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Maung ST, Deepan N, Decharatanachart P, Chaiteerakij R. Screening for viral hepatitis B infection in cancer patients before receiving chemotherapy - A systematic review and meta-analysis. Asia Pac J Clin Oncol 2024; 20:335-345. [PMID: 38512893 DOI: 10.1111/ajco.14055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 02/08/2024] [Accepted: 03/03/2024] [Indexed: 03/23/2024]
Abstract
AIM We conducted a systematic review and meta-analysis to assess the hepatitis B virus (HBV) screening rate in cancer patients before systemic chemotherapy, aiming to identify those needing antiviral prophylaxis for HBV reactivation. METHODS We searched PubMed, Embase, Scopus, and Google Scholar for relevant studies. The pooled screening rate was estimated using a random effects model. Subgroup analyses were conducted based on malignancy types, chemotherapy regimens, study period, and HBV endemic regions. RESULTS The meta-analysis included 29 studies from various endemic regions (19 low-endemic, three lower intermediate-endemic, and seven higher intermediate-endemic). These studies encompassed hematologic malignancies (n = 10), solid-organ tumors (n = 4), and combinations (n = 15). Seven studies used rituximab-containing regimens, four did not, and the remaining 11 did not specify chemotherapy regimens. The pooled screening rate was 57% (95% confidence interval [95%CI]: 46%-68%, I2 = 100%). Over time, screening rates improved from 37% (95%CI: 23%-53%) in 2006-2010 to 68% (54%-80%) in 2011-2015 and 69% (48%-84%) in 2016-2020. Screening rates were highest at 89% (74%-96%) in high endemic countries, followed by 60% (45-73%) in lower-intermediate and 49% (34-64%) in low-endemic countries. Patients with hematological malignancies had a higher screening rate than those with solid organ tumors, 65% (55%-74%) versus 37% (21%-57%), respectively. A screening rate was higher in patients receiving rituximab-containing chemotherapy than non-rituximab regimens, 68% (55%-79%) versus 45% (27%-65%). CONCLUSION Despite existing guidelines, pre-chemotherapy HBV screening rate remains unsatisfactory, with substantial heterogeneous rates globally. These findings underscore the need for effective strategies to align practices with clinical guidelines.
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Affiliation(s)
- Soe Thiha Maung
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Ma Har Myaing Hospital, Yangon, Myanmar
| | - Natee Deepan
- Division of Academic Affairs, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | | | - Roongruedee Chaiteerakij
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Center of Excellence for Innovation and Endoscopy in Gastrointestinal Oncology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Aceituno L, Bañares J, Ruiz-Ortega L, Callejo-Pérez A, Muñoz-Couselo E, Ortiz-Velez C, Díaz-Mejía N, Barreira-Díaz A, Carreras MJ, Farriols A, Buti M, Riveiro-Barciela M. The Low Incidence of Viral Hepatitis Reactivation Among Subjects on Immunotherapy Reduces the Impact of Suboptimal Screening Rate. Front Med (Lausanne) 2022; 9:916213. [PMID: 35911389 PMCID: PMC9335294 DOI: 10.3389/fmed.2022.916213] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 05/30/2022] [Indexed: 11/21/2022] Open
Abstract
Background and Aims Immunotherapy with immune checkpoint inhibitors (ICIs) is a pillar of many advanced tumors. However, there is scarce data concerning the rate of viral hepatitis screening in this population or the risk of viral reactivation. Methods Retrospective–prospective study that includes all patients who began ICIs between January/2019 and December/2020 in a University Hospital. Data on viral hepatitis screening prior to the beginning of ICIs were collected. In subjects lacking information, serological tests were requested prospectively. Among HBsAg, anti-HBc, or anti-HCV positive subjects, reactivation was prospectively assessed. Results During the 2-year period of study, 595 subjects received ICIs (61.2% male, mean age 63 years). The most prevalent cancers found were 35.5% lung cancer, 12.1% melanoma, and 8.2% head and neck; ICIs schemes were mainly anti-PD1 (65.7%), followed by anti-PD-L1 (19.2%), and combined therapy (13.6%). Prior to immunotherapy, anti-HCV screening was performed in 462 (77.6%) subjects, HBsAg in 462 (77.6%), anti-HBc in 335 (56.3%), and the complete screening in 328 (55.1%). The anti-HBc screening was more frequently ordered among patients treated with concomitant systemic therapy (p = 0.003), especially in the case of chemotherapy (p = 0.015), though HCV screening was more commonly performed in concomitant therapies different from chemotherapy (p = 0.001). Serological tests were completed prospectively in those alive, leading to an overall prevalence for anti-HCV of 3.5%, HBsAg at 1.3%, and anti-HBc of 15.2%. HCV-RNA was detected in 2/19 (both patients with hepatocellular carcinoma), HBV-DNA in 4/7 HBsAg positive, and in 1/75 anti-HBc positive subject. Five out of the 7 HBsAg carriers and 1/75 anti-HBc+ subjects (due to concomitant antiretroviral therapy) received antiviral prophylaxis. Neither cases of HBV reactivation nor changes in HCV viral load were observed. Discussion HBV and HCV screening prior to immunotherapy is suboptimal. Though the rate of viral hepatitis reactivation seems extremely low, efforts should be made to optimize viral hepatitis screening prior to immunotherapy for the selection of candidates for either antiviral prophylaxis or periodical follow-up.
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Affiliation(s)
- Laia Aceituno
- Liver Unit, Hospital Vall d'Hebrón, Barcelona, Spain
| | - Juan Bañares
- Liver Unit, Hospital Vall d'Hebrón, Barcelona, Spain
| | | | - Ana Callejo-Pérez
- Oncology Department, Instituto de Oncología Vall d'Hebron (VHIO), Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital, Barcelona, Spain
| | - Eva Muñoz-Couselo
- Oncology Department, Instituto de Oncología Vall d'Hebron (VHIO), Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital, Barcelona, Spain
| | - Carolina Ortiz-Velez
- Oncology Department, Instituto de Oncología Vall d'Hebron (VHIO), Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital, Barcelona, Spain
| | - Nely Díaz-Mejía
- Oncology Department, Instituto de Oncología Vall d'Hebron (VHIO), Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital, Barcelona, Spain
| | | | | | - Anna Farriols
- Pharmacy Department, Vall d'Hebron Hospital, Barcelona, Spain
| | - María Buti
- Liver Unit, Hospital Vall d'Hebrón, Barcelona, Spain
- Centro de Investigaciones Biomédicas de la Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Mar Riveiro-Barciela
- Liver Unit, Hospital Vall d'Hebrón, Barcelona, Spain
- Centro de Investigaciones Biomédicas de la Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain
- *Correspondence: Mar Riveiro-Barciela
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Cao X, Wang Y, Li P, Huang W, Lu X, Lu H. HBV Reactivation During the Treatment of Non-Hodgkin Lymphoma and Management Strategies. Front Oncol 2021; 11:685706. [PMID: 34277431 PMCID: PMC8281013 DOI: 10.3389/fonc.2021.685706] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/16/2021] [Indexed: 12/14/2022] Open
Abstract
Hepatitis B virus reactivation (HBV-R), which can lead to HBV-related morbidity and mortality, is a common and well-known complication that occurs during the treatment of non-Hodgkin lymphoma (NHL) patients with current or past exposure to HBV infection. HBV-R is thought to be closely associated with chemotherapeutic or immunosuppressive therapies. However, immunosuppressive agents such as anti-CD20 antibodies (e.g., rituximab and ofatumumab), glucocorticoids, and hematopoietic stem cell transplantation (HSCT) administered to NHL patients during treatment can cause deep immunodepression and place them at high risk of HBV-R. In this review, we explore the current evidence, the guidelines of several national and international organizations, and the recommendations of expert panels relating to the definition, risk factors, screening and monitoring strategies, whether to use prophylaxis or pre-emptive therapy, and the optimal antiviral agent and duration of antiviral therapy for HBV-R.
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Affiliation(s)
- Xing Cao
- Department of Oncology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yafei Wang
- Department of Respiratory and Critical Care Medicine, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Panyun Li
- Department of Oncology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wei Huang
- Department of Oncology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaojuan Lu
- Department of Oncology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hongda Lu
- Department of Oncology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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4
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High hepatitis B virus screening rate among patients receiving systemic anticancer treatment in Japan. Int J Clin Oncol 2020; 25:1327-1333. [PMID: 32200482 DOI: 10.1007/s10147-020-01655-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 03/08/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Patients with hepatitis B virus (HBV) infection have a risk of reactivation after chemotherapy. All patients undergoing chemotherapy should be screened for HBV infection. No large-scale studies have been conducted to examine HBV screening practice in Japan. METHODS We analyzed health insurance claims equivalent data linked with a nationwide hospital-based cancer registry. Patients diagnosed with cancer in 2014, who were aged 20 years and older and those who underwent systemic anticancer treatment in 2014-15 were included. We assessed the HBV screening rates by the HBsAg or anti-HBc tests, HBV-DNA tests, and entecavir prescriptions. Multiple logistic regression models were used to identify factors related to the receipt of screening. RESULTS Of 177,597 patients (mean [SD] age, 65.6 [12.2] years), 82.6% and 12.9% patients had a solid tumor and hematologic malignancy, respectively. Among them, 88.1%, 6.3%, and 5.5% received cytotoxic chemotherapy, targeted therapy, and anti-CD20 antibodies, respectively. Overall, 70.6% of patients were screened. The positive predictor of HBV screening was receiving anti-CD20 antibodies [odds ratio (OR); 2.23, 95% confidence interval (CI) 2.06-2.41, p < 0.001] and negative predictors were age ≥ 85 (OR 0.76, 95% CI 0.71-0.81), age 75-84 (OR 0.77, 95% CI 0.75-0.79) and targeted therapy (OR 0.69, 95% CI 0.67-0.72). Among the screened patients, 13.2% were tested for HBV-DNA, and 1.49% were prescribed entecavir. CONCLUSIONS The HBV screening rate in Japan is higher than in other countries. Further improvement of the HBV screening rate is needed to prevent reactivation and avoidable deaths of patients with HBV infection.
