From the Guidelines
Patients receiving chemotherapy should be screened for hepatitis B virus (HBV) and hepatitis C virus (HCV) prior to starting treatment. For HBV, screening should include hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (anti-HBs), and hepatitis B core antibody (anti-HBc) 1. The most recent and highest quality study recommends that screening for HBsAg and anti-HBc before immunosuppression or chemotherapy is necessary, and if either is positive, HBV DNA testing should be performed 1.
Key Points to Consider:
- HBV reactivation can occur in patients with HBsAg-positive or HBsAg-negative and anti-HBc-positive status, especially when immunosuppressed 1.
- Antiviral prophylaxis should be initiated before or at the start of immunosuppression or chemotherapy if HBsAg is positive or HBV DNA is detected 1.
- The choice of antiviral agent should be based on comprehensive consideration of serum HBV DNA levels, the intensity and duration of immunosuppression or chemotherapy, and the cost 1.
- Prophylactic antiviral therapy should be maintained for at least 6 months after the termination of immunosuppression or chemotherapy and for at least 12 months after the termination of therapy if rituximab was included 1.
- For HCV-positive patients, the risk of reactivation is lower than with HBV, but monitoring liver function tests during chemotherapy is recommended 1.
- Hepatitis A virus (HAV) screening is not routinely recommended before chemotherapy, as it does not cause chronic infection or reactivation. In terms of specific antiviral therapy, entecavir 0.5 mg daily or tenofovir 300 mg daily can be used for prophylaxis 1. It is essential to note that the risk of HBV reactivation is high when prophylactic lamivudine is discontinued about 3 months after the end of chemotherapy, especially when the serum HBV DNA prior to the treatment is elevated 1. Therefore, patients who test positive for HBsAg or anti-HBc should receive prophylactic antiviral therapy before starting chemotherapy and continuing for at least 6-12 months after completion of chemotherapy. Regular monitoring of serum HBV DNA is recommended during and after prophylactic antiviral therapy to prevent relapse 1. By following these guidelines, the risk of HBV reactivation and its associated morbidity and mortality can be minimized in patients receiving chemotherapy.
From the FDA Drug Label
Test all patients for evidence of current or prior HBV infection by measuring HBsAg and anti-HBc before initiating HCV treatment with SOVALDI HBV reactivation has also been reported in patients receiving certain immunosuppressant or chemotherapeutic agents;
In someone receiving chemotherapy, you should screen for Hepatitis B Virus (HBV).
- The screening should include measuring HBsAg and anti-HBc to check for evidence of current or prior HBV infection 2.
From the Research
Hepatitis Viruses to Screen for in Chemotherapy Patients
The following hepatitis viruses should be screened for in patients receiving chemotherapy:
Rationale for Screening
Screening for HBV is crucial because reactivation can occur in up to 78% of patients receiving cytotoxic chemotherapy for nonhepatic malignancies, leading to hepatic dysfunction, jaundice, and fulminant hepatic failure 3. HBV reactivation can be effectively prevented by antiviral prophylaxis 4.
Screening Practices
Current recommendations include screening patients at risk for HBV prior to immunosuppressive therapy and initiating antiviral prophylaxis in patients with chronic HBV 3. However, studies have shown that HBV screening among patients undergoing cancer chemotherapy is suboptimal, especially in community oncology clinics 5.
Risk Factors for Reactivation
Patients with hematologic tumors, those receiving chemotherapy with higher HBV reactivation risk, and those with age ≥ 50 years or Asian ethnicity are at increased risk for HBV reactivation 5, 6.
Management of Reactivation
Antiviral prophylaxis can reduce the risk for HBV reactivation, HBV-related hepatitis, and chemotherapy interruption 6. Monitoring anti-HBs levels may help identify patients at risk for clinically significant HBV reactivation 7.