Jul 27, 2020
An interview with Dr. Jessica Hwang from MD Anderson Cancer Center and Dr. Andrew Artz from City of Hope Cancer Center on “Hepatitis B Virus Screening and Management for Patients with Cancer Prior to Therapy: ASCO Provisional Clinical Opinion Update.” This update presents a clinically pragmatic approach to HBV screening and management that calls for universal HBV serological testing of patients at the onset of anticancer therapy. Read the full PCO at www.asco.org/supportive-care-guidelines
Transcript
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Hello, and welcome to the ASCO Guidelines podcast series brought to
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My name is Brittany Harvey. And today, I'm interviewing Dr. Jessica
Hwang from the University of Texas M.D. Anderson Cancer Center in
Houston, Texas, and Dr. Andrew Artz from the City of Hope
Comprehensive Cancer Center in Duarte, California, co-chairs on
hepatitis B screening and management for patients with cancer prior
to therapy, ASCO provisional clinical opinion update. Thank you for
being here, Dr. Hwang and Dr. Artz.
Thank you for inviting us.
Thank you so much.
First, I'd like to note that ASCO takes great care in the
development of its guideline products and ensuring that the ASCO
conflict of interest policy is followed. The full conflict of
interest information for this provisional clinical opinion panel is
available online with the publication in the Journal of Clinical
Oncology. Dr. Hwang, do you have any relevant disclosures that are
related to this topic?
Well, I have received some research funding from Gilead, a maker of
a hepatitis drug in the past.
And, Dr. Artz, do you have any relevant disclosures?
I have no relevant disclosures.
OK, then so, Dr. Artz, so this provisional clinical opinion, or
PCO, on hepatitis B screening and management for patients with
cancer prior to therapy was first published in 2010 and then last
updated in 2015. What prompted this update to the PCO?
This PCO guidance, more broadly, is necessary because the hepatitis
B status for most patients is actually unknown at the time they're
starting cancer therapy. In 2015, the PCO though suggested that we
limit hepatitis B screening to patients who were at most risk for
hepatitis B reactivation, if they were hepatitis B carriers, so
those receiving anti-CD20 antibodies, such as rituximab or stem
cell transplant. But for the remaining patients, most patients
receiving cancer therapy, the guidance was to survey patients about
their close contacts or exposures to hepatitis B and determine if
formal hepatitis testing should ensue.
This 2020 PCO represents an evolution in our understanding of
hepatitis B screening and the dangers of hepatitis B after
anticancer therapy. We've learned from studies, including those
done by my colleague, Dr. Hwang, that questionnaires to detect
hepatitis B are not very effective or practical. We also have
accumulating information that many of our anticancer therapies pose
a significant danger for hepatitis B related complications in
hepatitis B infected patients. We believe appropriate monitoring
and treatment, as outlined in the PCO, will reduce these
dangers.
So given that new information, I'd like to discuss the updated
statements for the PCO. So first, Dr. Hwang, for patients who will
receive systemic anticancer therapy, who should be tested for HBV
and how should they be tested?
That's a great question, Brittany. Thanks. I think that the data is
really clear now that all patients with cancer anticipating
systemic anticancer therapy should be tested for hepatitis B virus.
That includes all solid tumor patients, as well as hematologic
malignancy patients.
And they can be tested with a simple blood test. The hepatitis B
virus can be tested by three blood tests for hepatitis. It's the
hepatitis B surface antigen, HBsAG, or the hepatitis B core
antibody. There are two types of this. It's either the IgG or the
total IG, which shows, if positive, could indicate a patient has
past infection. There is a IgM version of that core antibody test.
And that tells, if positive, tells whether a patient has acute
infection. So for our purposes, it's recommended that the IgG or
total IG is used and not the IgM, because we are interested in
whether a patient has past infection.
So the third test is a hepatitis B surface antibody. And this is a
protective antibody. So if positive, it shows that a patient has
had some exposure in the past or perhaps a vaccination in the past.
And so this is a good test to have positive.
So then what does the PCO state for patients with chronic HBV
infection?
Patients with chronic HBV infection, that is those patients with a
positive hepatitis B surface antigen test, these patients really
should have very close monitoring during as well as after
anticancer therapy. These patients will need antiviral therapy
prophylactically prior to enduring as well as after the cancer
treatment. They should also see a clinician experienced in the
management of hepatitis B, whether it's a hepatologist, a
gastroenterologist, an infectious disease specialist, or maybe a
primary care doctor who's experienced in treating and caring and
monitoring for patients with hepatitis B. That's really important
for these patients with a chronic hepatitis B, because they are at
high risk of developing complications during and as well as perhaps
even shortly thereafter of receiving systemic anticancer
therapy.
