Study Supports HBV Screening, Prophylaxis in Chemotherapy Patients

SAN FRANCISCO – When cancer patients have hepatitis B virus, prophylaxis to prevent its reactivation during chemotherapy lowers their mortality, but screening for the virus remains uncommon, said researchers from M.D. Anderson Cancer Center in Houston.

Just 17% (1,787) of 10,729 patients who started chemotherapy there during a 3-year study were screened beforehand for hepatitis B virus (HBV), despite recommendations to do so from the Centers for Disease Control and Prevention and other groups.

Of those screened, 151 (8%) proved to be positive for hepatitis B surface antigen (HBsAg) and/or antibody to hepatitis B core antigen (anti-HBc). In all, 34 of them (23%) reactivated during chemotherapy. Most were being treated for hematologic malignancies.

Among the nine patients whose hepatitis B reactivated despite prophylaxis – in most cases with lamivudine (Epivir) – two patients (22%) died. Among the 11 who were treated with antivirals only after reactivation, 8 (72%) died. And of the 14 who were not treated with antivirals for their reactivation, 10 (71%) died.

M.D. Anderson probably isn’t the only institution failing to follow the HBV screening and prophylaxis recommendations, and physicians may be unaware of the guidelines, said lead investigator Dr. Jessica Hwang at the annual meeting of the American Association for the Study of Liver Diseases.

There’s also been – at least until now – a lack of large studies supporting the practice of screening and prophylaxis for HBV before chemotherapy. The evidence gap has led to debate about the merits of the approach, said Dr. Hwang, assistant professor in the department of general internal medicine at M.D. Anderson.

Now the study findings address this gap, showing that "preventable reactivation does occur. Prophylactic antivirals [can] dramatically reduce mortality in cancer patients with hepatitis B infection. You need to prophylax them before chemotherapy," Dr. Hwang said.

At least one observer agreed. It’s "a very simple solution to prevent potentially life-threatening complications" from the virus, said Dr. T. Jake Liang, president of the American Association for the Study of Liver Diseases and chief of the Liver Diseases Branch of the National Institute of Diabetes and Digestive and Kidney Diseases.

Patients in the study were more likely to be screened if they were male, treated with rituximab (Rituxan), had hematologic cancers, or had at least one HBV risk factor. The risk factors include injection drug use, living with a person who has chronic hepatitis B, and hemodialysis, among others.

Patients were more likely to screen positive for HBV if they had a risk factor, or if they were male, Asian, or black.

The study also found that reactivators tended to be slightly younger – 47 years on average – than HBV-positive patients who did not reactivate; their mean age was 54.

Dr. Liang said he has no disclosures. Dr. Hwang disclosed grant support form Bristol-Myers Squibb, maker of the anti-HBV drug entecavir (Baraclude). The company funded the study, together with the National Cancer Institute and the American Cancer Society.

SAN FRANCISCO – When cancer patients have hepatitis B virus, prophylaxis to prevent its reactivation during chemotherapy lowers their mortality, but screening for the virus remains uncommon, said researchers from M.D. Anderson Cancer Center in Houston.

Just 17% (1,787) of 10,729 patients who started chemotherapy there during a 3-year study were screened beforehand for hepatitis B virus (HBV), despite recommendations to do so from the Centers for Disease Control and Prevention and other groups.

Of those screened, 151 (8%) proved to be positive for hepatitis B surface antigen (HBsAg) and/or antibody to hepatitis B core antigen (anti-HBc). In all, 34 of them (23%) reactivated during chemotherapy. Most were being treated for hematologic malignancies.

Among the nine patients whose hepatitis B reactivated despite prophylaxis – in most cases with lamivudine (Epivir) – two patients (22%) died. Among the 11 who were treated with antivirals only after reactivation, 8 (72%) died. And of the 14 who were not treated with antivirals for their reactivation, 10 (71%) died.

M.D. Anderson probably isn’t the only institution failing to follow the HBV screening and prophylaxis recommendations, and physicians may be unaware of the guidelines, said lead investigator Dr. Jessica Hwang at the annual meeting of the American Association for the Study of Liver Diseases.