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5
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Riveiro-Barciela M, Gubern P, Roade L, Abrisqueta P, Carreras MJ, Farriols A, Bosch F, Esteban R, Buti M. An electronic alert system increases screening for hepatitis B and C and improves management of patients with haematological disorders. Sci Rep 2020; 10:3038. [PMID: 32080253 PMCID: PMC7033156 DOI: 10.1038/s41598-020-59476-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 01/15/2020] [Indexed: 01/18/2023] Open
Abstract
Treatment of haematological disorders in patients with chronic hepatitis B or resolved infection (anti-HBc-positive) is associated with a risk of hepatitis B reactivation. Moreover, patients with chronic hepatitis C have a higher risk of haematological malignancies than general population. An electronic alert system was developed to promote screening of hepatitis B (HBV) and C (HCV) in patients starting haematological therapies. The system included screening and linkage to care and a request for testing in those without data. From March, 2017 to March, 2018 data from 420 consecutive patients with haematological diseases were included. At first prescription before the alerts, the HCV and HBV screening rate was 60.5%. Following the alerts, an additional 115 were screened, increasing the overall screening rate to 87.9%. Anti-HBc alone was detected in 57, anti-HCV in 13, and HBsAg in 2 patients. Overall, 68% of patients with any viral hepatitis markers were previously not know, and the impact was particularly important for anti-HBc detection (47/57 unknown). Nucleoside analogues were prescribed in 28 (49.1%) anti-HBc-positive and the 2 HBsAg-positive patients. Prospective follow-up with HBV DNA and HBsAg testing showed no cases of HBV reactivation. An estimated 1.2 HBV reactivations were avoided as consequence of the alert system. In summary, an electronic alert system increased viral hepatitis screening in patients receiving haematological treatment and led to improvements in the management of these patients, including avoided HBV reactivation.
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Affiliation(s)
- Mar Riveiro-Barciela
- Liver Unit, Internal Medicine Department, Vall d'Hebron Hospital, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Paula Gubern
- Liver Unit, Internal Medicine Department, Vall d'Hebron Hospital, Barcelona, Spain
| | - Luisa Roade
- Liver Unit, Internal Medicine Department, Vall d'Hebron Hospital, Barcelona, Spain
| | - Pau Abrisqueta
- Department of Hematology, Vall d'Hebron Hospital, Barcelona, Spain
| | | | - Anna Farriols
- Pharmacy Department, Vall d'Hebron Hospital, Barcelona, Spain
| | - Francesc Bosch
- Department of Hematology, Vall d'Hebron Hospital, Barcelona, Spain
| | - Rafael Esteban
- Liver Unit, Internal Medicine Department, Vall d'Hebron Hospital, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - María Buti
- Liver Unit, Internal Medicine Department, Vall d'Hebron Hospital, Barcelona, Spain. .,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain.
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Abstract
PURPOSE OF REVIEW To provide an update on recent studies of hepatitis B virus (HBV) and hepatitis C virus (HCV) infections in cancer patients with an emphasis on viral reactivation after cancer treatment, new antiviral therapies, and safety concerns. RECENT FINDINGS The diagnostic criteria for HBV reactivation in patients receiving cancer therapy were revised in 2018. HBV reactivation in these patients is preventable, even with the use of new cancer therapies. HCV reactivation also has been reported in cancer patients, particularly those with hematologic malignancies, and is not a virologic condition usually associated with poor outcome. Prophylaxis to prevent HCV reactivation is not recommended because therapy with direct-acting antivirals eradicates the infection in the majority of cancer patients. SUMMARY Cancer patients with HBV or HCV infection are at risk for viral reactivation, with many similarities between these two infections. Patients at high risk for reactivation will benefit significantly from taking oral antivirals, which will reduce the risk of HBV reactivation or prevent development of HCV reactivation following its virologic cure.
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Kanda T, Lau GKK, Wei L, Moriyama M, Yu ML, Chuang WL, Ibrahim A, Lesmana CRA, Sollano J, Kumar M, Jindal A, Sharma BC, Hamid SS, Kadir Dokmeci A, Mamun-Al-Mahtab, McCaughan GW, Wasim J, Crawford DHG, Kao JH, Ooka Y, Yokosuka O, Sarin SK, Omata M. APASL HCV guidelines of virus-eradicated patients by DAA on how to monitor HCC occurrence and HBV reactivation. Hepatol Int 2019; 13:649-661. [PMID: 31541423 PMCID: PMC6861433 DOI: 10.1007/s12072-019-09988-7] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 08/30/2019] [Indexed: 12/13/2022]
Abstract
In the direct-acting antiviral (DAA) era for hepatitis C virus (HCV) infection, sustained virological response (SVR) is very high, but close attention must be paid to the possible occurrence of hepatocellular carcinoma (HCC) and reactivation of hepatitis B virus (HBV) in patients with co-infection who achieved SVR in short term. HCC occurrence was more often observed in patients with previous HCC history. We found occurrence of HCC in 178 (29.6%) of 602 patients with previous HCC history (15.4 months mean follow-up post-DAA initiation) but, in contrast, in only 604 (1.3%) of 45,870 patients without previous HCC history (18.2 months mean follow-up). Thus, in these guidelines, we recommend the following: in patients with previous HCC history, surveillance at 4-month intervals for HCC by ultrasonography (US) and tumor markers should be performed. In patients without previous HCC history, surveillance at 6- to 12-month intervals for HCC including US is recommended until the long-term DAA treatment effects, especially for the resolution of liver fibrosis, are confirmed. This guideline also includes recommendations on how to follow-up patients who have been infected with both HCV and HBV. When HCV was eradicated in these HBsAg-positive patients or patients with previous HBV infection (anti-HBc and/or anti-HBs-positive), it was shown that HBV reactivation or HBV DNA reappearance was observed in 67 (41.4%) of 162 or 12 (0.9%) of 1317, respectively. For these co-infected patients, careful attention should be paid to HBV reactivation for 24 weeks post-treatment.
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Affiliation(s)
- Tatsuo Kanda
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - George K K Lau
- Humanity and Health Medical Center, Hong Kong SAR, China
| | - Lai Wei
- Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - Mitsuhiko Moriyama
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Ming-Lung Yu
- College of Biological Science and Technology, National Chiao Tung University, Hsin-Chu, Taiwan.,Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wang-Long Chuang
- Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Alaaeldin Ibrahim
- GI/Liver Division, Department of Internal Medicine, University of Benha, Banha, Egypt
| | - Cosmas Rinaldi Adithya Lesmana
- Digestive Disease and GI Oncology Centre, Medistra Hospital, Jakarta, Indonesia.,Hepatobiliary Division, Department of Internal Medicine, Dr. Cipto Mangunkusumo Hospital, Universitas Indonesia, Jakarta, Indonesia
| | - Jose Sollano
- University Santo Tomas Hospital, Manila, Philippines
| | - Manoj Kumar
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ankur Jindal
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | | | - Saeed S Hamid
- Department of Medicine, Aga Khan University and Hospital, Stadium Road, Karachi, 74800, Pakistan
| | - A Kadir Dokmeci
- Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey
| | - Mamun-Al-Mahtab
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, 1000, Bangladesh
| | - Geoffrey W McCaughan
- Royal Prince Alfred Hospital, Centenary Institute, University of Sydney, Sydney, Australia
| | - Jafri Wasim
- Department of Medicine, Aga Khan University and Hospital, Stadium Road, Karachi, 74800, Pakistan
| | - Darrell H G Crawford
- University of Queensland, School of Medicine, Woolloongabba, QLD, 4102, Australia
| | - Jia-Horng Kao
- National Taiwan University College of Medicine, and National Taiwan University Hospital, Taipei, Taiwan
| | - Yoshihiko Ooka
- Chiba University, Graduate School of Medicine, Chiba, Japan
| | - Osamu Yokosuka
- Chiba University, Graduate School of Medicine, Chiba, Japan
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Masao Omata
- Yamanashi Prefectural Central Hospital, 1-1-1 Fujimi, Kofu-shi, Yamanashi, 400-8506, Japan. .,The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
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8
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Pauly MP, Tucker LY, Szpakowski JL, Ready JB, Baer D, Hwang J, Lok ASF. Incidence of Hepatitis B Virus Reactivation and Hepatotoxicity in Patients Receiving Long-term Treatment With Tumor Necrosis Factor Antagonists. Clin Gastroenterol Hepatol 2018; 16:1964-1973.e1. [PMID: 29702293 DOI: 10.1016/j.cgh.2018.04.033] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 03/13/2018] [Accepted: 04/13/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Tumor necrosis factor (TNF) antagonists are the first-line treatment for many autoimmune diseases. However, they have been associated with reactivation of hepatitis B virus (HBV). We determined the rate of HBV reactivation and hepatotoxicity grade 3 or 4 (HT ≥3) in patients treated with an anti-TNF agent for an autoimmune disease. METHODS We collected data from 8887 adult patients in the Kaiser Permanente Northern California database who began treatment with TNF antagonists for autoimmune diseases (dermatologic, rheumatologic, or gastrointestinal) from 2001 through 2010, followed through December 2012. We obtained data on HBV infection (52% of patients were screened for HBV before treatment), demographic features, comorbidities, and use of immunosuppressive agents. HBV reactivation was defined as 1 of the following: >1 log increase in HBV DNA, HBV DNA-positive when previously negative, HBV DNA >2000 IU/mL if no baseline level was available, or reverse seroconversion. HT ≥3 was defined according to the National Cancer Institute Common Toxicity Criteria. We performed multivariable logistic regression to identify factors associated with HT ≥3. RESULTS Twenty-three patients tested positive for HB surface antigen (HBsAg) at baseline and 9 of these had HBV reactivation; of the 4267 patients with unknown HBV status at baseline, 2 had HBV reactivation. None of the 178 patients who were HBsAg negative and positive for the hepatitis B core antibody (anti-HBc+) had HBV reactivation. HBV reactivation occurred in 1/5 HBsAg+ patients who received prophylactic antiviral therapy and 8/18 who did not (P = .61). No one with HBV reactivation had liver failure. HT ≥3 occurred in 273 patients (2.7%), but only 3 cases were attributed to HBV. Cirrhosis was significantly associated with HT ≥3 (P < .001). CONCLUSION In a retrospective analysis of patients treated with TNF antagonists for autoimmune diseases, we found HBV reactivation in 39% of patients who were HBsAg+ before therapy, but not in any patients who were HBsAg-negative and anti-HBc+ before therapy. Patients should be screened for HBV infection before anti-TNF therapy; HBsAg+ patients should receive prophylactic antiviral therapy, but not HBsAg-negative, anti-HBc+ patients.
