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Post Info TOPIC: Post Treatment SVR HCC rates?
Tig


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DAAs do not affect HCC risk, SVR reduces risk. Healio/Gastroenterology update.

DAAs do not affect HCC risk, SVR reduces risk

Kanwal F, et al. Gastroenterol. 2017;doi:10.1053/j.gastro.2017.06.012.

July 10, 2017

Recently published data showed a link between sustained virologic response and a reduced risk for hepatocellular carcinoma among patients treated with direct-acting antivirals for hepatitis C.

 

“Data on HCC risk following DAA induced SVR are still sparse and conflicting,” Fasiha Kanwal, MD, MSHS, from the DeBakey Veterans Affairs Medical Center, Houston, Texas, and colleagues wrote. “We found that, among patients treated with DAA, virological cure of HCV resulted in a considerable reduction in the risk of HCC. However, the absolute risk of HCC was high in several patient groups who achieved cure, including [approximately] 40% of patients who had progressed to cirrhosis.”

To assess the risk and determinants for HCC in patients cured with DAAs, the researchers gathered data on 22,500 patients treated for HCV with DAAs from the Veterans Health Administration system, 19,518 of whom achieved SVR.

 

The 2,982 patients who did not achieve SVR were more likely to be Hispanic (5.3% vs. 3.5%; P < .0001) and have cirrhosis (42.6% vs. 38.4%; P < .0001), HCV genotype 3 (8.8% vs. 3.5%; P < .0001) and a history of alcohol (66.7% vs. 60.6%; P < .0001) or drug use (58.9% vs. 53.4%; P < .0001), compared with those who did achieve SVR.

 

Among those who achieved SVR, 183 developed HCC during 20,415 person-years of follow-up for an annual incidence of 0.9 per 100 person-years (95% CI, 0.77-1.03). This was considerably lower than the rate of 3.45 per 100 person-years among the 88 patients who did not achieve SVR and developed HCC during 2,547 person-years of follow-up (95% CI, 2.73-4.18).

 

Researchers observed a strong association between SVR and time until development of HCC (P < .0001), and a 76% decrease in the risk for HCC (HR = 0.24; 95% CI, 0.19-0.31).

 

On a multivariate model, other factors that affected the risk for HCC in this cohort included cirrhosis (HR = 4.73; 95% CI, 3.34-6.68) and alcohol use compared with those without alcohol use (HR = 1.56; 95% CI, 1.11-2.18). Compared with Caucasian patients, African-American patients had a lower risk for HCC (HR = 0.56; 95% CI, 0.39-0.81).

 

 

“Our data highlight the potential consequences of delaying treatment — either by lack of access or by patient/provider choice — on subsequent risk of HCC, and support treatment of all patients with HCV prior to their progression to advanced fibrosis and cirrhosis. Delaying treatment until patients progress to cirrhosis might be associated with substantial downstream costs incurred as part of life long HCC surveillance and/or management of HCC,” the researchers concluded. “We did not find any evidence to suggest that DAAs promote HCC either during or after treatment.” – by Talitha Bennett

 



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Tig

61 yo GT1A - 5 Mil - A2/F3 - (1996) Non Responder, (2013) Peg/Riba/Vic SOT:05/23/13 EOT:12/04/13 SVR 1-4 years!

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Tig


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Here's a great description of the RFA (Radiofrequency ablation) procedure. I hope you find it interesting and informative.

RFA Ablation



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Tig

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VetwithC,

Can't find these particular articles right now, but, in my readings ... your overall factors (cirrhosis, AFP levels, etc., etc.) will be ALL be taken into consideration, and for lesions, "size matters", or at least to a degree, and may also have a bearing on your doc(s) reaching a decision about what is best to do next, size seems to have some bearing on whether they decide to adopt the wait and see repeat imaging approach, or ablate (just to be on the safe side, to obliterate it "on principal" even if it is just unruly cells versus Ca).

Over 2 cm they "seem" to have more of a tendency to ablate, 1 cm and under (the teeny weenies) they tend to watch - that's what I have been reading in my travels anyway - but, i could be dead wrong and reading outdated stupid stuff! You are seem to be in the middle of the road between small and teeny, about 1 1/2 cm?

How are your ALT/AST's and AFP's? Sometime's AFP's are not very useful, at the best of times, but if they hold any value in helping support suspicions or assessments, then (I have also read) often AFP's may not even be elevated with small lesions anyway (you can have a 2 cm or less lesion) and no AFP elevation, even larger lesions may not evoke an AFP rise, so, for what AFP's are worth (as a sometimes good additional guiding tool), they can hold some value (and limitations). That is why they should take ALL your factors into consideration, all your labs, conditions, history when deciding to take a wait and see posture or to ablate.

