An Interview With
Interview with Nezam Afdhal, MD | Associate Professor of Medicine
There are strong correlations of liver stiffness with liver fibrosis in Hepatitis C, Hepatitis B, and also in other causes of liver disease such as NAFLD and NASH.
FibroScan measures stiffness in the liver via VCTE™, which involves a wave of 50Hz entering the liver with an ultrasound acquisition of the shear wave’s transmission speed and velocity. There are other devices on the market that use similar technologies, but FibroScan is the only device on the market using true transient elastography. The other devices are less validated and certainly do not give us the comfort and reassurance that we have with FibroScan.
In the United States, this is the only device that is approved for use with these indications.
I would recommend this as the only real validated technique for the measurement of transient elastography and liver stiffness.
Mount Sinai Health System expanding the use of FibroScan to promote essential screenings
Interview with Douglas Dieterich, MD | Professor of Medicine in the Division of Liver Disease
Our goal is to provide the highest level of liver care across the Mount Sinai system, and FibroScan is an integral part of our strategy.
FibroScan has dramatically changed the way we practice-for the better. It has had a significant impact on our patients’ overall long-term treatment. We use it as an opportunity to make recommendations for prognosis and testing. It is also a great way to provide immediate reinforcement for patients. We can say, “your liver looks good”, and give them a print out to bring back to their PCP. We don’t have to wait three days for blood tests to come back to give them an idea of how their liver looks.
We’re using FibroScan for every patient with liver disease. Once you have a FibroScan, you start thinking of more and more ways to use it.
FibroScan is incredibly fast and useful. Minutes after we enter the exam room, we know the state of a patient’s liver disease: we have a better understanding of fibrosis and the amount of fat in the liver.
Before VCTE and CAP, the only real diagnostic option for assessing patients with hepatitis C virus was biopsy, and even then we couldn’t always pick up ‘borderline’ cases. We’ve almost stopped doing biopsies now, except in rare diagnostic dilemmas.
Yes. The baby boomer cohort is increasingly presenting with sicker livers. It really becomes important to know their level of fibrosis. Even with stage 3 fibrosis, patients can be at-risk for liver cancer. So we are now beginning to scan patients in the diabetes clinic for HCV.
Early detection is critical, but we found that there is inadequate screening for HCV and NAFLD in primary care settings. We are using the availability of the FibroScan technology to encourage screening for liver diseases. We’re putting a portable unit into the diabetes clinic and have just begun a program to screen every patient in the obesity clinic, using FibroScan.
In addition to the liver stiffness quantification with the VCTE, we think its important to track CAP as well. The score is a surrogate marker for the amount of fat present in the liver. What we have learned is that patients who are cured of hepatitis C have dramatic reductions in their fibrosis levels as measured by VCTE. However, those who also have fatty liver disease frequently will not improve even after a viral response.
The ability to collect and track VCTE and CAP measurements allows our practice to remain involved with these patients throughout their liver care. It’s difficult for a community doctor to understand and monitor fatty liver. And today, even more than hepatitis, fatty liver is contributing to cirrhosis and liver cancer.
Even on a patient’s first visit… if we see a CAP over 300, we know we probably have to follow this patient for life. The first step is a diet and exercise program for diabetes.
When we treat and cure HCV in these patients, the fatty liver seems to prevent resolution of the fibrosis measured by FibroScan.
Today, our Liver Service is growing as we expand outreach. We feel it’s imperative to have FibroScan in all of our clinics. We’ve purchased several portable units about the size of a carry –on suitcase that our providers can travel with to our outlying clinics. They have proven incredibly useful. Patients still like to visit multiple clinics so if we can bring the liver specialist to the diabetes and obesity clinics we see improved adherence to care. That’s something we learned from the HIV world.
Interview with Stephen Esposito, MD
Hepatobiliary Associates of NY | NY Presbyterian Hospital
Basically, anything involving the liver. We use it with fatty liver (NAFLD), hepatitis B, hepatitis C, alcoholic liver disease, NASH, some of the auto-immune diseases, and for patients with hemochromatosis. FibroScan is a simple, safe and cost-effective screening test for us.
The first thing that’s important to me, for all of the patients in our practice, is to get a baseline—for all my liver patients. From there, you may have different questions for each disease: For example, with HCV patients, we use FibroScan® to approve anti-viral medicines, even though many states have dropped the fibrosis requirement, we’ve seen much faster approvals for anti-virals whenwe include the FibroScan® results versus a blood test alone.
With HBV patients, you’ll face a different scenario. Their lab results may reveal normal ALT, negative HBV EAg, and their fibrosis may be very variable. We can use FibroScan® data to decide which patients may benefit from the administration of antiviral medicines.
When we can actually measure how much fibrosis is present with a patient, we can determine those who may be at higher risk for other conditions. So, for example, I might recommend closer screenings for hepatocellular carcinoma, or we might want to do an endoscopy to look for portal hypertension. When I see a heightened stiffness score – say 20 kPa or above – I know that this patient is at risk for a liver-averse event. I can’t tell you how many times we’ve seen someone with a normal platelet count have significant fibrosis. FibroScan helps identify high-risk patients that you wouldn’t discover otherwise. Up to 60% of our NASH patients have normal liver enzymes. It may be difficult without a liver biopsy or a FibroScan to know the status of their liver disease.
I think that our patients find it very encouraging, on the whole. If we have a patient with SVR, for example, we can track a progression of their fibrosis. I think they find it very encouraging to see a concrete metric showing their liver is getting better.
Historically, the majority of our patients come from PCPs, but I’m starting to get a higher number of other gastroenterologists referring specific patients as well. I think those doctors are beginning to understand the advantages of the FibroScan exam – and I try to reassure them that the patients will return to them for their endoscopies or colonoscopies. With our FibroScan, we have also noticed increases in our radiology practice, as we work to catch disease states sooner. We now have a sonogram tech who visits the practice twice weekly.
Overall, I think we’ve tracked an increase in patient volume of maybe 10% or 15%, most notably, we have seen an increase in endoscopic procedures.
Honestly, I can’t imagine my life without a FibroScan now. I don’t know how we practiced without it. It has really changed my workup of a patient. In some cases, it’s become more important, to me, than an endoscopy. It has improved our entire practice in the sense that I feel more comfortable knowing which patients we need to worry about, which patients require frequent re-calls and so forth.
And I believe that physicians and payers are coming to understand the benefits of it as well. This diagnostic test will pick out people at high risk that no other routine test is going to find, unless you’re going to CT scan every patient. If you think about it, if you uncover that one cirrhotic liver, you save that one trip to the ER with a variceal bleed, you understand how beneficial that can be.