CHICAGO—Routine screening for hepatitis B virus (HBV) in all patients being started on immunosuppressive therapy uncovers a significant percentage with HBV surface antigen (HBsAg) and HBV core antibody (HBcAb), said Emmy Ludwig, MD, at the 2010 annual meeting of the American Society of Clinical Oncology (ASCO).
As such, she recommends a universal screening program for HBV at all cancer centers. Chemotherapy and immuno suppressive drugs can cause reactivation of HBV in persons who have the virus, with morbid and potentially fatal consequences.
The recommendation for universal screening in this population is at odds with ASCO, which recently issued a provisional clinical opinion stating that the net benefits and harms of routine screening for HBV are not known for cancer patients who are about to receive cytotoxic or immunosuppressive therapy as part of their cancer therapy. The official stance of ASCO, therefore, is that HBV screening in cancer patients requires clinical judgment. The opinion was published online on June 1 in the Journal of Clinical Oncology.
All patients at Memorial Sloan- Kettering Cancer Center who were started on immunosuppressive therapy (chemo therapy and/or corticosteroids) were screened for HBV from June to December 2009, consisting of serologies for HBsAg and HBcAb and subsequent measurement of HBV polymerase chain reaction (PCR) if either test was positive.
The screening program was begun after Ludwig and her colleagues identified cases in their center in which HBV was reactivated after immunosuppressive therapy, four of whom died (three who had solid tumors) and 19 of whom were hospitalized (one who required liver transplant). Two of the patients were being treated with steroids.
In all, 1720 patients were screened prior to immunosuppressive therapy. During those 6 months, 1.1% were positive for HBsAg and 9.2% were positive for HBcAb. Less than half with HBsAg were born in Asia, where HBV is pandemic. More than nine (91%) of 10 positive tests were in patients with a solid tumor.
Four of the 155 patients in whom HBcAb was positive but HBsAg was negative had a positive HBV PCR, meaning that new HBV was being made despite the negative HBsAg test.
If screening was positive, patients were treated with prophylactic antiviral therapy with entecavir, 0.5 mg/day, which has proved 100% effective in preventing reactivation, said Ludwig, a gastroenterologist at Memorial-Sloan Kettering. Entecavir prophylaxis is given for the entire duration of cancer therapy and continued for an additional 6 months.