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. Patients who have isolated anti-HBc may need further work-up because the HBV management for these patients depends on the type of anticancer therapy administered. July 27, 2020. Anti-HBs also develops in a person who has been successfully vaccinated against hepatitis B. Epub 2020 Oct 9. CancerLinQ ASCO published an updated PCO on this topic in 2015 that introduced a risk-adaptive clinical algorithm to help clinicians identify and treat patients with HBV infection to reduce their risk of HBV reactivation from anticancer therapy.2 This 2020 PCO update presents a clinically pragmatic approach to HBV screening and management that calls for universal HBV serologic testing of patients at the onset of anticancer therapy. 1 It is not part of the routine blood tests done by your doctor, so you need to ask for a test. Patients who are found to have chronic HBV infection should be informed of their status. See Table 3 for details of the HBV conditions based on screening test results. Past HBV infection refers to patients who have a negative HBsAg with positive anti-HBc, regardless of anti-HBs status; HBV DNA is usually undetectable. Notably, 2 panel members in 2015 offered a minority viewpoint, namely, a strategy of universal HBsAg and selective anti-HBc testing. Medical experts and public health agencies opinions can differ All members of the Expert Panel completed ASCO’s disclosure form, which requires disclosure of financial and other interests, including relationships with commercial entities that are reasonably likely to experience direct regulatory or commercial impact as a result of promulgation of the guideline. Subscribers Contact Us Permissions, Authors ASCO Connection COVID-19 is an emerging, rapidly evolving situation. A positive anti-HBs test likely attenuates the risk of reactivation in patients with past HBV infection (see text for details). While prospective studies are needed, they would likely be impractical; thus, large, multicenter retrospective studies with long-term follow-up may be a preferred option. Electronic address: email@example.com, et al. New patient leaflets about hepatitis B will be available soon Those of you who work in the NHS and deliver the NHS infectious diseases in pregnancy screening (IDPS) programme will be aware of the hepatitis B quality improvement project, which aims to significantly improve the care and services for pregnant women living with hepatitis B and their babies. Apply for and manage the VA benefits and services you’ve earned as a Veteran, Servicemember, or family member—like health care, disability, education, and more. All patients with cancer anticipating systemic anticancer therapy should be tested for hepatitis B virus (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 (anti-HBs)—prior to, or at the beginning of, systemic anticancer therapy. Monitoring recommendations include checking alanine aminotransferase (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. As a result, the reliability of outcome data from these studies may be limited, thereby creating constraints for expert groups to make recommendations for care in this heterogeneous patient population. were Expert Panel co-chairs. Administrative support: Mark R. Somerfield, Collection and assembly of data: Jessica P. Hwang, Mark R. Somerfield, Andrew S. Artz, Data analysis and interpretation: All authors, Final approval of manuscript: All authors, Accountable for all aspects of the work: All authors. The pattern of test results can identify a person who has a current active infection, was exposed to HBV in the past, or has immunity as a result of vaccination. Hepatitis flares, presenting as elevated ALT levels, can occur after the discontinuation of antiviral therapy. Hepatitis D is a defective virus that requires hepatitis B to replicate and is only found with hepatitis B co-infection. Categories for disclosure include employment; leadership; stock or other ownership; honoraria, consulting or advisory role; speaker's bureau; research funding; patents, royalties, other intellectual property; expert testimony; travel, accommodations, expenses; and other relationships. European Association for the Study of the Liver. Using bootstrapping methods, the investigators developed various models to determine the most efficient number and type of HBV risk questions to minimize the false-negative rate so that patients with HBV would not be missed, as this would be potentially devastating after anticancer therapy. | Most published efforts use electronic health records (EHR). There were no cases of clinical hepatitis, liver failure, or death. Patients who are negative for all HBV screening tests (negative HBsAg, anti-HBc, and anti-HBs) are considered not to be immune to HBV, have never been exposed to HBV, and may benefit from HBV vaccination,14 taking into consideration a patient’s clinical situation and timing of anticancer therapy. Patients with chronic HBV 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. These patients should start antiviral prophylaxis prior to anticancer therapy and continue it at least 12 months after the end of anticancer therapy and even longer, as their cumulative risk of reactivation increases until nearly 2 years after the cessation of anticancer therapy. Effective Date: October 14, 2020 Applicable Codes The following list(s) of procedure and/or diagnosis codes is (|) Hepatitis flare: alanine aminotransferase (ALT) > 100 U/mL and 3 times baseline.17 (¶) 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.11,17 An HBV specialist is a clinician experienced in HBV management. Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or Table 4 summarizes the methods and results of the 6 cost-effectiveness analyses identified by the targeted literature search. All changes were incorporated prior to Clinical Practice Guidelines Committee review and approval. 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. It is not only the standard of care for HBV screening aligned with public health guidelines,12 but a positive anti-HBs likely attenuates the risk of HBV reactivation in patients with past HBV infection.17 In a meta-analysis of 20 studies involving 1,672 patients with hematologic malignancies, the reactivation risk was 14% in 388 patients who were anti-HBc–positive and anti-HBs–negative and 5% in 1,284 patients who were anti-HBc–positive and anti-HBs–positive.19 Other studies have shown that the timing and presence of anti-HBs at baseline before anticancer therapy,20 as well as a high titer of anti-HBs,21 is protective against HBV reactivation among patients with hematologic malignancies. In our PCO (Fig 1), we use a simplified cut-off threshold of HBV DNA > 1,000 IU/mL to assist and guide oncology providers with respect to the threshold above which further management is warranted in patients with past HBV infection. In another prospective study, Hwang et al3 explored a broader set of HBV risk factors in a study of 2,124 patients with a hematologic malignancy or a solid tumor awaiting systemic anticancer therapy over a 17-month period during 2013-2014 in Houston, Texas. The Clinical Practice Guidelines and other guidance published herein are provided by the American Society of Clinical Oncology, Inc. (ASCO) to assist providers in clinical decision making. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST. 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. ASCO Author Services Archive The PCO was sent for an open comment period of 2 weeks, allowing the public to review and comment on the recommendations after submitting a confidentiality agreement. However, in this latter group, the optimal timing for the antiviral initiation is not yet clear, as strong data about the risk of HBV reactivation due to various anticancer therapies are not available. Studies of patients with solid tumors, by contrast, at lower risk of HBV reactivation due to the treatments received, have been less consistent. doi: 10.1097/MD.0000000000020600. Open Payments is a public database containing information reported by companies about payments made to US-licensed physicians (Open Payments). The consistency of the results from studies estimating the cost effectiveness of different screening or prophylaxis approaches varies depending on the population studied. 2008 Oct;(174):1-671. 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 ≥ 1,000 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). Epub 2017 Sep 28. Monitoring recommendations include checking alanine aminotransferase (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. Previous immunotherapy clinical trials excluded patients with HBV; however, a few case reports of HBV reactivation have been published.38,39 Recently, a prospective study followed 129 HBsAg-positive patients after PD-1 blockade.40 Among those who had undetectable HBV DNA and had not been on antiviral therapy at baseline, the rate of HBV reactivation was 21% (5/24). 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. HBV DNA should be obtained at baseline and followed every 6 months during antiviral therapy. Serologic testing for Hepatitis B surface antigen (HBsAg) is the primary way to identify persons chronic HBV infection. A simple blood test can also determine if you're immune to the condition. 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