And then what does the PCO state for patients with past HBV
infection?
This is a really good question. The patients with past HBV
infection are those who have a negative hepatitis B surface antigen
and a positive hepatitis B core antibody. This represents maybe
some 6% at least of the US population. It could be much higher. So
this is a sizable group of patients. And it's really important to
know that it is sort of a tailored approach.
So patients with past HBV infection who are anticipated to receive
one of the high risk anticancer therapies that Dr. Artz mentioned
just a few moments ago, namely stem cell transplantation or maybe
one of the anti-CD20 monoclonal antibodies, these patients are at
really high risk of reactivation. So these patients would need a
very close monitoring plan. They would need their hepatitis B and
liver test monitored during their anticancer therapy. And most
often they would need antiviral prophylaxis before, during, and
even after their immunosuppressive therapy ends.
So there are patients, of course, who don't receive these high-risk
therapies. So that is patients with past HBV infection who are
receiving anticancer therapy that's not a stem cell transplant and
not an anti-CD20 monoclonal antibody. These patients could be
monitored carefully. They could have hepatitis B and/or liver
testing monitoring during anticancer therapy. And if they have any
elevations in their surface antigen or their ALT, then they could
have further hepatitis B testing to see if they have any evidence
of complications from their hepatitis B. So that's in general what
the PCO recommends for these two groups.
Well, thank you for reviewing those highlights from the PCO. So Dr.
Artz, what is the importance of this PCO and how will its
implementation impact practice?
Thank you for the question. This PCO I feel dramatically simplifies
the challenge of hepatitis B screening by proposing universal
hepatitis B testing, as Dr. Hwang outlined, at a defined point in
time. That is at the initiation of therapy.
And clinicians have really struggled with hepatitis B testing for
lots of different reasons. They're difficulties in knowing who to
screen, how to screen, in part because the data have started to
emerge that many of the therapies may pose some risks and the prior
suggestion that we use questionnaires, but there wasn't a standard
set of questionnaires that we could use if we wanted to identify
people based on risk factors of acquiring hepatitis B. So this led
to a lot of confusion on testing.
I think by standardizing this makes it considerably easier. And
also, the guidance from the PCO is better harmonized with other
organizations, such as the Centers for Disease Control and our
Liver Society colleagues who actually participated in the panel.
And so now the guidance clinicians receive are more consistent
across organizations. So I think this will allow doctors and health
care systems overall to now invest in the implementation of
hepatitis B screening, rather than the question about who should we
do it and can we do it and when should we do it, but rather more on
the implementation to help patients.
Great. And then finally, what is the impact of this updated PCO for
patients?
Well, I'll take the first part of that. I believe that the
implementation should permit safer systemic anticancer therapy by
reducing hepatitis B related complications. Whenever patients have
complications or there's even uncertainty about whether hepatitis
might be contributing, this also can lead to delays in our
treatments. If we know in advance and we appropriately manage and
monitor this, we should have fewer treatment delays as well. Dr.
Hwang, I know, might also have some comments on this.
Thanks. I do have a few general comments beyond the cancer care
implications. And I'd like to say I think that hepatitis B testing
and then the results of that and sharing that information with
patients is really important. Letting patients know their hepatitis
B status, especially if they're positive, empowers them to seek
further care, get connected with a hepatitis B specialist person
who's experienced in managing hepatitis B, and also to look around
the local environment to their household and close contacts because
hepatitis B is a virus that is transmitted from person to person
through blood-borne sexual transmission and close family or
household contact.
So I think it's important for patients to know their status to
protect themselves during cancer therapy, as Dr. Artz mentioned,
but just in general for good health care for themselves and for
those around them. And in addition, I think that it's important for
the family members and those close contacts to then get screened
and perhaps even consider getting vaccinated if they haven't been
vaccinated.
Well, thank you both for your hard work on updating this PTO and
for taking the time to speak with me today, Dr. Hwang and Dr.
Artz.
Thank you, Brittany.
Thank you, Brittany.
And thank you to all of our listeners for tuning into the ASCO
Guidelines podcast series. To read the full provisional clinical
opinion go to www.asco.org/supportive-care-guidelines. This PCO
also has a companion cancer.net podcast episode. Cancer.net is the
patient information website of ASCO. And we encourage you to learn
more by tuning into their episode. You can find their podcast and
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