Screening for Hepatitis B Virus Before Cancer Treatment, with Andrew Artz, MD, MS, and Jessica Hwang, MD, MPH

July 27, 2020
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In this podcast, Dr. Andrew Artz and Dr. Jessica Hwang discuss ASCO's updated provisional clinical opinion on hepatitis B virus screening and management for patients with cancer prior to therapy.



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Brielle Gregory: Hi, everyone. I'm Brielle Gregory, a member of the Cancer.Net content team, and I'll be your host for today's Cancer.Net podcast. Cancer.Net is the patient information website of ASCO, the American Society of Clinical Oncology. Today we're going to be talking about hepatitis B virus. Our guests are Dr. Andrew Artz and Dr. Jessica Hwang. Dr. Artz is an associate clinical professor in the Department of Hematology and Hematopoietic Cell Transplantation, the director of the Program for Aging and Blood Cancers, and the deputy director of the Center for Cancer and Aging at City of Hope Comprehensive Cancer Center in Duarte, California. Dr. Hwang is a tenured professor in the Department of General Internal Medicine in the Division of Internal Medicine at the University of Texas MD Anderson Cancer Center in Houston, Texas. Thanks for joining us today, Dr. Artz and Dr. Hwang.

Dr. Hwang: Thank you, Brielle. Nice to be here.

Dr. Artz: Yes. Likewise, Brielle. Thank you so much.

Brielle Gregory: Today ASCO is publishing a new provisional clinical opinion on hepatitis B virus screening and management for patients with cancer prior to therapy. Dr. Artz and Dr. Hwang served as the co-chairs for this provisional clinical opinion. Before we begin, we should mention that Dr. Artz has no relationships to disclose related to this provisional clinical opinion and Dr. Hwang has one relationship to disclose. Their full disclosure statements can be found on Cancer.Net.

Now, let's talk a little bit about what this provisional clinical opinion means for people with cancer and those who care for them. Dr. Artz, to begin, what is a provisional clinical opinion and how does it influence cancer care?

Dr. Artz; Yes. Absolutely. We appreciate that new information develops very quickly in oncology, and provisional clinical opinions are really a way to respond to the rapid information accumulation in the field. They're evidence-based guidances, and they're meant to offer timely direction to the ASCO membership, which means the physicians and the other providers in the oncology team. Usually it follows practice-changing information, and then there may be updates. Such is the case for this PCO, which was initiated in 2010, updated in 2015, and now we have the next version, the 2020 update that we're discussing today.

Brielle Gregory: So basically, these opinions are updates with the latest information to make sure that patients are getting the most up-to-date care as possible. Is that correct?

Dr. Artz: Yes. Absolutely.

Brielle Gregory: And Dr. Hwang, can you define for us what hepatitis B virus is and how it's connected to cancer?

Dr. Hwang: Hepatitis B virus infects the liver. In an acute setting, it can cause jaundice or yellowing of the eyes, yellowing of the skin, nausea, vomiting, abdominal pain. So that's really the acute phase. But oftentimes hepatitis can infect a person and not even cause any symptoms. This is a troublesome virus that can infect the liver, and once it infects the liver, it can live latently or very quietly in the liver for a long time, and maybe sometimes not even cause problems in certain people. But it can cause some really serious problems, like cirrhosis, which is hardening of the liver. It can even lead to liver cancer and a lot of complications from that because it's very difficult to control at that point.

But what I want to bring to mind today in our discussion is that hepatitis B can linger in a person's liver once infected. And should that person require some sorts of medication that would weaken the immune system - say, for instance, cancer treatments or chemotherapy or one of the newer agents - it's possible that a person's weakened immune system would allow the virus to just start growing and replicating and not be checked. And that can lead to liver complications during, as well as after, that cancer treatment.

Brielle Gregory: Thank you so much for explaining that. So going a little bit into this update, who should be screened for hepatitis B virus and when should people be screened?

Dr. Hwang: Well, that's a really important point, and one that we want to highlight today. Dr. Artz and I were able to participate in a group of really experienced clinicians to try to figure out who should be screened and how best to screen them. And the group really thinks that everybody should be screened who is about to get cancer therapy. So really all patients with any type of cancer, whether it's a cancer that affects a solid organ of the body or perhaps one of the blood cancer conditions. Any patient with any type of cancer really is at risk of having a potential complication if they have hepatitis B, so we just advocate that everybody get screened. It's just a simple blood test, and there are 3 hepatitis B blood tests, and they are routine tests available at all labs, and they're fairly easy to get and the results are available rapidly. So I think it's really just a good practice to get everybody tested before they start their cancer therapy so that they can be well protected.