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Affiliation(s)
- Mary Patricia Pauly
- Department of Gastroenterology, Kaiser Permanente Northern California, Sacramento, California.
| | - Lue-Yen Tucker
- Division of Research, Kaiser Permanente Northern California, Sacramento, California
| | - Jean-Luc Szpakowski
- Department of Gastroenterology, Kaiser Permanente Northern California, Sacramento, California
| | - Joanna B Ready
- Department of Gastroenterology, Kaiser Permanente Northern California, Sacramento, California
| | - David Baer
- Department of Hematology and Oncology, Kaiser Permanente Northern California, Sacramento, California
| | - Jessica Hwang
- Department of General Internal Medicine, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Anna S-F Lok
- Department of Internal Medicine and Gastroenterology, University of Michigan, Ann Arbor, Michigan
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9
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Hwang JP, Lok AS, Fisch MJ, Cantor SB, Barbo A, Lin HY, Foreman JT, Vierling JM, Torres HA, Granwehr BP, Miller E, Eng C, Simon GR, Ahmed S, Ferrajoli A, Romaguera J, Suarez-Almazor ME. Models to Predict Hepatitis B Virus Infection Among Patients With Cancer Undergoing Systemic Anticancer Therapy: A Prospective Cohort Study. J Clin Oncol 2018; 36:959-967. [PMID: 29447061 PMCID: PMC7351320 DOI: 10.1200/jco.2017.75.6387] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Most patients with cancer are not screened for hepatitis B virus (HBV) infection before undergoing anticancer therapy, and optimal screening strategies are unknown. We sought to develop selective HBV screening strategies for patients who require systemic anticancer therapy. METHODS This prospective cohort study included adults age ≥ 18 years with solid or hematologic malignancies who received systemic anticancer therapy at a comprehensive cancer center during 2013 and 2014. Patients underwent hepatitis B surface antigen, hepatitis B core antibody, and hepatitis B surface antibody testing, and completed a 19-question modified Centers for Disease Control and Prevention (CDC) HBV survey. Multivariable models that predict chronic or past HBV infection were developed and validated using bootstrapping. RESULTS A total of 2,124 patients (mean age, 58 ± 13 years) completed the risk survey and HBV testing. Of these, 54% were women; 77% were non-Hispanic white, 11% Hispanic, 8% black, and 4% Asian; and 20% had a hematologic malignancy and 80% a solid tumor. Almost 12% were born outside the United States. The prevalence was 0.3% for chronic HBV infection and 6% for past HBV infection. Significant predictors of positive hepatitis B surface antigen or hepatitis B core antibody tests were as follows: men who had sex with men, black or Asian race, birthplace outside the United States, parent's birthplace outside the United States, household exposure to HBV, age ≥ 50 years, and history of injection drug use. The area under the receiver operating characteristic curve of the model on the basis of these seven predictors was 0.79 (95% CI, 0.73 to 0.82). The modified CDC survey and brief tools with fewer than seven questions yielded similar false-negative rates (0% and 0% to 0.7%, respectively). CONCLUSION An internally validated risk tool performed as well as the modified CDC survey; however, more than 90% of patients who completed the tool would still require HBV testing. Universal HBV testing is more efficient than risk-based screening.
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Affiliation(s)
- Jessica P. Hwang
- Jessica P. Hwang, Scott B. Cantor, Andrea Barbo, Heather Y. Lin, Jessica T. Foreman, Harrys A. Torres, Bruno P. Granwehr, Ethan Miller, Cathy Eng, George R. Simon, Sairah Ahmed, Alessandra Ferrajoli, Jorge Romaguera, and Maria E. Suarez-Almazor, The University of Texas MD Anderson Cancer Center; John M. Vierling, Baylor College of Medicine, Houston, TX; Anna S. Lok, University of Michigan, Ann Arbor, MI; and Michael J. Fisch, Aim Specialty Health, Chicago, IL
| | - Anna S. Lok
- Jessica P. Hwang, Scott B. Cantor, Andrea Barbo, Heather Y. Lin, Jessica T. Foreman, Harrys A. Torres, Bruno P. Granwehr, Ethan Miller, Cathy Eng, George R. Simon, Sairah Ahmed, Alessandra Ferrajoli, Jorge Romaguera, and Maria E. Suarez-Almazor, The University of Texas MD Anderson Cancer Center; John M. Vierling, Baylor College of Medicine, Houston, TX; Anna S. Lok, University of Michigan, Ann Arbor, MI; and Michael J. Fisch, Aim Specialty Health, Chicago, IL
| | - Michael J. Fisch
- Jessica P. Hwang, Scott B. Cantor, Andrea Barbo, Heather Y. Lin, Jessica T. Foreman, Harrys A. Torres, Bruno P. Granwehr, Ethan Miller, Cathy Eng, George R. Simon, Sairah Ahmed, Alessandra Ferrajoli, Jorge Romaguera, and Maria E. Suarez-Almazor, The University of Texas MD Anderson Cancer Center; John M. Vierling, Baylor College of Medicine, Houston, TX; Anna S. Lok, University of Michigan, Ann Arbor, MI; and Michael J. Fisch, Aim Specialty Health, Chicago, IL
| | - Scott B. Cantor
- Jessica P. Hwang, Scott B. Cantor, Andrea Barbo, Heather Y. Lin, Jessica T. Foreman, Harrys A. Torres, Bruno P. Granwehr, Ethan Miller, Cathy Eng, George R. Simon, Sairah Ahmed, Alessandra Ferrajoli, Jorge Romaguera, and Maria E. Suarez-Almazor, The University of Texas MD Anderson Cancer Center; John M. Vierling, Baylor College of Medicine, Houston, TX; Anna S. Lok, University of Michigan, Ann Arbor, MI; and Michael J. Fisch, Aim Specialty Health, Chicago, IL
| | - Andrea Barbo
- Jessica P. Hwang, Scott B. Cantor, Andrea Barbo, Heather Y. Lin, Jessica T. Foreman, Harrys A. Torres, Bruno P. Granwehr, Ethan Miller, Cathy Eng, George R. Simon, Sairah Ahmed, Alessandra Ferrajoli, Jorge Romaguera, and Maria E. Suarez-Almazor, The University of Texas MD Anderson Cancer Center; John M. Vierling, Baylor College of Medicine, Houston, TX; Anna S. Lok, University of Michigan, Ann Arbor, MI; and Michael J. Fisch, Aim Specialty Health, Chicago, IL
| | - Heather Y. Lin
- Jessica P. Hwang, Scott B. Cantor, Andrea Barbo, Heather Y. Lin, Jessica T. Foreman, Harrys A. Torres, Bruno P. Granwehr, Ethan Miller, Cathy Eng, George R. Simon, Sairah Ahmed, Alessandra Ferrajoli, Jorge Romaguera, and Maria E. Suarez-Almazor, The University of Texas MD Anderson Cancer Center; John M. Vierling, Baylor College of Medicine, Houston, TX; Anna S. Lok, University of Michigan, Ann Arbor, MI; and Michael J. Fisch, Aim Specialty Health, Chicago, IL
| | - Jessica T. Foreman
- Jessica P. Hwang, Scott B. Cantor, Andrea Barbo, Heather Y. Lin, Jessica T. Foreman, Harrys A. Torres, Bruno P. Granwehr, Ethan Miller, Cathy Eng, George R. Simon, Sairah Ahmed, Alessandra Ferrajoli, Jorge Romaguera, and Maria E. Suarez-Almazor, The University of Texas MD Anderson Cancer Center; John M. Vierling, Baylor College of Medicine, Houston, TX; Anna S. Lok, University of Michigan, Ann Arbor, MI; and Michael J. Fisch, Aim Specialty Health, Chicago, IL
| | - John M. Vierling
- Jessica P. Hwang, Scott B. Cantor, Andrea Barbo, Heather Y. Lin, Jessica T. Foreman, Harrys A. Torres, Bruno P. Granwehr, Ethan Miller, Cathy Eng, George R. Simon, Sairah Ahmed, Alessandra Ferrajoli, Jorge Romaguera, and Maria E. Suarez-Almazor, The University of Texas MD Anderson Cancer Center; John M. Vierling, Baylor College of Medicine, Houston, TX; Anna S. Lok, University of Michigan, Ann Arbor, MI; and Michael J. Fisch, Aim Specialty Health, Chicago, IL
| | - Harrys A. Torres
- Jessica P. Hwang, Scott B. Cantor, Andrea Barbo, Heather Y. Lin, Jessica T. Foreman, Harrys A. Torres, Bruno P. Granwehr, Ethan Miller, Cathy Eng, George R. Simon, Sairah Ahmed, Alessandra Ferrajoli, Jorge Romaguera, and Maria E. Suarez-Almazor, The University of Texas MD Anderson Cancer Center; John M. Vierling, Baylor College of Medicine, Houston, TX; Anna S. Lok, University of Michigan, Ann Arbor, MI; and Michael J. Fisch, Aim Specialty Health, Chicago, IL
| | - Bruno P. Granwehr