Thanks for filling me in BTW - I WAS confused as to where you were/are. What a lovely place to live, as long as one could stay put on paradise, and not have to step off it! Then, it is not so convenient.

Unruly, uncooperative cells do not mean you have cancer, keep this in mind. There are hemanginoma's and other abberations that can show up that are notoriously bengin things!

I would try to get your Fscore, or degree of cirrhosis better defined, pull a more definitive "number" or opinion out of your docs. That old (single) fibroscan 3.9 Kpa number could have been a lost leader (written down wrong, done wrong, mis-construed - who knows!) compared to what they have been suggesting to you otherwise and since - I doubt they use dif scales in Thailand for a fibroscan, but who knows - maybe it was actually 13.9 not 3.9 kPa's!  

With only ultrasound's post-treatment (and this only being your first MRI imaging with no CATs and only one past fibroscan to rely on), that leaves only the labs and their good judgement to help determine your Fscores over time - you say your LFT's are OK - have they been doing lab tests like "Fibro-tests", or the like, all along, to give you a more definitive Fscore number? U/S's provide a lot a vlaubale info, as do MRI's as far as showing evidence of cirrhoisis, enlargement as you mentioned, or "signs of" cirrhosis. Always nice though to have a "number" (Fscore number) to follow, to see if you have been progressing, hovering or receding back and forth between F3 to 4 (for instance).

If it was me, my next step would more imaging, and I would consider ablation IF they are convinced this is wise by the data, evidence and in their experience. As much info as possible for both you and them is a good thing. C.



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HCV/HBV 1973. HBV resolved. HCV undiagnosed to 2015. 62 y.o. F. Canada.

GT3a, Fibroscan F3/12 kPa - F4/12.6 kPa, VL log 7.01 (10,182,417), steatosis, high iron load.

SOF/VEL with/without GS-9857 trial - NCT02639338.

SOT March 10 - EOT May 5, 2016 - SOF/VEL/VOX 8 week trial.

 

(SEE UPDATES IN BIO)



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Hey Tig......

Good to hear your input on this ablation procedure, which is new to me [and my VA PCP as well].

After speaking with my older more experienced Dr, his conservative seemed like the route to go as the lesion is small [hopefully benign and slow spreading].

His suggestion was to just wait for a couple of more months and repeat the MRI as he was of the opinion that even a needle biopsy was invasive and had it's dangers of spreading the cancer.  Maybe better to leave well enough alone for a while before invading my liver.

Thanks for the input. 

 



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DXed in year 1999 with geno 1a, went with a wait and see approach while my viral load increased from 240,000 to 3 mil and contacted VA when Harvoni came out and now have harvoni and starting TX on Monday.
Tig


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Hey Harry,

I would determine what that doctor was referring to when he said "invasive". The most common approach now is to attempt a procedure called ablation. It is invasive but minimally as noted below. A needle is used, not a knife happy surgeon! Your Dr. friend is offering some knowledgeable advice. First determine what is going on, get diagnosed and treated. 

 What is Cancer Ablation? This is a minimally invasive surgical method to treat solid cancers. Special probes are used to “burn” or “freeze” cancers without the usual surgery. Computed Tomography (CT), Ultrasound (US) or Magnetic Resonance Imaging (MRI) is used to guide and position the needle probe into the tumor. 



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Tig

61 yo GT1A - 5 Mil - A2/F3 - (1996) Non Responder, (2013) Peg/Riba/Vic SOT:05/23/13 EOT:12/04/13 SVR 1-4 years!

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Canuck wrote:

Hi again Vetwithc, 

Sorry a worry-evoking 15 mm lesion showed up on your liver with an MRI.

Back up a bit for me please, where do you live, I thought you lived in the USA, as you mention VA etc., but I know you had also mentioned being "worked-up" (colonoscopy stuff) in Thailand .... so , NOW, when you say I am on a remote island have to go "off island" to deal with lesion and VA, where do you live and where do you go and who do you see for your HCV follow-up care???

For instance, who did your MRI and where??

What did your doc say, as far as what he wants to do for a "next step"?

Since your HCV cure (how long has that been now, about a couple years SVR?) how many follow-up abd. U/S's, CATs, MRI's, and fibroscans have you had done (and, other than sporting that large gallstone) have ANY abnomalities in your imagings ever shown up before?? A bit of imaging history from the last couple years might be helpful to share, for thought.

