To the Editor: Chronic hepatitis C (HCV) infection affects more than 200 000 Australians.1 As the degree of hepatic fibrosis is the best predictor of morbidity, liver biopsy has a central role in management. Biopsy is also carried out to exclude additional pathology. However, because liver biopsy carries real risks and is expensive,2,3 debate exists as to whether liver biopsy should be performed routinely.3,4 Despite controversy surrounding the need to treat patients with minor histological changes,4 our impression is that many informed patients request treatment irrespective of liver histology. In Australia, liver biopsy is a prerequisite for antiviral therapy under the Pharmaceutical Benefits Scheme Highly Specialised Drugs Program (Box).5

To assess the impact of liver biopsy on management, we performed a retrospective study of patients with chronic HCV infection who underwent liver biopsy from March 1998 to December 2000. We identified 76 patients (51 men, 25 women), with a mean age of 29 years (range, 20–52 years). The biopsy was performed to stage and grade hepatitis C in all patients, and additionally to investigate a second pathology in seven patients. No alternative diagnoses were raised. Additional diagnoses (all suspected before biopsy) were confirmed in three patients and refuted in four patients. Biopsy findings were all consistent with chronic HCV infection, with some degree of fibrosis in 69 patients. There were five patients with histologically confirmed cirrhosis (including incomplete cirrhosis in three), and this was clinically evident in two patients. When S100 criteria at the time of biopsy were applied, after exclusions on clinical grounds, only one patient would have been ineligible for interferon monotherapy based on liver histology. Under current S100 criteria, nine patients would be ineligible for combination therapy, but all nine would remain eligible for monotherapy. Of our patients who attended follow-up and were HCV RNA positive, 62 of 64 patients received or are awaiting therapy.

Our results confirm the finding that liver biopsy in patients with chronic HCV infection rarely identifies alternative diagnoses.3 These data reflect the fact that most chronic liver diseases can be diagnosed before biopsy. Biopsy remains an important tool for histological diagnosis of cirrhosis. However, as unexpected findings are uncommon and some patients will be treated irrespective of liver histology, there is an emerging argument not to perform liver biopsy routinely. This argument will strengthen if valid biochemical markers of fibrosis are confirmed.6 We believe each patient should be assessed individually, and treatment could be offered without biopsy to patients who:

• meet all criteria for treatment under current guidelines other than known liver histology;

• have no alternative or additional diagnoses after thorough work-up;

• strongly desire treatment regardless of histology, and there is sound indication for treatment (eg, extrahepatic symptoms, concerns of vertical or occupational transmission);

• have a high chance of sustained viral response (eg, favourable genotype);

• have no clinical, biochemical or haematological suggestion of cirrhosis; and

• with the physician, accept the implications of treatment without biopsy.

An alternative strategy could be to consider a biopsy in patients who do not have a sustained virological response, to allow prognostication. Clearly, such changes would greatly affect biopsy practices in Australia.