- Jessica P. Hwang, Scott B. Cantor, Andrea Barbo, Heather Y. Lin, Jessica T. Foreman, Harrys A. Torres, Bruno P. Granwehr, Ethan Miller, Cathy Eng, George R. Simon, Sairah Ahmed, Alessandra Ferrajoli, Jorge Romaguera, and Maria E. Suarez-Almazor, The University of Texas MD Anderson Cancer Center; John M. Vierling, Baylor College of Medicine, Houston, TX; Anna S. Lok, University of Michigan, Ann Arbor, MI; and Michael J. Fisch, Aim Specialty Health, Chicago, IL
| | - Ethan Miller
- Jessica P. Hwang, Scott B. Cantor, Andrea Barbo, Heather Y. Lin, Jessica T. Foreman, Harrys A. Torres, Bruno P. Granwehr, Ethan Miller, Cathy Eng, George R. Simon, Sairah Ahmed, Alessandra Ferrajoli, Jorge Romaguera, and Maria E. Suarez-Almazor, The University of Texas MD Anderson Cancer Center; John M. Vierling, Baylor College of Medicine, Houston, TX; Anna S. Lok, University of Michigan, Ann Arbor, MI; and Michael J. Fisch, Aim Specialty Health, Chicago, IL
| | - Cathy Eng
- Jessica P. Hwang, Scott B. Cantor, Andrea Barbo, Heather Y. Lin, Jessica T. Foreman, Harrys A. Torres, Bruno P. Granwehr, Ethan Miller, Cathy Eng, George R. Simon, Sairah Ahmed, Alessandra Ferrajoli, Jorge Romaguera, and Maria E. Suarez-Almazor, The University of Texas MD Anderson Cancer Center; John M. Vierling, Baylor College of Medicine, Houston, TX; Anna S. Lok, University of Michigan, Ann Arbor, MI; and Michael J. Fisch, Aim Specialty Health, Chicago, IL
| | - George R. Simon
- Jessica P. Hwang, Scott B. Cantor, Andrea Barbo, Heather Y. Lin, Jessica T. Foreman, Harrys A. Torres, Bruno P. Granwehr, Ethan Miller, Cathy Eng, George R. Simon, Sairah Ahmed, Alessandra Ferrajoli, Jorge Romaguera, and Maria E. Suarez-Almazor, The University of Texas MD Anderson Cancer Center; John M. Vierling, Baylor College of Medicine, Houston, TX; Anna S. Lok, University of Michigan, Ann Arbor, MI; and Michael J. Fisch, Aim Specialty Health, Chicago, IL
| | - Sairah Ahmed
- Jessica P. Hwang, Scott B. Cantor, Andrea Barbo, Heather Y. Lin, Jessica T. Foreman, Harrys A. Torres, Bruno P. Granwehr, Ethan Miller, Cathy Eng, George R. Simon, Sairah Ahmed, Alessandra Ferrajoli, Jorge Romaguera, and Maria E. Suarez-Almazor, The University of Texas MD Anderson Cancer Center; John M. Vierling, Baylor College of Medicine, Houston, TX; Anna S. Lok, University of Michigan, Ann Arbor, MI; and Michael J. Fisch, Aim Specialty Health, Chicago, IL
| | - Alessandra Ferrajoli
- Jessica P. Hwang, Scott B. Cantor, Andrea Barbo, Heather Y. Lin, Jessica T. Foreman, Harrys A. Torres, Bruno P. Granwehr, Ethan Miller, Cathy Eng, George R. Simon, Sairah Ahmed, Alessandra Ferrajoli, Jorge Romaguera, and Maria E. Suarez-Almazor, The University of Texas MD Anderson Cancer Center; John M. Vierling, Baylor College of Medicine, Houston, TX; Anna S. Lok, University of Michigan, Ann Arbor, MI; and Michael J. Fisch, Aim Specialty Health, Chicago, IL
| | - Jorge Romaguera
- Jessica P. Hwang, Scott B. Cantor, Andrea Barbo, Heather Y. Lin, Jessica T. Foreman, Harrys A. Torres, Bruno P. Granwehr, Ethan Miller, Cathy Eng, George R. Simon, Sairah Ahmed, Alessandra Ferrajoli, Jorge Romaguera, and Maria E. Suarez-Almazor, The University of Texas MD Anderson Cancer Center; John M. Vierling, Baylor College of Medicine, Houston, TX; Anna S. Lok, University of Michigan, Ann Arbor, MI; and Michael J. Fisch, Aim Specialty Health, Chicago, IL
| | - Maria E. Suarez-Almazor
- Jessica P. Hwang, Scott B. Cantor, Andrea Barbo, Heather Y. Lin, Jessica T. Foreman, Harrys A. Torres, Bruno P. Granwehr, Ethan Miller, Cathy Eng, George R. Simon, Sairah Ahmed, Alessandra Ferrajoli, Jorge Romaguera, and Maria E. Suarez-Almazor, The University of Texas MD Anderson Cancer Center; John M. Vierling, Baylor College of Medicine, Houston, TX; Anna S. Lok, University of Michigan, Ann Arbor, MI; and Michael J. Fisch, Aim Specialty Health, Chicago, IL
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10
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Terrault NA, Lok ASF, McMahon BJ, Chang KM, Hwang JP, Jonas MM, Brown RS, Bzowej NH, Wong JB. Update on prevention, diagnosis, and treatment of chronic hepatitis B: AASLD 2018 hepatitis B guidance. Hepatology 2018; 67:1560-1599. [PMID: 29405329 PMCID: PMC5975958 DOI: 10.1002/hep.29800] [Citation(s) in RCA: 2330] [Impact Index Per Article: 388.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 01/11/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Norah A Terrault
- Division of Gastroenterology/Hepatology, University of California San Francisco, San Francisco, CA
| | - Anna S F Lok
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - Brian J McMahon
- Liver Diseases and Hepatitis Program, Alaska NativeTribal Health Consortium, Anchorage, AK
| | - Kyong-Mi Chang
- Division of Gastroenterology, Corporal Michael J. Crescenz VA Medical Center & University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jessica P Hwang
- Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Maureen M Jonas
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA
| | - Robert S Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY
| | | | - John B Wong
- Division of Clinical Decision Making, Tufts Medical Center, Tufts University School of Medicine, Boston, MA
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11
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Kwak YE, Stein SM, Lim JK. Practice Patterns in Hepatitis B Virus Screening Before Cancer Chemotherapy in a Major US Hospital Network. Dig Dis Sci 2018; 63:61-71. [PMID: 29177849 DOI: 10.1007/s10620-017-4850-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 11/14/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cancer patients receiving chemotherapy face an increased risk of reactivation of chronic hepatitis B virus infection. AIM To determine the HBV screening rate in patients receiving cancer chemotherapy in various clinical settings. METHOD We identified 11,959 adult cancer patients (age ≥ 18 years) receiving parenteral chemotherapy between 2012 and 2015 within a major US hospital network, including a large university hospital, community teaching hospitals, and community oncology clinics. RESULT Two thousand and forty-five patients (17.1%) were screened for either HBV surface antigen (HBsAg) or HBV core antibody (HBcAb) before chemotherapy, and 1850 patients (15.5%) had both HBsAg and HBcAb tested before chemotherapy. 8.4% were exposed to HBV, and 0.9% had chronic HBV infection (both HBsAg/HBcAb positive). Patients with hematologic tumor were more often screened than with solid tumor (55.6 vs. 8.3%, p < 0.001). Patients receiving chemotherapy with higher HBV reactivation risk had higher yet suboptimal HBV screening rate (41.1% B-depleting agents, 21.5% anthracycline, 14.9% steroid, 64.7% anti-TNF alpha and 18.6% other chemotherapy, p < 0.001). Patients with age ≥ 50 years (old 16.2% vs. young 23.9%, p < 0.001) and Asian ethnicity (Asian 13.6 vs. Caucasian 16.6%, p < 0.001) were screened less for HBV despite higher prevalence of HBV exposure (old 9.3% vs. young 4.3%, p < 0.001 and Asian 27.8% vs. Caucasian 6.4%, p < 0.001). Patients receiving chemotherapy in community oncology clinics were less screened versus community teaching hospitals or university hospital (12.7 vs. 19.1 vs. 19.7%, p < 0.001), despite similar prevalence of HBV infection. On multivariate analysis, receiving chemotherapy at a community oncology clinic [odds ratio (OR) 0.57, 95% confidence interval (CI) 0.45-0.72, p < 0.001] was independently associated with less HBV screening compared to receiving chemotherapy at a university or community teaching hospital. CONCLUSION HBV screening among patients undergoing cancer chemotherapy was suboptimal and less commonly performed in community oncology clinics compared to teaching hospitals.
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Affiliation(s)
- Ye Eun Kwak
- Department of Internal Medicine, Yale New Haven Health, Bridgeport Hospital, 267 Grant St, Bridgeport, CT, 06614, USA
| | - Stacy M Stein
- Department of Internal Medicine, Section of Medical Oncology and Smilow Cancer Center, Yale University School of Medicine, 35 Park St, Ste North Pavillion 8, New Haven, CT, 06511, USA
| | - Joseph K Lim
- Department of Internal Medicine, Section of Digestive Diseases and Yale Liver Center, Yale University School of Medicine, 333 Cedar Street, LMP 1080, New Haven, CT, 06520-8019, USA.