Have you had two consecutive imagings, showing the lesion twice, with any increase in it's size? How long ago was any prior imaging done (and what kind), prior to this MRI?

How are your labs -- LFT's and do you know what your AFP's have been, in the past and now?

Did you ever get to the bottom of "how" hard, or fibrotic or cirrhotic your liver was or might be? You had a biopsy pre-treatment, and I think a "fibroscan" once, which showed 3.9 kPa's (which is considered very good, in the normal range, Fscore F0, NOT cirrhotic) - so, do you know for sure what your Fscore is this year?

Assume the doc will do some further repeat imaging? - seeing a lesion increase, or just the size of a lesion, your history and labs, all have some bearing on whether they just keep monitoring it, biopsy it or ablate it. Your lesion might be "just a nothing" - that is a possiblity as well, that it could be an innocuous, benign, irksome thing that is just showing up to worry you! You should keep that possibilty in mind too - that it may turn out to be a nothing. I think you are getting ahead of yourself - (I know, I would be hitting the books and googling too, we can't help it!)  The keyword here is "possible" HCC ! But, good that imagings were being done (whatever imaging you have been getting all along) and that they have the abilty to see/find a lesion. Follow-up is always wise, so we and our docs can be alerted to any change and investigate it. 

What a lot of trouble and worry when these things show up - I am banking on it that it will be a nothing!, but good you are looking into it tout suite! My partner and I are on various "frequent recall" (the slave/patient-purgatory assembly-line) for repeat imaging/testings and such, kinda a good thing, but always worrisome when they see and find stuff! C. 


 Hi Canuck, 

Sorry about my confusing reply, blame it on brain fog, stress/fear etc.

First, to be more precise.................I now live in Hawaii on an outer island with few options in medical specialists and the closest decent hospitals are in Honolulu [$500rt].  We do have a small outpatient clinic on our island and that's where I got my Harvoni TX and successfully attained SVR almost 2 years ago.  Follow ups have been by 6 month US and blood work-ups and they reveal enlarged liver, cirrhosis, but otherwise normal liver function altho I feel worse than I did pre TX.

My most recent and first MRI revealed 'a worrisome 15 mm lesion that could be possibly HCC 2 weeks ago. 

My HCV was DXed in Thailand where I was comfortably retired and planning to spend the rest of my life and most probably die of cirrhosis ..............until they came up with the magic miracle cure and I rushed back  to gert TX offered by the VA which at the time was unavailable and even unknown by the 2 GI liver specialists there until I educated them. Now Indian knock off harvoni is easily available.

"I think a "fibroscan" once, which showed 3.9 kPa's (which is considered very good, in the normal range, Fscore F0, NOT cirrhotic)" Maybe they have a different scale than the US, but i remember the Thai Dr saying that it was borderline fibrosis to cirrhosis and VA confirms the cirrhosis.

 

I had an appointment with my VA PCP and he wanted me to go over to Honolulu and check into 'Tripler' [the big pink monster of a military hospital' that has a lot of ghosts of dead vets and he suggested some invasive surgery that I'm reluctant to commit to.  

Honolulu does have some  world class Dr's in the private sector that I may tr to get another opinion from before allowing them to open the 'can of worms' in my liver after reading and hearing the horror stories of invasive surgery, as after all, it's a small unidentified lesion. 

A conservative Dr friend suggested a more conservative approach of waiting a couple of months, then return for another MRI to see if has multiplied/grown or increased in size before letting some knife happy surgeon dive in to my liver and possibly stir things up more.  

 

What to do??



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DXed in year 1999 with geno 1a, went with a wait and see approach while my viral load increased from 240,000 to 3 mil and contacted VA when Harvoni came out and now have harvoni and starting TX on Monday.


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Wow Mike I am happy for you! It sounds like you are doing fantastic! Keep up the good work.

JimmyK



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Positive food for thought:

In my case, I was getting an MRI every 3 months back in 2014 in order to monitor an 18mm lesion (possible HCC ) in segment 5. During that time I was being treated with 24 weeks Sovaldi/ribavirin after which I did not achieve SVR although my liver lesion DID diminish in size to 7mm. Six months later I was treated with 24 weeks Harvoni after which I did achieve SVR (1-7-2015). I continue to have imaging done every 6 months (alternating between CT Scan / MRI) to monitor my liver. According to my latest CT scan in February that lesion is no longer seen ("The previously described subtle indeterminate enhancing nodule in segment V is not definitely identified on today's study.").

