Hepatitis B Reactivation During Cancer Chemotherapy
Hepatitis B Reactivation During Cancer Chemotherapy
Hepatitis B virus reactivation (HBVr) can be a serious complication of cancer chemotherapy. However, underutilization of HBV screening and secondary underutilization of antiviral prophylaxis have been frequently reported. The authors electronically distributed a 30-point questionnaire to members of the American Association for the Study of Liver Diseases to capture experiences with HBVr during cancer chemotherapy. The questionnaire specified diagnostic criteria and collected information on HBV screening, antiviral prophylaxis and clinical outcomes. Ninety-nine respondents reported 188 patients who met the criteria for HBV reactivation. Forty-one practised outside the United States, and most were hepatologists (n = 71) or gastroenterologists (n = 12). One hundred and twenty-six patients had haematologic malignancies, of which 88 (70%) had lymphoma. Seventy-five patients (40%) had screening for both hepatitis B surface antigen (HBsAg) and antibody to hepatitis B core antigen (anti-HBc), and an additional 24 patients (13%) had HBsAg screening alone. Prophylactic antiviral therapy was reported in only 18 patients (10%). Chemotherapy was interrupted in 52 patients (41%) with haematologic malignancies and 26 of 41 patients (63%) with solid tumours (P = 0.01). Rituximab-treated patients (n = 66) required hospitalization more frequently (P = 0.04), but their overall survival did not differ from individuals not treated with rituximab. Death due to liver failure was reported in 43 patients overall (23%). Underutilization of prophylactic antiviral therapy occured in a substantial number of patients who were found to be HBV infected prior to the initiation of cancer chemotherapy. The reasons for this need further exploration because reactivation results in serious yet preventable outcomes.
Hepatitis B virus (HBV) reactivation is a common and potentially serious complication of treatment with immunosuppressive drugs. Reactivation is a virologic phenomenon, and it may occur without any change in liver chemistries. However, in many cases, it is associated with an increase in serum aminotransferase levels due to an exacerbation of hepatitis, and in severe cases, there may be marked elevations of serum aminotransferase levels, acute-on-chronic liver failure and death. Prophylactic antiviral therapy has been shown to significantly reduce the frequency of reactivation in hepatitis B surface antigen (HBsAg) carriers and in patients who are HBsAg negative but positive for antibody to hepatitis B core antigen (anti-HBc).
Despite recommendations by the Centers for Disease Control and several international liver disease organizations to screen for HBV in all patients who will undergo chronic immunosuppressive drug therapy, it has been shown that oncologists, dermatologists and rheumatologists do this infrequently. This may reflect a lack of awareness of the above recommendations and/or absence of specific screening recommendations in their individual specialty practice guidelines. The frequency of HBV screening by gastroenterologists and hepatologists has not been defined but is anticipated to be higher.
Much of the published data on HBV reactivation during cancer chemotherapy comes from large cancer centres or other types of institutions outside the United States. These studies describe clinical outcomes such as the rate of severe hepatitis, liver failure and death. Relatively little information, however, is available on other significant outcomes, such as the need for hospitalization, intensive care management or alteration of chemotherapy.
Here, we present the results of a recently completed questionnaire in which we asked all American Association for the Study of Liver Diseases (AASLD) members about their experience with HBV reactivation during cancer chemotherapy. We envisioned that this study might provide a unique data set on screening and treatment practices and also capture information on reactivation-related outcomes that had not been emphasized previously.
Abstract and Introduction
Abstract
Hepatitis B virus reactivation (HBVr) can be a serious complication of cancer chemotherapy. However, underutilization of HBV screening and secondary underutilization of antiviral prophylaxis have been frequently reported. The authors electronically distributed a 30-point questionnaire to members of the American Association for the Study of Liver Diseases to capture experiences with HBVr during cancer chemotherapy. The questionnaire specified diagnostic criteria and collected information on HBV screening, antiviral prophylaxis and clinical outcomes. Ninety-nine respondents reported 188 patients who met the criteria for HBV reactivation. Forty-one practised outside the United States, and most were hepatologists (n = 71) or gastroenterologists (n = 12). One hundred and twenty-six patients had haematologic malignancies, of which 88 (70%) had lymphoma. Seventy-five patients (40%) had screening for both hepatitis B surface antigen (HBsAg) and antibody to hepatitis B core antigen (anti-HBc), and an additional 24 patients (13%) had HBsAg screening alone. Prophylactic antiviral therapy was reported in only 18 patients (10%). Chemotherapy was interrupted in 52 patients (41%) with haematologic malignancies and 26 of 41 patients (63%) with solid tumours (P = 0.01). Rituximab-treated patients (n = 66) required hospitalization more frequently (P = 0.04), but their overall survival did not differ from individuals not treated with rituximab. Death due to liver failure was reported in 43 patients overall (23%). Underutilization of prophylactic antiviral therapy occured in a substantial number of patients who were found to be HBV infected prior to the initiation of cancer chemotherapy. The reasons for this need further exploration because reactivation results in serious yet preventable outcomes.
Introduction
Hepatitis B virus (HBV) reactivation is a common and potentially serious complication of treatment with immunosuppressive drugs. Reactivation is a virologic phenomenon, and it may occur without any change in liver chemistries. However, in many cases, it is associated with an increase in serum aminotransferase levels due to an exacerbation of hepatitis, and in severe cases, there may be marked elevations of serum aminotransferase levels, acute-on-chronic liver failure and death. Prophylactic antiviral therapy has been shown to significantly reduce the frequency of reactivation in hepatitis B surface antigen (HBsAg) carriers and in patients who are HBsAg negative but positive for antibody to hepatitis B core antigen (anti-HBc).
Despite recommendations by the Centers for Disease Control and several international liver disease organizations to screen for HBV in all patients who will undergo chronic immunosuppressive drug therapy, it has been shown that oncologists, dermatologists and rheumatologists do this infrequently. This may reflect a lack of awareness of the above recommendations and/or absence of specific screening recommendations in their individual specialty practice guidelines. The frequency of HBV screening by gastroenterologists and hepatologists has not been defined but is anticipated to be higher.
Much of the published data on HBV reactivation during cancer chemotherapy comes from large cancer centres or other types of institutions outside the United States. These studies describe clinical outcomes such as the rate of severe hepatitis, liver failure and death. Relatively little information, however, is available on other significant outcomes, such as the need for hospitalization, intensive care management or alteration of chemotherapy.
Here, we present the results of a recently completed questionnaire in which we asked all American Association for the Study of Liver Diseases (AASLD) members about their experience with HBV reactivation during cancer chemotherapy. We envisioned that this study might provide a unique data set on screening and treatment practices and also capture information on reactivation-related outcomes that had not been emphasized previously.