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Hepatitis B infection: An Under- Recognized Problem in Oncology Atif Zaman MD MPH Professor of Medicine Division of Gastroenterology and Hepatology. Case Presentation. 66 year old male who presented for evaluation of severe shoulder and chest pain.

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Hepatitis B infection: An Under- Recognized Problem in OncologyAtif Zaman MD MPHProfessor of MedicineDivision of Gastroenterology and Hepatology

case presentation
Case Presentation
  • 66 year old male who presented for evaluation of severe shoulder and chest pain.
  • Medical history significant for amelanotic spindle cell melanoma (0.90mm, Clarks III-IV) on the left cheek, s/p excision in February 2007
  • Presented to urgent care, CXR and subsequent chest CT abnormal:
    • CT chest: Numerous skeletal lesions (in bilateral ribs, vertebral bodies, and sternum) with the largest lytic mass involving the right 8th rib and posterior elements of T8 on the right with encroachment into the pleural space of the right lung and into the right paraspinous musculature. No pulmonary nodules.

In accord with ORS.41675 related to QA, Teaching & Supervision of Medical Staff Physicians

case presentation1
Case Presentation
  • PET scan revealed: Multifocal hypermetabolic activity throughout the axial and appendicular skeleton, with soft tissue masses at right T8 costovertebral junction (SUV 25) and costochondral junction of the right second rib.
  • CT-guided biopsy:Plasma cell neoplasm
  • Laboratory studies: SPEP: IgG kappa monoclonal protein detected; M-protein = 2.2 g/dL. B-2-M: 3.3, alb 3.9, Hb 14.4, Cr 0.99, Ca 9.7.
  • Bone marrow biopsy: 50-60% plasma cells
  • Karyotype and FISH: Karyotype normal, FISH 10% cells deletion 13.

In accord with ORS.41675 related to QA, Teaching & Supervision of Medical Staff Physicians

case presentation2
Case Presentation
  • Salmon-Durie Stage IIIA, ISS 1
  • Chemotherapeutic regimens:
    • 6 cycles of DVD from 4/11 - 9/11 (modified due to Doxil shortage)
    • In 10/11 he received XRT 30Gy to R T8/rib lesion and R humerus
    • In 11/11 Restaging studies found PR, collected stem cells. Precollection standard studies found HepBcAB+, viral load undetectable
    • began maintenance VD q2 weeks + methylpred 20 q2day
    • BACBADAT (Bortezomib, Ascorbic acid, cytoxan, biaxin, acyclovir, dexamethasone, ASA, thalidomide) on 6th cycle

WHEN…

In accord with ORS.41675 related to QA, Teaching & Supervision of Medical Staff Physicians

case continued
Case- continued
  • Early August :
    • Darkening of urine
    • Labs revealed acute hepatitis with marked elevation of transaminases, mildly elevated bilirubin.
    • Patient has been on Zetia and Crestor, concerned this is the main cause, but additional concerns include viral hepatitis reactivation vs. other medications vs. other viral causes.

In accord with ORS.41675 related to QA, Teaching & Supervision of Medical Staff Physicians

laboratory testing
Laboratory Testing

In accord with ORS.41675 related to QA, Teaching & Supervision of Medical Staff Physicians

case continued1
Case-continued
  • With HBsAg now positive HBV oral agent was started ASAP (HBV DNA level was still pending)
  • By two weeks…

In accord with ORS.41675 related to QA, Teaching & Supervision of Medical Staff Physicians

laboratory testing1
Laboratory Testing

In accord with ORS.41675 related to QA, Teaching & Supervision of Medical Staff Physicians

what is going on here
What is Going on Here?!
  • Did somebody drop the ball?
  • Did this patient actually have chronic HBV infection prior to therapy and was it missed?
  • Should this patient have been preemptively started on HBV meds, nucleoside analogues (NAs)?
  • How closely should this patient be monitored during chemotherapy?
  • This patient did well, but what if he went into liver failure?
hepatitis b some sobering facts
Hepatitis B: Some Sobering Facts
  • 350 million people chronically infected
  • 2 billion with evidence of past or present infection
  • Country of origin is THE major risk factor

Prevalence of HBsAg

High ≥ 8%

Intermediate 2% to 7%

Low < 2%

World Health Organization. Hepatitis B Fact Sheet. Centers for Disease Control and Prevention. CDC Health Information for International Travel 2012. New York: Oxford University Press; 2012.

typical interpretation of serologic test results for hbv infection
Typical Interpretation ofSerologic Test Results for HBV Infection

Modified from Weinbaum CM, et al. MMWR Recomm Rep. 2008;57(RR-8):1-20.

natural history of chronic hbv infection
Natural History of Chronic HBV Infection

Immune Control

(Nonreplicative)

