1Jessica P. Hwang, University of Texas MD Anderson Cancer Center; Anita L. Sabichi, Baylor College of Medicine, Houston, TX; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; Devena E. Alston-Johnson, Upstate Oncology Associates, Greenville, SC; Donna R. Cryer, Global Liver Institute, Washington, DC; Jordan J. Feld, Toronto Western Hospital Liver Centre, Toronto, Ontario, Canada; Barnett S. Kramer, National Cancer Institute, Bethesda, MD; Sandra L. Wong, University of Michigan, Ann Arbor, MI; and Andrew S. Artz, University of Chicago, Chicago, IL.
This updated provisional clinical opinion presents a revised opinion based on American Society of Clinical Oncology panel consensus in the context of an evolving database.
Despite the 2010 provisional clinical opinion recommendation, there is still evidence of suboptimal hepatitis B virus (HBV) screening among patients at high risk for HBV infection or HBV reactivation after chemotherapy. This updated provisional clinical opinion introduces a risk-adaptive strategy to identify and treat patients with HBV infection to reduce their risk of HBV reactivation.
PROVISIONAL CLINICAL OPINION:
Medical providers should screen by testing patients for HBV infection before starting anti-CD20 therapy or hematopoietic cell transplantation. Providers should also screen patients with risk factors for HBV infection. Screening should include both hepatitis B surface antigen (HBsAg) and hepatitis B core antibody (anti-HBc), because reactivation can occur in patients who are HBsAg positive/anti-HBc positive or HBsAg negative/anti-HBc positive. Either total anti-HBc or anti-HBc immunoglobulin G (not immunoglobulin M) test should be used. Clinicians should start antiviral therapy for HBsAg-positive/anti-HBc-positive patients before or contemporaneously with cancer therapy and monitor HBsAg-negative/anti-HBc-positive patients for reactivation with HBV DNA and ALT levels, promptly starting antivirals if reactivation occurs. Clinicians can initiate antivirals for HBsAg-negative/anti-HBc-positive patients anticipating cancer therapies associated with a high risk of reactivation, or they can monitor HBV DNA and ALT levels and initiate on-demand antivirals. For patients who neither have HBV risk factors nor anticipate cancer therapy associated with a high risk of reactivation, current evidence does not support HBV screening before initiation of cancer therapy. Two panel members provided a minority viewpoint, involving a strategy of universal HBsAg and selective anti-HBc testing.