Hepatitis B Virus Screening and Management for Patients With Cancer Prior to Therapy: ASCO Provisional Clinical Opinion Update

Abstract

Purpose: This Provisional Clinical Opinion update presents a clinically pragmatic approach to hepatitis B virus (HBV) screening and management.

Provisional clinical opinion: All patients anticipating systemic anticancer therapy should be tested for HBV by 3 tests-hepatitis B surface antigen (HBsAg), hepatitis B core antibody (anti-HBc) total immunoglobulin (Ig) or IgG, and antibody to hepatitis B surface antigen-but anticancer therapy should not be delayed. Findings of chronic HBV (HBsAg-positive) or past HBV (HBsAg-negative and anti-HBc-positive) infection require HBV reactivation risk assessment.Patients with chronic HBV receiving any systemic anticancer therapy should receive antiviral prophylactic therapy through and for minimum 12 months following anticancer therapy. Hormonal therapy alone should not pose a substantial risk of HBV reactivation in patients with chronic HBV receiving hormonal therapy alone; these patients may follow noncancer HBV monitoring and treatment guidance. Coordination of care with a clinician experienced in HBV management is recommended for patients with chronic HBV to determine HBV monitoring and long-term antiviral therapy after completion of anticancer therapy.Patients with past HBV infection undergoing anticancer therapies associated with a high risk of HBV reactivation, such as anti-CD20 monoclonal antibodies or stem-cell transplantation, should receive antiviral prophylaxis during and for minimum 12 months after anticancer therapy completion, with individualized management thereafter. Careful monitoring may be an alternative if patients and providers can adhere to frequent, consistent follow-up so antiviral therapy may begin at the earliest sign of reactivation. Patients with past HBV undergoing other systemic anticancer therapies not clearly associated with a high risk of HBV reactivation should be monitored with HBsAg and alanine aminotransferase during cancer treatment; antiviral therapy should commence if HBV reactivation occurs.Additional information is available at www.asco.org/supportive-care-guidelines.

Fig 1.

(*) Evidence of hepatitis B virus (HBV) infection refers to hepatitis B surface antigen (HBsAg)–positive or hepatitis B core antibody (HBc)–positive (either total immunoglobulin [Ig] or IgG; do not order IgM unless acute HBV infection is suspected). If evidence of HBV infection, do not delay anticancer therapy while obtaining further testing or referrals. See Table 3 for details for serologic interpretation of HBV screening tests. (†) Past HBV: HBsAg-negative, anti-HBc–positive, regardless of anti-HBs status. A positive anti-HBs test likely attenuates the risk of reactivation in patients with past HBV infection (see text for details). (‡) All other systemic anticancer therapy besides anti-CD20 therapy or stem-cell transplantation. Due to the lack of strong data, the risk of HBV reactivation is unclear for specific anticancer drugs besides anti-CD20 therapy or stem-cell transplantation. It is possible that these anticancer therapies have a low risk of reactivation for patients with past HBV infection and may not require routine monitoring. (§) 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 so long as patients and providers are able to adhere to frequent and consistent follow-up during and for up to 12 months after last anticancer therapy (see text for details). (|) Hepatitis flare: alanine aminotransferase (ALT) > 100 U/mL and 3 times baseline. (¶) Long-term antiviral therapy management for patients with cancer after the cessation of anticancer therapy should follow national hepatology recommendations for all patients with chronic HBV.^, An HBV specialist is a clinician experienced in HBV management.