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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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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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