Although hepatitis B reactivation has been best studied in patients receiving chemotherapy for haematological malignancies, it has also been reported during the treatment of solid tumours.r
Based on the available literature and the accessibility of accurate HBV screening test, the Centres for Disease Control and Preventions (CDC)r, the American Association for the study of Liver Diseases (AASLD)r and the 2008 National Institutes of Health Consensus Development Conference on Hepatitis Br all recommend universal screening of patients for Hepatitis B prior to receiving chemotherapy or immunosuppressive therapy. Those that are HBsAg positive should receive pre-emptive antiviral therapy. Those that are HBV naive should be immunised against hepatitis B, as should BMT donors.
The European Association for the Study of the Liver (EASL) recommends that HBsAg-positive patients receiving chemotherapy or immunosuppressive therapy (including the established and emerging range of biological response modifiers) be screened for HBsAg and anti-HBc prior to the initiation of treatment.r
In 2011, Day at alr sought to determine the practice of Australian oncologists with regard to HBV screening in patients with solid tumours and their clinical experience of HBV reactivation. They concluded a 19% universal prechemotherapy HBV screening rate among Australian oncologists is similar to the findings of the pooled haematologist and oncologist surveys from the United States, which reported respective universal testing rates of 13% and 14%.rr
Additionally, in 2010 the American Society of Clinical Oncology (ASCO)r produced a Provisional Clinical Opinion that does not support universal HBV screening. The ASCO Opinion take a less aggressive approach stating that the evidence is insufficient to support routine screening for chronic HBV infection in individuals who will receive chemotherapy or immunosuppressive. ASCO instead suggest that HBV screening requires clinical judgement and to consider screening patients in “high- risk” groups or those who require intensive immunosuppressive therapy including but not limited to BMT and regimens including rituximab. Supporting this was an Australian paper by Day et al,r which suggested that testing for all HBV serology markers in patients with solid tumours is not cost effective, and each physician individually should decide whether or not to screen for HBV.
HBsAg positive patients are usually asymptomatic, with many not recognising that they are infected. Current assays for HBsAg and anti-HBc are sensitive, specific, inexpensive and widely available. As effective treatment exists to prevent HBV reactivation if started early, and given the inaccuracies in ascertaining risks for HBV infection, we recommend the adoption of routine HBV screening of all haematology patients, including those being treated with an immunosuppressive monoclonal antibody therapy (e.g. rituximab) and those patients with solid tumours receiving curative treatment ONLY, before starting chemotherapy or immunosuppressive therapies. Screening can potentially reduce not only the incidence of HBV reactivation, but also HBV-related morbidity and mortality.
Different combinations of serology markers are used to determine the clinical status of the hepatitis B infections. For more information link to Interpretation of hepatitis B serologic test results.r