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12
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Hwang JP, Suarez-Almazor ME, Cantor SB, Barbo A, Lin HY, Ahmed S, Chavez-MacGregor M, Donato-Santana C, Eng C, Ferrajoli A, Fisch MJ, McLaughlin P, Simon GR, Rondon G, Shpall EJ, Lok AS. Impact of the timing of hepatitis B virus identification and anti-hepatitis B virus therapy initiation on the risk of adverse liver outcomes for patients receiving cancer therapy. Cancer 2017; 123:3367-3376. [PMID: 28518219 DOI: 10.1002/cncr.30729] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 02/28/2017] [Accepted: 03/17/2017] [Indexed: 01/26/2023]
Abstract
BACKGROUND Data on the incidence of adverse liver outcomes are limited for cancer patients with chronic (hepatitis B surface antigen [HBsAg]-positive/hepatitis B core antibody [anti-HBc]-positive) or past (HBsAg-negative/anti-HBc-positive) hepatitis B virus (HBV) after chemotherapy. This study was aimed at determining the impact of test timing and anti-HBV therapy on adverse liver outcomes in these patients. METHODS Patients with solid or hematologic malignancies who received chemotherapy between 2004 and 2011 were retrospectively studied. HBV testing and anti-HBV therapy were defined as early at the initiation of cancer therapy and as late after initiation. Outcomes included hepatitis flares, hepatic impairment, liver failure, and death. Time-to-event analysis was used to determine incidence, and multivariate hazard models were used to determine predictors of outcomes. RESULTS There were 18,688 study patients (80.4% with solid tumors). The prevalence of chronic HBV was 1.1% (52 of 4905), and the prevalence of past HBV was 7.1% (350 of 4905). Among patients with solid tumors, late identification of chronic HBV was associated with a higher risk of hepatitis flare (hazard ratio [HR], 4.02; 95% confidence interval [CI], 1.26-12.86), hepatic impairment (HR, 8.48; 95% CI, 1.86-38.66), liver failure (HR, 9.38; 95% CI, 1.50-58.86), and death (HR, 3.90; 95% CI, 1.19-12.83) in comparison with early identification. Among patients with hematologic malignancies and chronic HBV, the risk of death was 7.8 (95% CI, 1.73-35.27) times higher for persons with late initiation of anti-HBV therapy versus early initiation. Patients with late identification of chronic HBV had late or no anti-HBV therapy. Chronic HBV predicted liver failure in patients with solid or hematologic malignancies, whereas male sex and late identification were predictors for patients with solid tumors. CONCLUSIONS Early identification correlates with early anti-HBV therapy and reduces the risk of liver failure and death in chronic HBV patients receiving chemotherapy. Cancer 2017;123:3367-76. © 2017 American Cancer Society.
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Affiliation(s)
- Jessica P Hwang
- Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Maria E Suarez-Almazor
- Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Scott B Cantor
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Andrea Barbo
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Heather Y Lin
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sairah Ahmed
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mariana Chavez-MacGregor
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Christian Donato-Santana
- Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Cathy Eng
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Alessandra Ferrajoli
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Peter McLaughlin
- Physicians Network, MD Anderson Cancer Center, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - George R Simon
- Department of Thoracic Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Gabriela Rondon
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Elizabeth J Shpall
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Anna S Lok
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
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13
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Abstract
AIMS/OBJECTIVES/BACKGROUND Individuals with current or previous infection with the hepatitis B virus (HBV) can experience viral reactivation when treated with immunosuppression. Rituximab, an anti-CD20 antibody used to treat many diseases, has potent immunosuppressant effects with a high risk of causing HBV reactivation. Reactivation can range from elevated liver enzymes to acute severe hepatitis with liver failure and a significant mortality risk. HBV screening and appropriate use of prophylactic antiviral therapy can prevent reactivation. This work describes the introduction of a local policy for HBV testing in patients before rituximab treatment and assesses its impact. METHODS AND RESULTS A baseline review (before policy introduction) of 90 patients showed that only 21 (23%) had hepatitis B surface antigen (HBsAg) and 17 (19%) had hepatitis B core antibody (anti-HBcAb) tested before receiving rituximab. Following introduction of the policy (on the basis of international guidelines), improved laboratory reporting protocols and targeted education sessions, two further reviews of HBV testing rates among patients being initiated onto rituximab were performed. There was a marked increase in pre-rituximab testing for HBsAg from 23 to 79% and for anti-HBcAb from 19 to 78%. Throughout the study period, a total of one (0.8%) HBsAg-positive and six (4.7%) anti-HBcAb-positive patients were identified. CONCLUSIONS This work clearly indicates that simple strategies can markedly improve appropriate HBV screening. In our cohort, 6% (of whom only 43% had recognized HBV risk factors) required antiviral prophylaxis, which emphasizes the importance of universal screening before rituximab. Reinforcement of the guidelines and ongoing education is needed to further increase testing rates.
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14
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Persistent risk of HBV reactivation despite extensive lamivudine prophylaxis in haematopoietic stem cell transplant recipients who are anti-HBc-positive or HBV-negative recipients with an anti-HBc-positive donor. Clin Microbiol Infect 2016; 22:946.e1-946.e8. [PMID: 27475741 DOI: 10.1016/j.cmi.2016.07.021] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 07/08/2016] [Accepted: 07/16/2016] [Indexed: 02/08/2023]
Abstract
The overall rate of hepatitis B virus (HBV) reactivation was evaluated in a population of 373 haematological stem cell transplant (HSCT) patients treated with lamivudine (LMV) if they were anti-HBc-positive/HBV-DNA-negative recipients or if they were HBV-negative recipients with an anti-HBc-positive donor. The incidence of HBV reactivation was calculated in two groups of autologous (auto) or allogeneic (allo) HSCT patients who were stratified according to their HBV serostatus. The former group included 57 cases: 10 auto-HSCT and 27 allo-HSCT anti-HBc-positive recipients, two auto-HSCT and three allo-HSCT inactive carriers, and 15 allo-HSCT recipients with an anti-HBc-positive donor. Forty-seven (82.4%) patients in this group received LMV prophylaxis (the median (interquartile range, IQR) of LMV treatment was 30 (20-38) months). The second group consisted of 320 anti-HBc-negative auto-HSCT and allo-HSCT recipients with anti-HBc-negative donors. None of these patients received any prophylaxis. Two patients in the first group and two in the second group experienced reactivation of HBV infection, with an incidence of 3.5% (95% CI 0.4-12.1%) and 0.6% (95% CI 0.1-2.2%), respectively. Only one out of four reactivated patients was LMV-treated. The cumulative probability of HBV reactivation at 6 years from HSCT was 15.8% (95% CI 15.2-16.4%). Three of four viral isolates obtained from the HBV-reactivated patients harboured mutations in the immune-active HBsAg-region. In a HSCT population carefully evaluated for HBV prophylaxis, a risk of HBV reactivation persisted in the group of patients who were not LMV-treated. Only one LMV-treated patient experienced reactivation of HBV with a resistant HBV isolate.
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15
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Ozoya OO, Sokol L, Dalia S. Hepatitis B Reactivation with Novel Agents in Non-Hodgkin's Lymphoma and Prevention Strategies. J Clin Transl Hepatol 2016; 4:143-50. [PMID: 27350944 PMCID: PMC4913070 DOI: 10.14218/jcth.2016.00005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Revised: 04/25/2016] [Accepted: 04/26/2016] [Indexed: 12/12/2022] Open
Abstract
Hepatitis B virus (HBV) infection remains an endemic disease in most parts of the world despite available prophylactic vaccines. Non-Hodgkin's lymphoma is the most common hematological malignancy, and certain patients undergoing therapy are at increased risk of HBV reactivation. Rituximab, a monoclonal antibody, is well studied in HBV reactivation, but newer agents have been implicated as well. Here, we review novel agents suspected in HBV reactivation and effective strategies to prevent HBV reactivation. Fifteen years of literature were reviewed in order to better understand the reactivation rates of hepatitis B in patients with non-Hodgkin's lymphoma. Anti-CD20 antibodies continue to be the main medications that can lead to HBV reactivation, and HBV reactivation rates have decreased with increased awareness. HBV reactivation is uncommon when using other novel agents. Entecavir and lamivudine remain the agents of choice to prevent HBV reactivation in high risk patients. In conclusion, the immunosuppressive effect of NHL and its therapy provide a pathway for HBV reactivation, especially in patients treated with anti-CD20 antibody. Since many HBV positive patients are often excluded from clinical trials of novel agents in NHL, more aggressive post-market surveillance of new agents, well-designed best practice advisories, and timely case reports are needed to reduce the incidence of HBV reactivation. Lastly, large prospective investigations coupled with well-utilized best practice advisories need to be conducted to understand the impact of more potent novel NHL therapy on HBV reactivation.
