Original article
Pancreas, biliary tract, and liver
Low Level of Hepatitis B Virus Screening Among Patients Receiving Chemotherapy

https://doi.org/10.1016/j.cgh.2014.10.032Get rights and content

Background & Aims

Chemotherapy of patients with inactive hepatitis B virus (HBV) infection can lead to viral reactivation and hepatitis flares. We investigated the proportion of patients screened for HBV infection before chemotherapy over time and the outcomes of screened patients.

Methods

In a retrospective study, we collected data from a pharmacy database on patients who underwent cytotoxic chemotherapy for solid or hematologic malignancies at the Mayo Clinic in Rochester, Minnesota, from January 1, 2006, through September 30, 2011. Laboratory data were collected from electronic medical records. Screening was identified based on tests for hepatitis B surface antigen, for any reason at any time before chemotherapy.

Results

Of 8005 patients undergoing chemotherapy, 1279 (16%) were screened for HBV infection before chemotherapy, including 668 of 1805 patients with hematologic malignancies (37%). The proportion of patients screened for HBV increased from 14.3% in 2006 to 2008 to 17.7% in 2009 to 2011 (P < .01). This trend was attributed mostly to an increase in the proportion of patients with hematologic malignancies, from 32.7% in 2006 to 2008 to 40.6% in 2009 to 2011 (P < .01). Of 13 patients who tested positive for HBV, 5 did not receive prophylactic antiviral therapy; HBV infection was reactivated in 2 of these patients. None of the 8 patients who received an antiviral agent before chemotherapy experienced HBV reactivation. Of 58 unscreened patients who had increases in their alanine aminotransferase level (>300 U/L), only 1 patient appeared to have an undiagnosed HBV infection.

Conclusions

Only a small percentage of patients receiving chemotherapy are screened for HBV infection. However, a larger proportion of patients was screened during 2009 to 2011 than during 2006 to 2008, especially patients with hematologic malignancies. Strategies are needed to ensure that patients receiving chemotherapy are protected from the consequences of undiagnosed HBV infection.

Section snippets

Data Sources

After approval was obtained from the Institutional Review Board of the Mayo Clinic, an electronic pharmacy database was queried to identify a cohort of patients who underwent cytotoxic chemotherapy as an outpatient for the first time at the Mayo Clinic (Rochester, MN) between January 1, 2006, and September 30, 2011. Pharmaceutical agents or antibodies that may suppress the immune system such as high-dose steroids were included, whereas antibodies that do not affect immune function such as

Results

During the study period, 8005 patients initiated chemotherapy, 23% (n = 1805) of whom had hematologic malignancies. The median age was 61 years (interquartile range [IQR], 51.4–70.0 y) and men accounted for 50.8% (n = 4064). In Table 1, screening for HBV before chemotherapy occurred in 1279 (16%) patients, including 668 (37%) with hematologic malignancies. The median interval between HBV testing and initiation of chemotherapy was approximately 6 months (0.46 y; IQR, 0.06–4.10). In addition, 523

Discussion

In this study, we analyzed a cohort of patients undergoing chemotherapy and assessed screening for HBV infection and the resultant outcome. The main findings included the following: (1) the overall frequency of testing, be it for screening or diagnostic purposes, was low with fewer than a quarter of the patients ever being tested for HBV before or after initiation of chemotherapy; although screening did increase over time, mostly among patients with hematologic malignancies; (2) in addition to

References (15)

  • G.K. Lau et al.

    Early is superior to deferred preemptive lamivudine therapy for hepatitis B patients undergoing chemotherapy

    Gastroenterology

    (2003)
  • C. Hsu et al.

    A revisit of prophylactic lamivudine for chemotherapy-associated hepatitis B reactivation in non-Hodgkin's lymphoma: a randomized trial

    Hepatology

    (2008)
  • C.M. Weinbaum et al.

    Recommendations for identification and public health management of persons with chronic hepatitis B virus infection

    MMWR Morb Mortal Wkly Rep

    (2008)
  • A.S. Lok et al.

    Chronic hepatitis B: update 2009

    Hepatology

    (2009)
  • A.S. Artz et al.

    American Society of Clinical Oncology provisional clinical opinion: chronic hepatitis B virus infection screening in patients receiving cytotoxic chemotherapy for treatment of malignant diseases

    J Clin Oncol

    (2010)
  • F.L. Day et al.

    Cost-effectiveness of universal hepatitis B virus screening in patients beginning chemotherapy for solid tumors

    J Clin Oncol

    (2011)
  • U. Zurawska et al.

    Hepatitis B virus screening before chemotherapy for lymphoma: a cost-effectiveness analysis

    J Clin Oncol

    (2012)
There are more references available in the full text version of this article.

Cited by (25)

  • Cost-Effectiveness Analysis of Screening for Hepatitis B Virus Infection in Patients With Solid Tumors Before Initiating Chemotherapy

    2020, Clinical Gastroenterology and Hepatology
    Citation Excerpt :

    Our analyses remained robust to these assumptions. Importantly, we modeled a 10% rate of HBV screening in high-risk patients, which is consistent with population-based estimates.9,10 Even at rates of HBV screening more than twice this value, a screen all strategy was preferred.

  • Reactivation of hepatitis B virus in cancer patients treated with chemotherapy for solid tumors. Is the prophylaxis really required?

    2017, Digestive and Liver Disease
    Citation Excerpt :

    The magnitude of risk for clinically significant hepatitis B virus reactivation with chemotherapy for non-hematological tumors is not fully clear. Indeed, chemotherapy for solid tumors is carried out with drugs that have a minor documented effect on immune system, if compared to drugs used in hematologic malignancies [9–15,20–22]. The rate of HBV reactivation is higher in patients with breast cancer (41–56%) [23–26], and appears to be lower in those treated for other solid tumors (14–21%) [27–29].

View all citing articles on Scopus

This article has an accompanying continuing medical education activity on page e51. Learning Objective–Upon completion of this activity, successful learners will be able to identify factors associated with screening for HBV in patients receiving chemotherapy.

Conflicts of interest The authors disclose no conflicts.

Funding This work was supported by grants from the National Institutes of Health (DK-82843 and DK-92336).

View full text