Physicians should consider screening patients belonging to groups at heightened risk for chronic HBV infections if highly immunosuppressive therapy is planned. Deaths from liver failure, resulting from hepatitis B activation, can occur in patients who had potentially been cured of their cancer.

The new protocol introduced at Memorial Sloan-Kettering Cancer Center (MSKCC; New York, NY USA), recommends screening all patients who will receive anticancer therapy, including hormonal therapy and high-dose steroids (equivalent to a cumulative dose of prednisolone of >80 mg). A retrospective review of the MSKCC experience found 23 documented cases of hepatitis B reactivation in cancer patients on immunosuppressive therapy in the previous three years. Four patients died, three of whom had solid tumors.

Under the new protocol, cancer patients are screened for hepatitis surface antigen (HBsAg), which indicates a chronic infection, and for hepatitis B core antibody (HBcAb), which indicates a previous infection. If either or both are positive, then patients also undergo a reflexive HBV DNA polymerase chain reaction (PCR) assay.

Patients who test positive for HBsAg and for HBV DNA PCR are started on prophylactic antiviral therapy, which continues throughout their cancer therapy and for 6 months after it ends. Patients who test negative for HBsAg and for HBV DNA PCR but test positive for HBcAb are not given prophylactic antiviral therapy, but are followed and retested with PCR every 3 months. If they are slated for a bone marrow transplant or fludarabine and cyclophosphamide therapy, they receive the HBV specific antiviral drug entecavir (Bristol-Myers Squibb, New York, NY, USA).

Of the 1,720 cancer patients who were screened, 18 patients (1.1%) tested positive for HBsAg, of whom 91% had solid tumors and 46% were Asian. There were 155 patients (9.2%) who tested positive for HBcAb, of whom 76% had solid tumors and 19% were Asian. Only half of those with evidence of HBV surface antigen were from regions endemic for HBV.

Emmy Ludwig, M.D., an MSKCC gastroenterologist, presented the new protocol in June, 2010 at the American Society of Clinical Oncology (ASCO) Annual Meeting held in Chicago, (IL, USA). "Our findings demonstrate that risk-group-based screening misses many patients who are at risk for reactivation. We therefore recommend other cancer centers implement a similar universal screening program,” Dr. Ludwig said.

Related Links:
Memorial Sloan-Kettering Cancer Center
Bristol-Myers Squibb