Hepatitis B Virus Screening and Management for Patients With Cancer Prior to Therapy: ASCO Provisional Clinical Opinion Update

Abstract

PURPOSE This Provisional Clinical Opinion update presents a clinically pragmatic approach to hepatitis B virus (HBV) screening and management. PROVISIONAL CLINICAL OPINION All patients anticipating systemic anticancer therapy should be tested for HBV by 3 tests—hepatitis B surface antigen (HBsAg), hepatitis B core antibody (anti-HBc) total immunoglobulin (Ig) or IgG, and antibody to hepatitis B surface antigen—but anticancer therapy should not be delayed. Findings of chronic HBV (HBsAg-positive) or past HBV (HBsAg-negative and anti-HBc–positive) infection require HBV reactivation risk assessment. Patients with chronic HBV receiving any systemic anticancer therapy should receive antiviral prophylactic therapy through and for minimum 12 months following anticancer therapy. Hormonal therapy alone should not pose a substantial risk of HBV reactivation in patients with chronic HBV receiving hormonal therapy alone; these patients may follow noncancer HBV monitoring and treatment guidance. Coordination of care with a clinician experienced in HBV management is recommended for patients with chronic HBV to determine HBV monitoring and long-term antiviral therapy after completion of anticancer therapy. Patients with past HBV infection undergoing anticancer therapies associated with a high risk of HBV reactivation, such as anti-CD20 monoclonal antibodies or stem-cell transplantation, should receive antiviral prophylaxis during and for minimum 12 months after anticancer therapy completion, with individualized management thereafter. Careful monitoring may be an alternative if patients and providers can adhere to frequent, consistent follow-up so antiviral therapy may begin at the earliest sign of reactivation. Patients with past HBV undergoing other systemic anticancer therapies not clearly associated with a high risk of HBV reactivation should be monitored with HBsAg and alanine aminotransferase during cancer treatment; antiviral therapy should commence if HBV reactivation occurs. Additional information is available at www.asco.org/supportive-care-guidelines .

Clinical and economic evaluation of a surveillance protocol to manage hepatitis B virus (HBV) reactivation among lymphoma patients with resolved HBV infection receiving rituximab

“…The decision between surveillance or prophylaxis should be tailored according to the healthcare setting and individual patient with careful consideration of the following factors: patient adherence to the surveillance protocol, accessibility to HBV DNA testing, and the total cost of antiviral prophylaxis. Our findings add to the ongoing discussion on the most optimal approach to manage HBV reactivation among patients with cancer 10. ACK N OWLED G M ENTSWe would like to thank Mr Mohamad Haniffa Hasan Mohamed, Ms Alisa Noor Hidayah Sairi, Miss Jaclyn Jia Jun Mah, and Miss Yan Xiang Gan for their assistance in managing the study and collecting data.…”

“…An alternative approach would be to monitor HBV DNA levels closely and initiate antiviral treatment only when reactivation is detected to prevent hepatitis. 9,10 Surveillance alone, conducted at frequent and regular intervals, has been shown to exhibit comparable clinical outcomes to antiviral prophylaxis, such as low rates of hepatitis and reactivation-associated death. [11][12][13] Although more visits to the hospital may be required for additional HBV DNA testing, this strategy offers the advantages of lower drug costs and pill burden for cancer patients during and after antineoplastic treatment.…”

“…An alternative approach would be to monitor HBV DNA levels closely and initiate antiviral treatment only when reactivation is detected to prevent hepatitis 9,10 . Surveillance alone, conducted at frequent and regular intervals, has been shown to exhibit comparable clinical outcomes to antiviral prophylaxis, such as low rates of hepatitis and reactivation‐associated death 11–13 .…”

Risk of HBV reactivation in patients with immune checkpoint inhibitor-treated unresectable hepatocellular carcinoma

“…Accordingly, we still have to keep awareness of HBV reactivation during ICI treatment for HBV-HCC. 42 In checkmate-040 and Keynote-224 trials, patients were required to receive effective anti-viral therapy and had a viral load <100 IU/mL before initiating ICI treatment. 5 6 In the real life, however, ICIs would be delivered to more complex populations of patients than those of clinical trials that raise a question to the necessity of keeping low viral load before ICI therapy.…”

Management of Hepatitis B Virus in Allogeneic Hematopoietic Stem Cell Transplantation

“…A recent publication suggested that serological HBV should be obtained at baseline and evaluated every 6 months during antiviral therapy. Additionally, it should also be checked at least monthly for the first 3 months after the cessation of antiviral therapy and every 3 months thereafter ( 56 ). Although there is no consensus on duration of antiviral treatment, the majority of recommendations for prophylactic antiviral treatment duration vary from 6 months to 12 months after discontinuation of immunosuppressive therapy ( 10 , 11 , 13 , 54 ).…”