 So today I'm doing as my doctor suggest by continuing to eat healthy, getting some exercise and showing up for imaging every 6 months, but I don't lose any sleep worrying about this otherwise. smile



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57 yo, geno 1a, Dx 1994 HCV-HIV co-inf, Dx 2013 decompensated cirrhosis
Tx #1 - 24wks Sov+Riba /SOT 7-24-2014/UND@EOT/DETECTED@EOT+16 wks
Tx #2 - 24wks Harvoni /SOT 7-25-2015/UND@EOT,+12,+24,+52,+115wks = SVR-115

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I had ablation done on a small liver tumour in Dec.

I had successfully finished treatment the Dec before. (Don't know if theres a relationship to treatment...I thought I was doing treatment to lower my chances of getting HCC)

I went to hospital for 6:30 am, had the ablation around 8:30 (I think) and went home by 1:30 or 2.

it was pretty easy as far as stuff like that goes. Minor pain.  For me, detoxing the drugs out was probably harder on my body than the actual ablation. Felt pretty tender/low for a day or two.

You have to be awake (but medicated) when they insert the thingy that has the microwave in it because they might need you to take/hold a big breath while they are guiding they thingy to the tumour. You have (freezing cold) grounding pads on your inner thighs.

They locate the beasty and then give you something to make you sleep. 

You wake up with a teeny tiny cut above your liver and no more tumour...in my case I barely needEd a bandaid. 

Best of luck,

A

 



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2 year post tx- dragon slayer 



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Hi again Vetwithc, 

Sorry a worry-evoking 15 mm lesion showed up on your liver with an MRI.

Back up a bit for me please, where do you live, I thought you lived in the USA, as you mention VA etc., but I know you had also mentioned being "worked-up" (colonoscopy stuff) in Thailand .... so , NOW, when you say I am on a remote island have to go "off island" to deal with lesion and VA, where do you live and where do you go and who do you see for your HCV follow-up care???

For instance, who did your MRI and where??

What did your doc say, as far as what he wants to do for a "next step"?

Since your HCV cure (how long has that been now, about a couple years SVR?) how many follow-up abd. U/S's, CATs, MRI's, and fibroscans have you had done (and, other than sporting that large gallstone) have ANY abnomalities in your imagings ever shown up before?? A bit of imaging history from the last couple years might be helpful to share, for thought.

Have you had two consecutive imagings, showing the lesion twice, with any increase in it's size? How long ago was any prior imaging done (and what kind), prior to this MRI?

How are your labs -- LFT's and do you know what your AFP's have been, in the past and now?

Did you ever get to the bottom of "how" hard, or fibrotic or cirrhotic your liver was or might be? You had a biopsy pre-treatment, and I think a "fibroscan" once, which showed 3.9 kPa's (which is considered very good, in the normal range, Fscore F0, NOT cirrhotic) - so, do you know for sure what your Fscore is this year?

Assume the doc will do some further repeat imaging? - seeing a lesion increase, or just the size of a lesion, your history and labs, all have some bearing on whether they just keep monitoring it, biopsy it or ablate it. Your lesion might be "just a nothing" - that is a possiblity as well, that it could be an innocuous, benign, irksome thing that is just showing up to worry you! You should keep that possibilty in mind too - that it may turn out to be a nothing. I think you are getting ahead of yourself - (I know, I would be hitting the books and googling too, we can't help it!)  The keyword here is "possible" HCC ! But, good that imagings were being done (whatever imaging you have been getting all along) and that they have the abilty to see/find a lesion. Follow-up is always wise, so we and our docs can be alerted to any change and investigate it. 

What a lot of trouble and worry when these things show up - I am banking on it that it will be a nothing!, but good you are looking into it tout suite! My partner and I are on various "frequent recall" (the slave/patient-purgatory assembly-line) for repeat imaging/testings and such, kinda a good thing, but always worrisome when they see and find stuff! C. 



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HCV/HBV 1973. HBV resolved. HCV undiagnosed to 2015. 62 y.o. F. Canada.

GT3a, Fibroscan F3/12 kPa - F4/12.6 kPa, VL log 7.01 (10,182,417), steatosis, high iron load.

SOF/VEL with/without GS-9857 trial - NCT02639338.

SOT March 10 - EOT May 5, 2016 - SOF/VEL/VOX 8 week trial.

 

(SEE UPDATES IN BIO)



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A 15mm 'lesion "possibly HCC" was recently observed during a MRI and I will have to go off island for TX as I'm living on a more remote island and dealing with the VA. Been stressing a lot about this with 'google' as my only friend, but he often overloads me or gives me confliction info.

Can I ask about the ablation process?? Is it performed as an outpatient??  Will the TX be invasive?? [painful?]