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Affiliation(s)
| | - Lubomir Sokol
- Department of Hematological Malignancies, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Samir Dalia
- Oncology and Hematology, Mercy Clinic Joplin, Joplin, MO, USA
- *Correspondence to: Samir Dalia, Oncology and Hematology, Mercy Clinic Joplin, 100 Mercy Way, Joplin, MO 64804, USA. Tel: +1-417-782-7722, Fax: +1-417-556-3063, E-mail: or
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16
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Hicks LK, Lien K, Chan KKW. ASCO Provisional Clinical Opinion for Hepatitis B Virus Screening Before Cancer Therapy: Are These the Right Tests in the Right Patients? J Oncol Pract 2016; 11:e490-4. [PMID: 26188049 DOI: 10.1200/jop.2015.004945] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Affiliation(s)
- Lisa K Hicks
- St Michael's Hospital, University of Toronto; and Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Kelly Lien
- St Michael's Hospital, University of Toronto; and Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Kelvin K W Chan
- St Michael's Hospital, University of Toronto; and Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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17
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Brasseur M, Heurgué-Berlot A, Barbe C, Brami C, Rey JB, Vella-Boucaud J, Dabouz F, Deslée G, Grange F, Volet J, Bouché O. Prevalence of hepatitis B and C and sensibility of a selective screening questionnaire in patients receiving chemotherapy for solid tumors. BMC Cancer 2015; 15:999. [PMID: 26694960 PMCID: PMC4688993 DOI: 10.1186/s12885-015-2033-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Accepted: 12/17/2015] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Reactivation of hepatitis B or C virus can occur in patients undergoing chemotherapy. Recommendations for selective or systematic hepatitis B virus testing prior chemotherapy for solid tumors differ. The primary aim was to determine the seroprevalence of hepatitis B or C in a low endemic country. The second objective was to assess the relevance of a questionnaire on hepatitis B/C risk factors to consider a selective screening. METHODS Patients were prospectively tested for hepatitis B/C markers. HBs antigen positive patients and isolated anti-HBc positive patients with detectable viral load received antiviral preventive treatment. Patients or physicians completed the questionnaire on infection risk factors. RESULTS Among the 450 patients included, 388 were tested for all serological markers and had gastrointestinal (63.7%), lung (31.2%) and skin (4.6%) cancers. The prevalence of subjects exposed to hepatitis B virus was 8.5% (33/388). One patient tested positive for HBs antigen and received preventive treatment. Prevalence of subjects exposed to hepatitis C was 1.3% (5/388). The questionnaire sensitivity was 45.5%, 100% and 50% for detecting carriers of hepatitis B, C and one or the other, respectively. CONCLUSIONS Seroprevalence of hepatitis B was low. Selective screening with the questionnaire was insufficiently sensitive. Systematic screening with serological tests prior to chemotherapy in patients with solid tumors is therefore relevant.
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Affiliation(s)
- Mathilde Brasseur
- CHU Reims, Hôpital Robert Debré, Structure Interne d'Hépato-Gastro-Entérologie et Cancérologie Digestive, Avenue du Génénal Kœnig, Reims, F-51092, France.
| | - Alexandra Heurgué-Berlot
- CHU Reims, Hôpital Robert Debré, Structure Interne d'Hépato-Gastro-Entérologie et Cancérologie Digestive, Avenue du Génénal Kœnig, Reims, F-51092, France.
| | - Coralie Barbe
- CHU Reims, Hôpital Robert Debré, Unité d'Aide Méthodologique, Avenue du Génénal Kœnig, Reims, F-51092, France.
| | - Cloé Brami
- CHU Reims, Hôpital Robert Debré, Unité de Médecine Ambulatoire Cancérologie Hématologie, Avenue du Génénal Kœnig, Reims, F-51092, France.
| | - Jean-Baptiste Rey
- Institut de Cancérologie Jean Godinot, Département de Pharmacie, Avenue du Génénal Kœnig, Reims, F-51100, France. .,Université de Reims Champagne-Ardenne, Laboratoire EA4691, Avenue du Maréchal Juin, Reims, F-51100, France.
| | - Juliette Vella-Boucaud
- CHU Reims, Hôpital Maison Blanche, Maladies Respiratoires et Allergologie, Avenue du Génénal Kœnig, Reims, F-51092, France.
| | - Fadia Dabouz
- CHU Reims, Hôpital Robert Debré, Structure interne de Dermatologie, Avenue du Génénal Kœnig, Reims, F-51092, France.
| | - Gaëtan Deslée
- CHU Reims, Hôpital Maison Blanche, Maladies Respiratoires et Allergologie, Avenue du Génénal Kœnig, Reims, F-51092, France.
| | - Florent Grange
- CHU Reims, Hôpital Robert Debré, Structure interne de Dermatologie, Avenue du Génénal Kœnig, Reims, F-51092, France.
| | - Julien Volet
- CHU Reims, Hôpital Robert Debré, Structure Interne d'Hépato-Gastro-Entérologie et Cancérologie Digestive, Avenue du Génénal Kœnig, Reims, F-51092, France. .,CHU Reims, Hôpital Robert Debré, Unité de Médecine Ambulatoire Cancérologie Hématologie, Avenue du Génénal Kœnig, Reims, F-51092, France.
| | - Olivier Bouché
- CHU Reims, Hôpital Robert Debré, Structure Interne d'Hépato-Gastro-Entérologie et Cancérologie Digestive, Avenue du Génénal Kœnig, Reims, F-51092, France. .,CHU Reims, Hôpital Robert Debré, Unité de Médecine Ambulatoire Cancérologie Hématologie, Avenue du Génénal Kœnig, Reims, F-51092, France.
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Sanagawa A, Kuroda J, Shiota A, Kito N, Takemoto M, Kawade Y, Esaki T, Kimura K. Outcomes of the implementation of the computer-assisted HBView system for the prevention of hepatitis B virus reactivation in chemotherapy patients: a retrospective analysis. J Pharm Health Care Sci 2015; 1:29. [PMID: 26819740 PMCID: PMC4729173 DOI: 10.1186/s40780-015-0030-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 10/22/2015] [Indexed: 12/16/2022] Open
Abstract
Background Screening for hepatitis B virus (HBV) infection is recommended worldwide for patients receiving systemic chemotherapy in accordance with clinical guidelines, but compliance varies by country and facility. Alert systems may be useful for promoting screening, but it is unclear how effective such systems are. In this study, we investigated HBV screening procedures and their incorporation into treatment regimens following the implementation of an alert system. Methods An alert system was introduced at our hospital in April 2012. The rates of HBV screening in the periods before and after the introduction of the alert system (September 2010 to March 2012 and April 2012 to October 2013, respectively) were investigated. We collected data on hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (HBsAb), hepatitis B core antibody (HBcAb), and HBV-DNA testing in patients. As a result of this analysis, we developed a system in which pharmacists would intervene to check and confirm whether HBV screening had occurred in patients scheduled to begin treatment with chemotherapy. We named our project the “HBView” project, and the rate of HBV screening and the number of times pharmacists intervened was studied during specific time periods before and after the HBView project commenced (July 2013 to December 2013 and January 2014 to June 2014, respectively). Results After introducing the alert system, the percentage of patients tested for HBsAb/HBcAb and HBV-DNA increased significantly, from 71.6 % to 84.9 % and from 44.5 % to 69.7 %, respectively. However, the rate of compliance with HBV testing guidelines was not 100 % after interventions. The numbers of patients who were not screened but should have been before and after the introduction of HBView were 6 and 17, respectively. Two patients at risk of HBV reactivation were identified after intervention by pharmacists; their intervention thus prevented HBV reactivation. Conclusions Compliance with clinical HBV screening guidelines was not sufficiently improved after the introduction of the automatic alert system; however, the HBView project proved useful in reinforcing the automatic alert system.
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Affiliation(s)
- Akimasa Sanagawa
- Department of Pharmacy, Nagoya City University Hospital, 1, Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601 Japan ; Department of Hospital Pharmacy, Graduate School of Pharmaceutical Sciences, Nagoya City University, 3-1, Tanabe-dori, Mizuho-ku, Nagoya 467-8603 Japan
| | - Junko Kuroda
- Department of Pharmacy, Nagoya City University Hospital, 1, Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601 Japan ; Department of Clinical Pharmacy, Graduate School of Medical Sciences, Nagoya City University, 1, Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601 Japan
| | - Arufumi Shiota
- Department of Pharmacy, Nagoya City University Hospital, 1, Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601 Japan ; Department of Clinical Pharmacy, Graduate School of Medical Sciences, Nagoya City University, 1, Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601 Japan
| | - Noriko Kito
- Department of Pharmacy, Nagoya City University Hospital, 1, Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601 Japan
| | - Masashi Takemoto
- Department of Pharmacy, Nagoya City University Hospital, 1, Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601 Japan
| | - Yoshihiro Kawade
- Department of Pharmacy, Nagoya City University Hospital, 1, Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601 Japan ; Department of Hospital Pharmacy, Graduate School of Pharmaceutical Sciences, Nagoya City University, 3-1, Tanabe-dori, Mizuho-ku, Nagoya 467-8603 Japan
| | - Tetsuo Esaki
- Department of Pharmacy, Nagoya City University Hospital, 1, Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601 Japan ; Department of Clinical Pharmacy, Graduate School of Medical Sciences, Nagoya City University, 1, Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601 Japan
| | - Kazunori Kimura
- Department of Pharmacy, Nagoya City University Hospital, 1, Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601 Japan ; Department of Hospital Pharmacy, Graduate School of Pharmaceutical Sciences, Nagoya City University, 3-1, Tanabe-dori, Mizuho-ku, Nagoya 467-8603 Japan ; Department of Clinical Pharmacy, Graduate School of Medical Sciences, Nagoya City University, 1, Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601 Japan
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Udagawa Y, Ohno S, Nakagawa S, Sugimoto K, Mochizuki J. Using Clinical Databases to Verify the Impact of Regulatory Agency Alerts in Japan: Hepatitis B Testing Behavior After an Alert Regarding Risk of Viral Reactivation. Drugs Real World Outcomes 2015; 2:227-237. [PMID: 27747569 PMCID: PMC4883216 DOI: 10.1007/s40801-015-0034-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Measures of the effectiveness of risk minimization activities are necessary for the appropriate use of drugs, and clinical databases are a low-cost method of quickly producing such results. OBJECTIVE The aim of this study was to explore the secondary application of clinical databases in verifying the impact of risk minimization activities; specifically, whether such databases could be used to identify changes in hepatitis B virus testing behavior after an alert from the Pharmaceuticals and Medical Devices Agency (PMDA) in Japan. METHODS Patient data from December 1, 2010 to November 30, 2012 were extracted from the Medical Data Vision clinical database. The percentages of patients tested for hepatitis B virus DNA (HBV-DNA), hepatitis B surface antigen (HBsAg), and hepatitis B surface antibody (HBsAb)/hepatitis B core antibody (HBcAb) were compared 1 year before (consecutive 6-month periods A and B) and 1 year after (consecutive 6-month periods C and D) a PMDA alert regarding viral reactivation in patients receiving immunosuppressive agents. RESULTS Data for 9866 patients in the clinical database were analyzed. After the PMDA alert, the percentage of patients tested for HBV-DNA linearly increased in periods A to D: 4.70 % (n = 262/5571), 5.78 % (n = 330/5710), 6.52 % (n = 398/6101), and 7.59 % (n = 479/6315). However, no changes were observed in the rates of HBsAg and HBcAb/HBsAb testing (around 50 and 70 %, respectively). Overall testing rates appeared to differ depending on disease and drug type. CONCLUSION These findings suggest that the PMDA alert was effective at recommending HBV-DNA testing. This secondary application of clinical databases may be effective for verifying the impact of risk minimization activities.
