost to follow up, especially vulnerable patients like those with active injecting drug use or suffering from homelessness [39]. Being able to provide prognostication and reassurance at the time of treatment initiation would be important, especially in patients at risk of lost to follow up after treatment. 2: reviewer’s comment: “Only 11 patients in that cohort developed HCC. 9/11 patients could be identified by the cut-off of 17.5 kPa. The authors mentioned that LSM >17.5 kPA was associated with age, male sex and diabetes. All these factors have been associated with HCC risk. Were the other 2 patients male, had older age and diabetes? Are these factors (in combination) more relevant than LSM? I wonder if the authors would not perform HCC surveillance in a male patient, with LSM of 14 kPA and diabetes mellitus? Thus, in my view the concluison is too stroing in my view based on the 11 patients with HCC.” Author’s reply: We have described the two patients with a LSM <17.4 under the heading “Hepatocellular carcinoma”: Of the two patients who were diagnosed with HCC post treatment, the first was a female in her mid-fifties with a pLSM of 4.7 kPa and no history of heavy alcohol use or diabetes while the other was a male in his late fifties with a pLSM of 13.0 kPa and a history of both heavy alcohol use and diabetes. We also added the following sentence in the discussion: “As the negative predictive value for the cut-off of 17.5 kPa was very high at 99.7 %, this could suggest that within the first three years after cure for hepatitis C, monoinfected patients with no prior episode of HCC or decompensated cirrhosis and with a pretreatment LSM below 17.5 kPa may not benefit from HCC surveillance. However, patients with a pLSM of 10-17.4 kPa and other risk factors for HCC should also be considered for HCC screening, based on individual risk assessment.” 3: reviewer’s comment: LSM may not be available in all settings. Other easier to use parameter may be more valuable. Several studies have investigated albumin (J Hepatol. 2020 Mar;72(3):472-480) or FIB-4 (e.g. Gastroenterology. 2019 Nov;157(5):1264-1278.e4.) as predictive marker. FIB-4 data could improve the study. Author’s reply: We agree that adding biomarkers would have improved the study. Unfortunately,blood samples, including albumin and especially ASAT were only available for a minority of patients in the study and we therefore could not include albumin or FIB-4 in the analyses. We have mentioned this in discussion: It would have been a great advantage to the study if serological markers of liver fibrosis, such as FIB-4, had been available to corroborate our LSM findings, but as aspartate aminotransferase (AST) was not a standard test in Denmark during the study period, and only available for a small proportion of patients. We also agree that the use of LSM is not available in all settings, limiting the applicability of the study, but when available, it can be practical in outreach programs among the most vulnerable patients where one contact prior to treatment initiation (using LSM and POC HCV RNA testing) is preferable. We have added the following text in the introduction: Using LSM as a predicting marker allows for less contacts with health care providers before treatment initiation, as compared to biomarkers. This can be advantageous in outreach programs among marginalized populations, such as homeless people and people who inject drugs. Response to reviewer 2: 1: reviewer’s comment: A valid LSM <2 years before treatment with DAA which is the index day might be quite long and might include a selection bias – subgroup analysis or time between LSM and index date as confounder in the multivariate would be important to show. Author’s reply: We agree that the long time from LSM to index date in some patients could represent a bias and have included the time between LSM and index date as a variable in the regression analyses. 2: reviewer’s comment: the primary outcome was HCC but more patient died than developing HCC during follow, authors should state and discuss how they dealt with competing risk (death before HCC). The figures show cumulative incidences which suggest that this was considered during analysis. Author’s reply: We agree that competing risk analysis should be used for HCC and decompensated cirrhosis and have changed from cox regression to competing risk regression and reported subhazard ratios for these outcomes. 3: reviewer’s comment: Multivariate data might be over fitted as incidence of 11 (HCC), 14 (dec. cirrhosis) and 38 for death restrict the number of confounder to maximum of four when calculating the risk of death and even 1-2 for the other endpoints. Authors reply: We have lowered the cutoff for including variables in multivariate analyzes from p<0.1 to p<0.05, thus lowering the number of confounders included. Attachments Attachment Submitted filename: Response to Reviewers .pdf https://doi.org/10.1371/journal.pone.0243725.r002
30 Oct 2020 Decision Letter - Pavel Strnad, Editor PONE-D-20-23907R1 Low incidence of HCC in chronic hepatitis C patients with pretreatment liver stiffness measurements below 17.5 kilopascal who achieve SVR following DAAs PLOS ONE Dear Dr. Søholm, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. As you can see, the reviewers aggreed that the manuscript substantially improved and only a minor revision is needed at this step. Please submit your revised manuscript by Dec 14 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols We look forward to receiving your revised manuscript. Kind regards, Pavel Strnad Academic Editor PLOS ONE [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed Reviewer #2: (No Response) ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: (No Response) Reviewer #2: No ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: (No Response) Reviewer #2: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: The authors have taken up my comments and critically discussed the limitations of the study. No further comments Reviewer #2: Soholm et al. addressed my previous comments and improved the impact of the manuscript. I have only one minor comment regarding the competing risk analysis: Authors should mention in the stats section or results section why this analysis was necessary - as death was competing substantially with the occurence of HCC or complications of cirrhosis. ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0243725.r003
Revision 2
27 Nov 2020 Author Response Response to Reviewers We would like to thank the the reviewers for their comments. We have addressed the queries in order below Response to reviewer 2: 1: reviewer’s comment: Authors should mention in the stats section or results section why this analysis was necessary - as death was competing substantially with the occurence of HCC or complications of cirrhosis. Author’s reply: We agree that this should be specified and have rewritten the section in the statistics section: Cox regression was used to estimate hazard ratios for all-cause death. Competing risk regression was used to estimate subhazard ratios for HCC and decompensated cirrhosis, as death was a substantial competing risk for these two outcomes. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0243725.r004
30 Nov 2020 Decision Letter - Pavel Strnad, Editor Low incidence of HCC in chronic hepatitis C patients with pretreatment liver stiffness measurements below 17.5 kilopascal who achieve SVR following DAAs PONE-D-20-23907R2 Dear Dr. Søholm, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Pavel Strnad Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0243725.r005
Formally Accepted
2 Dec 2020 Acceptance Letter - Pavel Strnad, Editor PONE-D-20-23907R2 Low incidence of HCC in chronic hepatitis C patients with pretreatment liver stiffness measurements below 17.5 kilopascal who achieve SVR following DAAs Dear Dr. Søholm: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Pavel Strnad Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0243725.r006

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