I did read of an 85% success rate.....true?

On a side note, a HVC speciality nurse mentioned to me that there has been an increase in HCC rates for us who have SVR rates of a year or more.....................could this be true??

Also read that even needle biopsies have the danger of 'seeding' and spreading the cancer cells, so is there danger of that as well?

 

Thanks in advance for any input.........



-- Edited by VetwithC on Sunday 7th of May 2017 08:33:47 PM

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DXed in year 1999 with geno 1a, went with a wait and see approach while my viral load increased from 240,000 to 3 mil and contacted VA when Harvoni came out and now have harvoni and starting TX on Monday.
Tig


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Thanks for the input Malcolm and Alison. It is very reassuring to read messages from members that provide their own firsthand experiences. The rates of HCC incidence by not destroying this virus, go up significantly as the disease progresses. The benefits of SVR are wide in scope. Just Do It!



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Tig

61 yo GT1A - 5 Mil - A2/F3 - (1996) Non Responder, (2013) Peg/Riba/Vic SOT:05/23/13 EOT:12/04/13 SVR 1-4 years!

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My post treatment, slightly elevated AFP is what alerted my Dr. to order a CTscan which did find a small,solitary tumour in my liver. It was successfully ablated in in Dec.

My Dr has me getting CTscans at 3 month intervals for now, then will probably put me back on 6 month ultrasounds.

A

 



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57 y/o, Infected via transfusion Oct'83, GT-1a, F-4 cirrhotic,
tx Holkira pak/moderiba 12 weeks

2 year post tx- dragon slayer 



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John,

I am now 4 years post treatment. My doc has about 1000 post-SVR patients. He has had 2 patients who developed solitary HCC's. Both were successfully ablated.

The 6 monthly imaging followup for cirrhotics allows detection of HCC's early, when the chance of easy ablation is highest.



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Geno 1b, IL28B CT,  x3 prior relapser,  ex-cirrhotic, 74 yo, did 48 weeks with Victrelis/Peg./Riba.  VL 1.28m at start, UNDET. at 8 ,12 ,16 ,24 ,30  and 48 weeks.  EOT 15 Feb 2013 , UNDET. at EOT + 28 weeks. SVR!  Still Undet. at EOT +4 years

Malcolm



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This is a concern of mine as well I was cured but unfortunately my Fibrosis/fibroscan score was 16. I have had all of my ultrasounds so far at the proper 6 month intervals. The article you posted from the AASLD shows that the AST to Platelet Ratio Index (APRI) was somewhat of a predictor for HCC (at least an increased occurrence). My question is the article stated that a APRI of over 2.5 showed an increased risk while under 2.5 the risk fell, it also stated that for every 1.0 rise in the APRI there was a 10% increased risk.

Well using the APRI post treatment mine was .4 pre treatment mine was 1.0(3 years prior it was .7). I think you would have to be nearly dead to have a 2.5 APRI post curative treatment. So it must be the pre-treatment APRI. www.hepatitisc.uw.edu/page/clinical-calculators/apri

Also I read in the United States doctors are having trouble getting folks to do these scans. I can understand why because of the stress produced by these scans, some people would rather forget about it and throw caution to the wind.

I am hoping in the future they come up with something like a blood test (not the AFP- I know it's inaccurate) that would indicate looking further into the problem with a scan it would be a money saver as well and might get more people to comply.



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Hi John,

I have been reading some reports that say one thing and then another. I like the article below. It provides some real world numbers and comes out of the AASLD Conference in Barcelona last year. The risk is always higher in cirrhotics, regardless of status. Achieving SVR does reduce the odds, but those with cirrhosis remain a higher risk. By clearing the virus, using any protocol, reduces the risk, not eliminate it. That's the reason they are advised to have 6 month ultrasounds to check for it. 

Do your best not to worry. You have your baseline fibrosis tests and scans and I assume are clear of HCC. If you follow the established AASLD/EASL guidelines on future monitoring, you haven't got anything to worry about. Just stay on top of it, keep living right and enjoy your Hep C free future!! 

DAA/SVR/HCC



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I am hearing conflicting reports about svr and the increase of HCC.  Can someone give me some stats/thoughts or news on HCC post svr?  I have been SVR for almost 2 years - but i do have cirrhosis.  Hope everyone is well!



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Undetected at week 2 on solvaldi/rib/interferon:  stayed through week 12 but virus came back as soon as I stopped.  on   Harvoni and ribravirin 24 weeks undetected after two. 8/2/15  12 week EOT  UNDETECTED!  SVR

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