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Affiliation(s)
- Yukio Udagawa
- Drug Safety Division, Chugai Pharmaceutical Co., Ltd., 1-1 Nihonbashi-Muromachi 2-Chome, Chuo-ku, Tokyo, Japan.
| | - Shinya Ohno
- Project and Lifecycle Management Unit, Chugai Pharmaceutical Co., Ltd, Tokyo, Japan
| | - Shintaro Nakagawa
- Clinical Development Division, Chugai Pharmaceutical Co., Ltd, Tokyo, Japan
| | - Kazutaka Sugimoto
- Drug Safety Division, Chugai Pharmaceutical Co., Ltd., 1-1 Nihonbashi-Muromachi 2-Chome, Chuo-ku, Tokyo, Japan
| | - Joji Mochizuki
- Drug Safety Division, Chugai Pharmaceutical Co., Ltd., 1-1 Nihonbashi-Muromachi 2-Chome, Chuo-ku, Tokyo, Japan
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Hsu PI, Lai KH, Cheng JS, Kao SS, Li YR, Sun WC, Chen WC, Lin KH, Shin CA, Chiang PH, Li YD, Ou WT, Chen HC, Yu HC. Prevention of acute exacerbation of chronic hepatitis B infection in cancer patients receiving chemotherapy in a hepatitis B virus endemic area. Hepatology 2015; 62:387-96. [PMID: 26041578 DOI: 10.1002/hep.27843] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Accepted: 04/07/2015] [Indexed: 12/20/2022]
Abstract
UNLABELLED Reactivation of hepatitis B viral (HBV) infection in cancer patients undergoing chemotherapy may cause interruption of chemotherapy and lead to liver failure and death. In our institute, a computerized order entry-based alert system was introduced in September 2011 to remind healthcare providers of HBV testing when prescribing chemotherapy. Since August 2012, an order entry-based therapeutic control system has been applied to ensure HBV prophylaxis during chemotherapy. This retrospective cohort study included cancer patients receiving chemotherapy in the Kaohsiung Veterans General Hospital from November 2009 to June 2013. The prechemotherapy HBV screening rate, HBV prophylactic rate, and severe HBV acute exacerbation rate were compared between stages with different order systems. Newly diagnosed cancer patients (n = 2512) were included. The HBV testing rate in the screening reminder stage was higher than that in the educational stage (93.5% versus 40.2%, P < 0.001), whereas the adequate HBV prophylactic rates in the two order entry-based stages were comparable (41.1% versus 39.2%). Patients in the order entry-based therapeutic control stage had a higher HBV screening rate (99.3% versus 40.2%, P < 0.001) and a higher HBV prophylactic rate (95.8% versus 39.2%, P < 0.001) than those in the educational stage. Additionally, the severe HBV acute exacerbation rate in the therapeutic control stage was lower than those in the educational and screening reminder stages (0% versus 1.2% and 1.2%, respectively; both P < 0.01). CONCLUSION A computerized order entry-based therapeutic control system can provide excellent prechemotherapy HBV screening for cancer patients undergoing chemotherapy and can effectively prevent severe acute exacerbation of HBV infection in hospitals among HBV endemic areas.
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Affiliation(s)
- Ping-I Hsu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital and National Yang-Ming University, Kaohsiung, Taiwan
| | - Kwok-Hung Lai
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital and National Yang-Ming University, Kaohsiung, Taiwan
| | - Jin-Shiung Cheng
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital and National Yang-Ming University, Kaohsiung, Taiwan
| | - Sung-Shuo Kao
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital and National Yang-Ming University, Kaohsiung, Taiwan
| | - Yuan-Rung Li
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital and National Yang-Ming University, Kaohsiung, Taiwan
| | - Wei-Chih Sun
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital and National Yang-Ming University, Kaohsiung, Taiwan
| | - Wen-Chi Chen
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital and National Yang-Ming University, Kaohsiung, Taiwan
| | - Kung-Hung Lin
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital and National Yang-Ming University, Kaohsiung, Taiwan
| | - Chih-An Shin
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital and National Yang-Ming University, Kaohsiung, Taiwan
| | - Po-Hung Chiang
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital and National Yang-Ming University, Kaohsiung, Taiwan
| | - Yun-Da Li
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital and National Yang-Ming University, Kaohsiung, Taiwan
| | - Wei-Ting Ou
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital and National Yang-Ming University, Kaohsiung, Taiwan
| | - Hui-Chun Chen
- Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung City, Taiwan
| | - Hsien-Chung Yu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital and National Yang-Ming University, Kaohsiung, Taiwan
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21
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Hwang JP, Somerfield MR, Alston-Johnson DE, Cryer DR, Feld JJ, Kramer BS, Sabichi AL, Wong SL, Artz AS. Hepatitis B Virus Screening for Patients With Cancer Before Therapy: American Society of Clinical Oncology Provisional Clinical Opinion Update. J Clin Oncol 2015; 33:2212-20. [PMID: 25964247 DOI: 10.1200/jco.2015.61.3745] [Citation(s) in RCA: 124] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
PURPOSE This updated provisional clinical opinion presents a revised opinion based on American Society of Clinical Oncology panel consensus in the context of an evolving database. CONTEXT Despite the 2010 provisional clinical opinion recommendation, there is still evidence of suboptimal hepatitis B virus (HBV) screening among patients at high risk for HBV infection or HBV reactivation after chemotherapy. This updated provisional clinical opinion introduces a risk-adaptive strategy to identify and treat patients with HBV infection to reduce their risk of HBV reactivation. PROVISIONAL CLINICAL OPINION Medical providers should screen by testing patients for HBV infection before starting anti-CD20 therapy or hematopoietic cell transplantation. Providers should also screen patients with risk factors for HBV infection. Screening should include both hepatitis B surface antigen (HBsAg) and hepatitis B core antibody (anti-HBc), because reactivation can occur in patients who are HBsAg positive/anti-HBc positive or HBsAg negative/anti-HBc positive. Either total anti-HBc or anti-HBc immunoglobulin G (not immunoglobulin M) test should be used. Clinicians should start antiviral therapy for HBsAg-positive/anti-HBc-positive patients before or contemporaneously with cancer therapy and monitor HBsAg-negative/anti-HBc-positive patients for reactivation with HBV DNA and ALT levels, promptly starting antivirals if reactivation occurs. Clinicians can initiate antivirals for HBsAg-negative/anti-HBc-positive patients anticipating cancer therapies associated with a high risk of reactivation, or they can monitor HBV DNA and ALT levels and initiate on-demand antivirals. For patients who neither have HBV risk factors nor anticipate cancer therapy associated with a high risk of reactivation, current evidence does not support HBV screening before initiation of cancer therapy. Two panel members provided a minority viewpoint, involving a strategy of universal HBsAg and selective anti-HBc testing.
