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.