Immunotolerance

Immune Clearance

HBV DNA

HBeAg+ HBeAg- HBeAb+

HBsAg+ HBsAg- HBsAb+

ALT

5-30 Yrs

Mos-Yrs

Mos-Yrs

Infection

Yim HJ, et al. Hepatology. 2006;43:S173-S181.

natural history of chronic hbv infection1

HBeAg+ HBeAg- HBeAb+

Natural History of Chronic HBV Infection

Immune Control

(Nonreplicative)

Immunotolerance

Immune Clearance

HBV DNA

  • Most Oncology Patients
  • Normal ALT
  • Low/undetectable HBV DNA
  • HBsAg+ and HBeAg-
  • or HBsAg-, anti-HBc+

HBsAg+ HBsAg- HBsAb+

ALT

5-30 Yrs

Mos-Yrs

Mos-Yrs

Infection

Yim HJ, et al. Hepatology. 2006;43:S173-S181.

do you ever really get rid of hbv
Do You Ever Really Get Rid of HBV?
  • Immune control—not clearance
  • “Resolved HBV” a misnomer—still HBV DNA in liver
  • ccDNA—episomal replicative intermediate responsible for persistent infection of hepatocytes

cccDNA

Werle-Lapostolle B, et al. Gastroenterology. 2004;126:1750-1758.

do you ever really get rid of hbv1

T cell

T cell

T cell

Do You Ever Really Get Rid of HBV?
  • Immune control—not clearance
  • “Resolved HBV” a misnomer—still HBV DNA in liver

cccDNA

Werle-Lapostolle B, et al. Gastroenterology. 2004;126:1750-1758.

along comes immune suppression

T cell

T cell

T cell

Along Comes Immune Suppression
  • Immune control can be lost
  • Immune-mediated liver damage with immune reconstitution

HIV

Steroids

Chemotx

cccDNA

Werle-Lapostolle B, et al. Gastroenterology. 2004;126:1750-1758.

along comes immune suppression1

T cell

T cell

T cell

Along Comes Immune Suppression
  • Immune control can be lost
  • Immune-mediated liver damage with immune reconstitution

HIV

Steroids

Chemotx

cccDNA

Werle-Lapostolle B, et al. Gastroenterology. 2004;126:1750-1758.

hbv reactivation
HBV Reactivation

HBeAg+ HBeAg- HBeAb+

HBeAg+

Immunotolerance

Immune Clearance

HBV DNA

ALT

5-30 Yrs

Mos-Yrs

Mos-Yrs

Infection

Hoofnagle JH. Hepatology. 2009;49(5 suppl):S156-S165.

hbv reactivation1
HBV Reactivation

HBeAg+ HBeAg- HBeAb+

HBeAg+

Immunotolerance

Immune Suppression

Immune Clearance

HBV DNA

ALT

5-30 Yrs

Mos-Yrs

Mos-Yrs

Infection

Hoofnagle JH. Hepatology. 2009;49(5 suppl):S156-S165.

hbv reactivation2
HBV Reactivation

HBeAg+ HBeAg- HBeAb+

HBeAg+

Immunotolerance

Immune Suppression

Immune Reconstitution

Immune Clearance

HBV DNA

ALT

5-30 Yrs

Mos-Yrs

Mos-Yrs

Infection

Hoofnagle JH. Hepatology. 2009;49(5 suppl):S156-S165.

hbv reactivation3
HBV Reactivation

Definition

  • Loss of HBV immune control in a patient with inactive or “resolved” HBV infection
  • Abrupt reappearance or increase in viral replication with liver damage occurring during and/or following immune reconstitution

Clinically

  • Range from subclinical to severe/fatal hepatitis
  • Rise in HBV DNA ± return of HBeAg
  • ALT increase (may be mild or very dramatic)
  • May progress to liver failure/death despite antiviral therapy

Hoofnagle JH. Hepatology. 2009;49(5 suppl):S156-S165.

subset of agents reported to cause hbv reactivation
Subset of Agents Reported to Cause HBV Reactivation

Yeo W, et al. Hepatology. 2006;43:209-220.

consequences of delayed recognition of hbv reactivation
Consequences of Delayed Recognition of HBV Reactivation

Hepatitis

  • May be severe or even fulminant
  • Occasionally may miss HBV DNA spike because HBV DNA may fall when ALT rises
    • This may lead to misdiagnosis and, ultimately, may result in subsequent flares of HBV
  • By the time ALT rises . . . may be too late to bring under control

Interruption of chemotherapy

  • Potential for poorer cancer-related outcome

Yeo W, et al. Hepatology. 2006;43:209-220.

rate of hbv reactivation solid tumors
Rate of HBV Reactivation: Solid Tumors
  • HBsAg-positive breast cancer patients receiving chemotherapy
    • Rate of HBV-associated acute hepatitis: 21%[1]
    • With careful HBV DNA monitoring, up to 41% with HBV reactivation[2]
    • HBV DNA may be undetectable by time of ALT peak
    • Limited data on other solid tumors
  • Of those who flare[2]:
    • 35% chemotherapy interruption
    • 35% premature termination of chemotherapy