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Affiliation(s)
- Jessica P Hwang
- Jessica P. Hwang, University of Texas MD Anderson Cancer Center; Anita L. Sabichi, Baylor College of Medicine, Houston, TX; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; Devena E. Alston-Johnson, Upstate Oncology Associates, Greenville, SC; Donna R. Cryer, Global Liver Institute, Washington, DC; Jordan J. Feld, Toronto Western Hospital Liver Centre, Toronto, Ontario, Canada; Barnett S. Kramer, National Cancer Institute, Bethesda, MD; Sandra L. Wong, University of Michigan, Ann Arbor, MI; and Andrew S. Artz, University of Chicago, Chicago, IL
| | - Mark R Somerfield
- Jessica P. Hwang, University of Texas MD Anderson Cancer Center; Anita L. Sabichi, Baylor College of Medicine, Houston, TX; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; Devena E. Alston-Johnson, Upstate Oncology Associates, Greenville, SC; Donna R. Cryer, Global Liver Institute, Washington, DC; Jordan J. Feld, Toronto Western Hospital Liver Centre, Toronto, Ontario, Canada; Barnett S. Kramer, National Cancer Institute, Bethesda, MD; Sandra L. Wong, University of Michigan, Ann Arbor, MI; and Andrew S. Artz, University of Chicago, Chicago, IL
| | - Devena E Alston-Johnson
- Jessica P. Hwang, University of Texas MD Anderson Cancer Center; Anita L. Sabichi, Baylor College of Medicine, Houston, TX; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; Devena E. Alston-Johnson, Upstate Oncology Associates, Greenville, SC; Donna R. Cryer, Global Liver Institute, Washington, DC; Jordan J. Feld, Toronto Western Hospital Liver Centre, Toronto, Ontario, Canada; Barnett S. Kramer, National Cancer Institute, Bethesda, MD; Sandra L. Wong, University of Michigan, Ann Arbor, MI; and Andrew S. Artz, University of Chicago, Chicago, IL
| | - Donna R Cryer
- Jessica P. Hwang, University of Texas MD Anderson Cancer Center; Anita L. Sabichi, Baylor College of Medicine, Houston, TX; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; Devena E. Alston-Johnson, Upstate Oncology Associates, Greenville, SC; Donna R. Cryer, Global Liver Institute, Washington, DC; Jordan J. Feld, Toronto Western Hospital Liver Centre, Toronto, Ontario, Canada; Barnett S. Kramer, National Cancer Institute, Bethesda, MD; Sandra L. Wong, University of Michigan, Ann Arbor, MI; and Andrew S. Artz, University of Chicago, Chicago, IL
| | - Jordan J Feld
- Jessica P. Hwang, University of Texas MD Anderson Cancer Center; Anita L. Sabichi, Baylor College of Medicine, Houston, TX; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; Devena E. Alston-Johnson, Upstate Oncology Associates, Greenville, SC; Donna R. Cryer, Global Liver Institute, Washington, DC; Jordan J. Feld, Toronto Western Hospital Liver Centre, Toronto, Ontario, Canada; Barnett S. Kramer, National Cancer Institute, Bethesda, MD; Sandra L. Wong, University of Michigan, Ann Arbor, MI; and Andrew S. Artz, University of Chicago, Chicago, IL
| | - Barnett S Kramer
- Jessica P. Hwang, University of Texas MD Anderson Cancer Center; Anita L. Sabichi, Baylor College of Medicine, Houston, TX; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; Devena E. Alston-Johnson, Upstate Oncology Associates, Greenville, SC; Donna R. Cryer, Global Liver Institute, Washington, DC; Jordan J. Feld, Toronto Western Hospital Liver Centre, Toronto, Ontario, Canada; Barnett S. Kramer, National Cancer Institute, Bethesda, MD; Sandra L. Wong, University of Michigan, Ann Arbor, MI; and Andrew S. Artz, University of Chicago, Chicago, IL
| | - Anita L Sabichi
- Jessica P. Hwang, University of Texas MD Anderson Cancer Center; Anita L. Sabichi, Baylor College of Medicine, Houston, TX; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; Devena E. Alston-Johnson, Upstate Oncology Associates, Greenville, SC; Donna R. Cryer, Global Liver Institute, Washington, DC; Jordan J. Feld, Toronto Western Hospital Liver Centre, Toronto, Ontario, Canada; Barnett S. Kramer, National Cancer Institute, Bethesda, MD; Sandra L. Wong, University of Michigan, Ann Arbor, MI; and Andrew S. Artz, University of Chicago, Chicago, IL
| | - Sandra L Wong
- Jessica P. Hwang, University of Texas MD Anderson Cancer Center; Anita L. Sabichi, Baylor College of Medicine, Houston, TX; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; Devena E. Alston-Johnson, Upstate Oncology Associates, Greenville, SC; Donna R. Cryer, Global Liver Institute, Washington, DC; Jordan J. Feld, Toronto Western Hospital Liver Centre, Toronto, Ontario, Canada; Barnett S. Kramer, National Cancer Institute, Bethesda, MD; Sandra L. Wong, University of Michigan, Ann Arbor, MI; and Andrew S. Artz, University of Chicago, Chicago, IL
| | - Andrew S Artz
- Jessica P. Hwang, University of Texas MD Anderson Cancer Center; Anita L. Sabichi, Baylor College of Medicine, Houston, TX; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; Devena E. Alston-Johnson, Upstate Oncology Associates, Greenville, SC; Donna R. Cryer, Global Liver Institute, Washington, DC; Jordan J. Feld, Toronto Western Hospital Liver Centre, Toronto, Ontario, Canada; Barnett S. Kramer, National Cancer Institute, Bethesda, MD; Sandra L. Wong, University of Michigan, Ann Arbor, MI; and Andrew S. Artz, University of Chicago, Chicago, IL
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22
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Riveiro-Barciela M, Artaza G, Abrisqueta P, Bosch F, Buti M. [Importance of hepatitis B virus screening in hematological patients]. GASTROENTEROLOGIA Y HEPATOLOGIA 2015; 38:563-4. [PMID: 25888287 DOI: 10.1016/j.gastrohep.2015.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 03/04/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Mar Riveiro-Barciela
- Servicio de Hepatología-Medicina Interna, Hospital Universitario Vall d'Hebron, Barcelona, España
| | - Gonzalo Artaza
- Servicio de Hematología. Hospital Universitario Vall d'Hebron, Barcelona, España
| | - Pau Abrisqueta
- Servicio de Hematología. Hospital Universitario Vall d'Hebron, Barcelona, España
| | - Francesc Bosch
- Servicio de Hematología. Hospital Universitario Vall d'Hebron, Barcelona, España
| | - María Buti
- Servicio de Hepatología-Medicina Interna, Hospital Universitario Vall d'Hebron, Barcelona, España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto Carlos III, España.
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23
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Sun WC, Hsu PI, Yu HC, Lin KH, Tsay FW, Wang HM, Tsai TJ, Chen WC, Lai KH, Cheng JS. The compliance of doctors with viral hepatitis B screening and antiviral prophylaxis in cancer patients receiving cytotoxic chemotherapy using a hospital-based screening reminder system. PLoS One 2015; 10:e0116978. [PMID: 25658926 PMCID: PMC4319781 DOI: 10.1371/journal.pone.0116978] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 12/17/2014] [Indexed: 12/29/2022] Open
Abstract
Background and Aim Screenings for hepatitis B surface antigen (HBsAg) and antiviral prophylaxis are recommended for HBsAg-positive patients before the start of cytotoxic chemotherapy; however, compliance with these recommendations varies among doctors. We investigated the compliance of doctors with these recommendations using a reminder system and assessed the outcomes of HBsAg-positive patients receiving cytotoxic chemotherapy. Methods Using a computer-assisted reminder system, doctors were alerted of both HBsAg screening and antiviral prophylaxis prior to prescribing chemotherapy. The compliance between different doctors and outcomes of patients were investigated during the period of execution of this system. The rates of compliance with both recommendations were compared among various cancer types. Results A total of 1053 patients were enrolled, of which only 88 had previous data pertaining to HBsAg status. Using this reminder system, an overall screening rate of 85.5% (825/965) was achieved and did not significantly differ according to cancer type. However, the overall antiviral prophylactic rate was only 45.5% (61/134). The rates of antiviral prophylaxis were lower for doctors treating lung, breast and colorectal cancers than for those treating hematological malignancies (all p<0.05). Consequently, the rate of HBV reactivation was lower in patients who received antiviral prophylaxis than in those who did not (1.6% vs. 15.1%; p<0.01). Multivariate analysis revealed that male gender and antiviral prophylaxis were both related to reactivation of hepatitis B (p<0.05). Conclusions By using this reminder system, the overall screening rate for HBsAg was satisfactory, whereas the antiviral prophylaxis was inadequate in patients with solid tumors due to the varying compliance of the attending doctors. Further strategies to improve both screening and prophylaxis are needed to minimize HBV-related events during cytotoxic chemotherapy.
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Affiliation(s)
- Wei-Chih Sun
- Division of Gastroenterology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- National Yang-Ming University, Taipei, Taiwan
| | - Ping-I Hsu
- Division of Gastroenterology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- National Yang-Ming University, Taipei, Taiwan
| | - Hsien-Chung Yu
- Division of Gastroenterology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- National Yang-Ming University, Taipei, Taiwan
- Department of Nursing, Meiho Institute of Technology, Ping-Tung, Taiwan
- * E-mail:
| | - Kung-Hung Lin
- Division of Gastroenterology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- National Yang-Ming University, Taipei, Taiwan
| | - Feng-Woei Tsay
- Division of Gastroenterology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- National Yang-Ming University, Taipei, Taiwan
| | - Huay-Min Wang
- Division of Gastroenterology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- National Yang-Ming University, Taipei, Taiwan
| | - Tzung-Jiun Tsai
- Division of Gastroenterology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- National Yang-Ming University, Taipei, Taiwan
| | - Wen-Chi Chen
- Division of Gastroenterology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- National Yang-Ming University, Taipei, Taiwan
| | - Kwok-Hung Lai
- Division of Gastroenterology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- National Yang-Ming University, Taipei, Taiwan
| | - Jin-Shiung Cheng
- Division of Gastroenterology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- National Yang-Ming University, Taipei, Taiwan
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24
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Dyson JK, Hudson M, McPherson S. Lesson of the month 2: Severe reactivation of hepatitis B after immunosuppressive chemotherapy. Clin Med (Lond) 2014; 14:551-5. [PMID: 25301924 PMCID: PMC4951972 DOI: 10.7861/clinmedicine.14-5-551] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Patients with current or past hepatitis B virus (HBV) infection are at risk of viral reactivation if they receive immune-modulating treatment or chemotherapy. This can range from subclinical elevation in HBV DNA levels, to abnormal liver function tests, to severe hepatitis with liver failure and risk of death. All patients should be screened for hepatitis B with surface antigen and core antibody before receiving immunosuppression. Patients with positive hepatitis B serology should be referred for specialist advice. Prophylactic antiviral treatment is recommended for patients with current/past hepatitis B who receive immunosuppressive chemotherapy.
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Affiliation(s)
- Jessica Katharine Dyson
- Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Mark Hudson
- Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust and Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Stuart McPherson
- Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust and Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
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