Hepatitis B Virus Screening and Management for Patients with Cancer Prior to Therapy

Publication Date: July 27, 2020


Key Recommendations


Key Recommendations

  • Screen all patients prior to starting systemic anticancer therapy with three tests: hepatitis B surface antigen (HBsAg), hepatitis B core antibody (anti-HBc, total Ig or IgG), and antibody to hepatitis B surface antigen (anti-HBs).
  • Patients with positive HBsAg or positive anti-HBc may require additional monitoring and/or antiviral treatment.

Diagnosis

All patients with cancer anticipating systemic anticancer therapy should be tested for HBV by three tests prior to, or at the beginning of, systemic anticancer therapy:
  • hepatitis B surface antigen (HBsAg)
  • hepatitis B core antibody (anti-HBc) total immunoglobulin (Ig) or IgG
  • antibody to hepatitis B surface antigen (anti-HBs)
(EB, S, B)
Note: Anticancer therapy should not be delayed for the results of these screening tests. Findings of chronic HBV (HBsAg-positive) or past HBV (HBsAg-negative and anti-HBc-positive with either negative or positive anti-HBs) infection require reactivation risk assessment.
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Treatment

Chronic HBV patients receiving any systemic anticancer therapy should receive antiviral prophylactic therapy for the duration of anticancer therapy, as well as for at least 12 months after receipt of the last anticancer therapy.
  • Monitoring recommendations include checking ALT and HBV DNA level at baseline prior to or at the beginning of their anticancer therapy, as well as every 6 months during antiviral therapy.
  • Hepatitis flares, presenting as elevated alanine aminotransferase (ALT) levels, can occur after the discontinuation of antiviral therapy.
    • As such, ALT levels should be monitored frequently, at least monthly for the first 3 months after the cessation of antiviral therapy and every 3 months thereafter.
  • Coordination of care with a clinician experienced in HBV management is highly recommended for chronic HBV patients, especially to monitor for withdrawal flares, determine monitoring and antiviral therapy after the cessation of anticancer therapy, and to evaluate for advanced liver disease such as cirrhosis or liver cancer.
(IC, S, B)
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Hormonal therapy without systemic anticancer therapy is unlikely to increase the risk of HBV reactivation in patients with chronic or past HBV.
  • Antiviral therapy and management for these patients should follow national HBV guidelines, independent of cancer therapy, including management by a clinician experienced in HBV management for prevention of liver disease such as cirrhosis or liver cancer.
  • Should their anticancer treatment regimen change beyond hormonal therapy alone, the risk of HBV reactivation based on their new anticancer therapy should be reassessed.
(IC, M, B)
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Patients with past HBV receiving anticancer therapies associated with an established high risk of HBV reactivation, such as anti-CD20 monoclonal antibodies or stem cell transplantation, should be started on antiviral prophylaxis at the beginning of anticancer therapy and continued on antiviral therapy for at least 12 months after the cessation of anticancer therapy.
  • HBV DNA should be obtained at baseline and followed every 6 months during antiviral therapy.
  • Patients with a negative anti-HBs may be at higher risk of HBV reactivation than patients who have a positive anti-HBs.
  • An alternative pathway is careful monitoring with HBsAg and HBV DNA every 3 months with immediate antiviral therapy at the earliest sign of HBV reactivation (appearance of HBsAg or HBV DNA ≥1000 IU/mL) so long as patients and providers are able to adhere to frequent and consistent follow up during anticancer therapy and for up to 12 months after last anticancer therapy (as delayed HBV reactivation may occur years after cessation of anticancer therapy).
  • If HBV DNA that is quantifiable but <1000 IU/mL, then repeat testing at monthly HBV-associated hepatitis flare intervals may be indicated.
  • Hepatitis flares, presenting as elevated ALT levels, can occur after the discontinuation of antiviral therapy.
    • As such, ALT levels should be monitored frequently, at least monthly for the first 3 months after the cessation of antiviral therapy and every 3 months thereafter.
(IC, S, B)
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Patients with past HBV undergoing anticancer therapies that are not clearly associated with a high risk of HBV reactivation (e.g., regimens that do not include anti-CD20 monoclonal antibodies or stem cell transplantation) should be followed carefully during cancer treatment, with HBsAg and ALT testing every 3 months (with subsequent HBV DNA testing if a hepatitis flare develops) with initiation of antiviral therapy only if HBsAg becomes positive or HBV DNA exceeds 1000 IU/mL in the setting of a hepatitis flare. (IC, S, B)
Note: Follow-up testing after the cessation of anticancer therapy is likely not necessary.
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Table 1. Definitions of HBV Reactivation and Outcomes

...efinitions of HBV Reactivation and Ou...

Table 2. Interpretation of HBV Test Results

...Interpretation of HBV Test ResultsHaving troubl...

Figure 1. Hepatitis B Virus Screening and Management for Patients with Cancer Prior to Therapy Algorithm

...Hepatitis B Virus Screening and Management for Pa...