From the Guidelines
The management of a patient with positive hepatitis B total core antibody (anti-HBc), negative hepatitis B surface antigen (HBsAg), negative hepatitis B core IgM, and negative hepatitis B surface IgM involves monitoring, as the risk of reactivation is unclear for specific anticancer drugs besides anti-CD20 therapy or stem-cell transplantation, according to the 2020 ASCO provisional clinical opinion update 1.
Key Considerations
- The patient's serological profile suggests past HBV infection, as indicated by the presence of anti-HBc and the absence of HBsAg, hepatitis B core IgM, and hepatitis B surface IgM.
- The ASCO guidelines recommend monitoring for patients with past HBV infection (HBsAg-negative, anti-HBc–positive) who are undergoing anticancer therapy, with the exception of anti-CD20 therapy or stem-cell transplantation, which require antiviral prophylaxis 1.
- The guidelines suggest checking HBsAg and ALT at baseline and every 3 months during anticancer therapy for patients with past HBV infection, and starting antiviral therapy immediately if HBsAg becomes positive 1.
Management Approach
- For patients with isolated anti-HBc positivity, the risk of HBV reactivation is unclear, and the decision to monitor or provide antiviral prophylaxis should be individualized based on the specific anticancer therapy and patient factors.
- If anti-HBs is positive, this indicates resolved hepatitis B infection with immunity, and no specific treatment is needed.
- If anti-HBs is negative, consider testing for hepatitis B viral DNA (HBV DNA) to rule out occult hepatitis B infection.
- Prophylactic antiviral therapy with entecavir 0.5 mg daily or tenofovir 300 mg daily may be considered for immunocompromised patients or those starting immunosuppressive therapy to prevent viral reactivation, as suggested by the ASCO guidelines 1.
From the Research
Management of Positive Hepatitis B Total Core Antibody
Negative Hepatitis B Surface Antigen, Negative Hepatitis B Core IgM, Negative Hepatitis B Surface IgM
- The management of patients with positive hepatitis B total core antibody, negative hepatitis B surface antigen, negative hepatitis B core IgM, and negative hepatitis B surface IgM is a complex issue [(2,3,4,5,6)].
- Studies have shown that patients with isolated anti-HBc (positive hepatitis B core antibody and negative hepatitis B surface antigen) have a low rate of reactivation 3.
- The level of anti-HBc has been associated with the seroclearance of HBV DNA and HBsAg in HBeAg-negative patients [(2,5)].
- A low level of anti-HBc (<3 log IU/mL) has been shown to be a predictor of HBsAg seroclearance 2.
- The combination of anti-HBc level and baseline HBsAg can identify patients who are more likely to achieve HBsAg clearance after treatment 5.
- Patients with isolated anti-HBc are at risk of occult HBV infection and HBV reactivation during immune suppression 6.
- The clinical significance of isolated anti-HBc is still a topic of debate, and further studies are needed to fully understand its implications 6.
- The detection of HBsAg, anti-HBcIgM, and anti-HBcIgG is important for the clinical classification and epidemiological surveillance of HBV infection 4.
- The sensitivity and specificity of these serological markers can vary, and their interpretation requires careful consideration of the patient's clinical history and epidemiological context 4.