There’s also been – at least until now – a lack of large studies supporting the practice of screening and prophylaxis for HBV before chemotherapy. The evidence gap has led to debate about the merits of the approach, said Dr. Hwang, assistant professor in the department of general internal medicine at M.D. Anderson.

Now the study findings address this gap, showing that "preventable reactivation does occur. Prophylactic antivirals [can] dramatically reduce mortality in cancer patients with hepatitis B infection. You need to prophylax them before chemotherapy," Dr. Hwang said.

At least one observer agreed. It’s "a very simple solution to prevent potentially life-threatening complications" from the virus, said Dr. T. Jake Liang, president of the American Association for the Study of Liver Diseases and chief of the Liver Diseases Branch of the National Institute of Diabetes and Digestive and Kidney Diseases.

Patients in the study were more likely to be screened if they were male, treated with rituximab (Rituxan), had hematologic cancers, or had at least one HBV risk factor. The risk factors include injection drug use, living with a person who has chronic hepatitis B, and hemodialysis, among others.

Patients were more likely to screen positive for HBV if they had a risk factor, or if they were male, Asian, or black.

The study also found that reactivators tended to be slightly younger – 47 years on average – than HBV-positive patients who did not reactivate; their mean age was 54.

Dr. Liang said he has no disclosures. Dr. Hwang disclosed grant support form Bristol-Myers Squibb, maker of the anti-HBV drug entecavir (Baraclude). The company funded the study, together with the National Cancer Institute and the American Cancer Society.

SAN FRANCISCO – When cancer patients have hepatitis B virus, prophylaxis to prevent its reactivation during chemotherapy lowers their mortality, but screening for the virus remains uncommon, said researchers from M.D. Anderson Cancer Center in Houston.

Just 17% (1,787) of 10,729 patients who started chemotherapy there during a 3-year study were screened beforehand for hepatitis B virus (HBV), despite recommendations to do so from the Centers for Disease Control and Prevention and other groups.

Of those screened, 151 (8%) proved to be positive for hepatitis B surface antigen (HBsAg) and/or antibody to hepatitis B core antigen (anti-HBc). In all, 34 of them (23%) reactivated during chemotherapy. Most were being treated for hematologic malignancies.

Among the nine patients whose hepatitis B reactivated despite prophylaxis – in most cases with lamivudine (Epivir) – two patients (22%) died. Among the 11 who were treated with antivirals only after reactivation, 8 (72%) died. And of the 14 who were not treated with antivirals for their reactivation, 10 (71%) died.

M.D. Anderson probably isn’t the only institution failing to follow the HBV screening and prophylaxis recommendations, and physicians may be unaware of the guidelines, said lead investigator Dr. Jessica Hwang at the annual meeting of the American Association for the Study of Liver Diseases.

There’s also been – at least until now – a lack of large studies supporting the practice of screening and prophylaxis for HBV before chemotherapy. The evidence gap has led to debate about the merits of the approach, said Dr. Hwang, assistant professor in the department of general internal medicine at M.D. Anderson.

Now the study findings address this gap, showing that "preventable reactivation does occur. Prophylactic antivirals [can] dramatically reduce mortality in cancer patients with hepatitis B infection. You need to prophylax them before chemotherapy," Dr. Hwang said.

At least one observer agreed. It’s "a very simple solution to prevent potentially life-threatening complications" from the virus, said Dr. T. Jake Liang, president of the American Association for the Study of Liver Diseases and chief of the Liver Diseases Branch of the National Institute of Diabetes and Digestive and Kidney Diseases.

Patients in the study were more likely to be screened if they were male, treated with rituximab (Rituxan), had hematologic cancers, or had at least one HBV risk factor. The risk factors include injection drug use, living with a person who has chronic hepatitis B, and hemodialysis, among others.

Patients were more likely to screen positive for HBV if they had a risk factor, or if they were male, Asian, or black.

The study also found that reactivators tended to be slightly younger – 47 years on average – than HBV-positive patients who did not reactivate; their mean age was 54.

Dr. Liang said he has no disclosures. Dr. Hwang disclosed grant support form Bristol-Myers Squibb, maker of the anti-HBV drug entecavir (Baraclude). The company funded the study, together with the National Cancer Institute and the American Cancer Society.