Brielle Gregory: And I know you mentioned that there are 3 tests for hepatitis B. So can you describe what those 3 tests are?

Dr. Hwang: Sure. One test is called the hepatitis B surface antigen. And if this test is positive, this really is indicative of a patient having one of the more severe forms of hepatitis B, what we talk about in the medical world as being chronic hepatitis B. Another test is called a hepatitis B core antibody, and this is a test that's positive in anybody who's had a past infection with hepatitis B. So it can be positive in patients with chronic disease, but assuredly it is positive in patients with past infection. And then the third test is a test called hepatitis B surface antibody, and that's a protective antibody. It's good to have that one positive. So if a person has had a previous vaccination, this hepatitis B surface antibody will hopefully be positive and indicate that they are protected against the hepatitis B.

Brielle Gregory: And what are some of the problems that hepatitis B can cause during cancer treatment?

Dr. Hwang: Well, Brielle, I mentioned just a few minutes ago that once infected, the hepatitis B virus can linger in the liver of an infected person. And though it might not cause problems, I think that the cancer treatments, if they're immunosuppressive and they weaken a person's immune system, that could lead to the virus replicating and growing out of control, so that it could then lead to liver damage, what we call flares of the liver. It could also lead to really acute liver injury, even liver failure. And there are reports of death from liver-related complications in patients with cancer and underlying hepatitis B from their cancer therapy. So it's a really serious, potentially serious condition, this hepatitis B reactivation that we're talking about, and I think that's why it's really important for patients to be tested for hepatitis B before they receive their cancer treatment.

Brielle Gregory: Thank you so much for explaining that. And Dr. Artz, for people who have previously had hepatitis B, as Dr. Hwang just mentioned, there is a risk that some cancer treatments could lead to a hepatitis B reactivation. So what does ASCO recommend to help reduce that risk of reactivation?

Dr. Artz: Yes. I think it's a really important point for this virus that through appropriate monitoring and treatment, we can largely avoid the complications that were just discussed. And that's really the key point why testing is so important, that it's not only to identify problems that might emerge, but that we have an approach that is likely, for many patients, to avoid complications. Specifically, there are pill or oral medications that are well tolerated, don't interact with most chemotherapy, that would be offered to most patients with what we call chronic hepatitis B—that is, hepatitis B surface antigen—receiving anti-cancer therapies that are systemic—that is, pills or IV chemotherapy—would receive a treatment to prevent chronic hepatitis B from worsening. With some exceptions, in patients receiving hormone therapy alone for prostate cancer or breast cancer—those are some special circumstances where that has to be discussed with an HBV specialist.

Now, for another group of patients, those who had past hepatitis B where the danger of hepatitis B re-emerging is less, we recommend the treatment against hepatitis B in those cases where the treatments the patients will receive weaken the immune system to such a degree that the hepatitis B might re-emerge even in that situation. And those are what we call anti-CD20 antibodies, such as rituximab or stem cell transplant, are the ones that we're most concerned about. But in addition to the medications against hepatitis B, monitoring is a major part of this. So patients who are on medications—or even if they're not on medications, we've outlined a monitoring strategy for clinicians to follow that informs people about the tests, the blood tests they should get, and also to monitor patients past the time of completing chemotherapy because the virus can reactivate even after stopping therapy. And that's really important to know for people.

I think another key point is that in this PCO, we really talk about a collaborative approach, and HBV—now that we'll be identifying it more often, a lot of times patients and clinicians were unaware of its presence. We need to work with HBV specialists—that is, those who have a lot of expertise in HBV in certain situations as a team. And I think that collaborative approach, for situations that are more challenging and we need a more nuanced approach, will allow patients to receive individualized care that's based on their situation.

Brielle Gregory: So just to clarify, both for patients who currently have hepatitis B and patients who have in the past had hepatitis B, there are options for them to hopefully avoid some of the problems that were discussed earlier. Is that correct?

Dr. Artz: Yes. Absolutely. I think identifying hepatitis B is an opportunity to avoid future problems and really safely receive their chemotherapy with fewer complications, or less chance of complications from hepatitis B.

Brielle Gregory: Great. Well, thank you so much for your time and for sharing your expertise today, Dr. Artz and Dr. Hwang. It was so great having you.

Dr. Hwang: It's been a pleasure. Thanks, Brielle.

Dr. Artz: Yeah. It's been a real pleasure. Thank you again.

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