Hepatitis C Infection & Liver Cancer Risk

This page is for anyone who has hepatitis C, has been cured of it, or is not sure whether they have been tested. It explains how the virus leads to liver cancer, how testing works, and why some people still need checks after a cure.

Hepatitis C is a virus spread through blood that infects liver cells. Fewer than half of people who catch it clear it in the first six months. In the rest, the infection becomes chronic and lasts for decades. During that time it usually causes no symptoms at all.

What it does cause is steady, mild inflammation (swelling and irritation). Over twenty to forty years, that inflammation leads to fibrosis, which means scarring. In some people fibrosis turns into cirrhosis, a heavy and lasting form of scarring. Cirrhosis is the soil in which liver cancer grows. The main type is hepatocellular carcinoma, cancer that starts in liver cells. Hepatitis C is a leading cause of liver cancer. It is also the top reason for liver transplants in the United States.

An estimated 2.4 to 4 million people in the United States were living with hepatitis C between 2017 and 2020. A large share do not know it.

CDC recommends that all adults aged 18 and older be tested at least once. That holds whether or not they have any risk factor. Pregnant people should be tested during each pregnancy.

Repeat testing is recommended for people with ongoing exposure. That includes:

• People who inject drugs and share equipment
• People on long-term kidney dialysis (hemodialysis)

One-time testing is also advised for:

• People with HIV
• People with abnormal liver tests
• People who received blood or organ donations before July 1992
• Anyone after a needlestick injury at work

CDC advises testing every adult because asking only about risk factors missed too many people. Being asked about it is not an accusation.

Diagnosis takes two steps. An antibody test shows whether you have ever been exposed. If it is positive, an HCV RNA test shows whether the virus is still present. Antibodies stay in the blood after the body clears the virus on its own. They also stay after a cure. So the RNA result is the one that answers the question. If your record holds a positive antibody test and no RNA result, that gap is worth closing.

Direct-acting antiviral medicines cure more than 95 percent of hepatitis C infections. Treatment is usually 8 to 12 weeks of tablets. Most people have few side effects. Doctors call a cure a sustained virologic response. It means no virus can be found twelve weeks after treatment ends.

Curing the infection greatly lowers liver cancer risk. Studies estimate a reduction of roughly 71 to 79 percent. It also slows or stops more scarring. In many people, some scarring even heals.

Even so, only about one in three people diagnosed in the United States has been cured. That figure comes from CDC's national hepatitis C clearance cascade analysis. Cost, insurance requirements, and access are real barriers. A case manager or patient navigator can sometimes help with them. Whether treatment is right for you, and which medicines, is a choice to make with your care team.

This is the part most often misunderstood. Cure removes the virus. It does not remove the scarring the virus already caused.

In people with hepatitis C and cirrhosis who are not treated, the yearly risk of liver cancer is roughly 1 to 4 percent. After cure, that risk drops sharply, but it does not reach zero. Enough risk remains in people with cirrhosis that it still adds up over the years.

For this reason, AASLD-IDSA guidance recommends that people with cirrhosis continue liver cancer surveillance indefinitely after cure. That means a belly ultrasound, often with an AFP blood test, about every six months. Lumps (nodules) over a centimeter get a closer look with a CT or MRI scan.

Surveillance is not recommended routinely after cure for people with stage 3 fibrosis who do not have cirrhosis. It is not needed at lower fibrosis stages. So bring a clear question to your care team: do I have cirrhosis, how was that determined, and does that put me in the surveillance group?

Other things add to liver cancer risk, and they keep acting after a cure:

• Alcohol
• Hepatitis B infection at the same time
• Fatty liver disease
• Diabetes
• Smoking

Vaccines against hepatitis A and B are recommended for people with long-term liver disease. You can also catch hepatitis C again. A cure gives no immunity.

• CDC: Hepatitis C testing recommendations
• CDC: Hepatitis C basics
• Hepatitis C Online: Surveillance for hepatocellular carcinoma
• SEER Cancer Stat Facts: Liver and Intrahepatic Bile Duct Cancer
• CDC MMWR: Hepatitis C Virus Clearance Cascade — United States, 2013–2022