1. Kim MK, et al. Korean J Intern Med. 2007;22:237-243.2. Yeo W, et al. J Med Virol. 2003;70:553-561.

hematologic malignancy the bigger risk
Hematologic Malignancy: The Bigger Risk

100 patients with NHL undergoing CHOP; 27 HBsAg positive

100

80

60

48

HBsAg Patients (%)

40

22

20

4

4

0

HBV

Reactivation

Jaundice

Nonfatal

Liver Failure

Death

Lok AS, et al. Gastroenterology. 1991;100:182-188.

risk factors for hbv reactivation
Risk Factors for HBV Reactivation
  • Malignancy
    • NHL: 40% to 58% of HBsAg positive
    • Breast cancer: up to 41% of HBsAg positive
  • Chemotherapy
    • Prednisone, anthracyclines, rituximab increased risk
    • “Potency of immunosuppression”
  • HBV DNA
    • HBV DNA > 3 × 105 copies/mL
    • Elevated if HBeAg positive
  • Demographics
    • Men > women

Yeo W, et al. Hepatology. 2006;43:209-220.

steroids increase risk of hbv reactivation
Steroids Increase Risk of HBV Reactivation
  • 50 patients with NHL who were HBsAg positive randomized to epirubicin, cyclophosphamide and etoposide (ACE) ± prednisolone (P)

ACE

100

PACE

73*

80

68

*P < .05

60

46

44*

HBsAg Patients (%)

38

36

35

40

*

28*

13

20

4

0

HBV

Reactivation

ALT

> 10 x ULN

Jaundice

Complete

Remission

Survival

at 4 Yrs

Prednisolone increased risk and severity of HBV reactivation

but trend toward improved NHL outcome

Cheng AL, et al. Hepatology. 2003;37:1320-1328.

what does american society of clinical oncology asco say about hbv screening prior to chemotherapy
What Does American Society of Clinical Oncology (ASCO) Say about HBV Screening Prior to Chemotherapy?
  • “Evidence is insufficient to determine the net benefits and harms of routine screening for chronic HBV infection . . . ”
  • “Physicians may consider screening . . . groups at heightened risk for chronic HBV infection or if highly immunosuppressive therapy is planned”
  • “ . . . antiviral therapy before and throughout the course of chemotherapy may be considered . . . ”

Artz AS, et al. J Clin Oncol. 2010;28:3199-3202.

evaluating asco s position
Evaluating ASCO’s Position
  • Evidence for antiviral therapy weak: small studies, questionable effect on mortality
    • Small studies but very strong effect and assessed TIMING, not value of therapy
    • RCTs of screening vs no screening very uncommon
  • Cost of screening and delay in starting chemotherapy
    • HBsAg costs $13
    • No need to delay chemotherapy for results of HBV testing
  • Antiviral therapy: safety and drug interactions
    • Very safe
    • No effect on chemotherapy pharmacokinetics

Artz AS, et al. J Clin Oncol. 2010;28:3199-3202.

who should be screened
Who Should Be Screened?
  • AASLD recommends screening high-risk individuals[1]
    • Immigrants
      • Asia, Africa, Pacific Islands, Middle East, Eastern Europe, South/Central America, Caribbean, Aboriginal
    • Children of immigrants
    • Men who have sex with men
    • HIV/HCV positive
    • History of IDU, incarceration
    • Hemodialysis patients

Lok AS, et al. Hepatology. 2009;50:661-662.

who should be screened1
Who Should Be Screened?
  • AASLD recommends screening high-risk individuals[1]
    • Immigrants
      • Asia, Africa, Pacific Islands, Middle East, Eastern Europe, South/Central America, Caribbean, Aboriginal
    • Children of immigrants
    • Men who have sex with men
    • HIV/HCV positive
    • History of IDU, incarceration
    • Hemodialysis patients

CDC[2,3] & EASL[4] recommend screening ALL

patients prior to starting chemotherapy

1. Lok AS, et al. Hepatology. 2009;50:661-662. 2. Weinbaum CM, et al. MMWR Recomm Rep. 2008:57(RR-8):1-20. 3. Weinbaum CM, et al. Hepatology. 2009:49(suppl 5):S35-S44. 4. EASL. J Hepatol. 2012;57:167-185.

what is currently being done
What Is Currently Being Done?

Chart Review

of Actual Screening (208 Pts at Single

Institution)[2]

Self-Reported HBV Screening

Practices of 131 US Oncologists[1]

100

80

62

60

HBV Screening (%)

40

24

14

14

20

0

None

High Risk

All

ActualScreening Rate

Few oncologists routinely screen all patients initiating chemotherapy for HBV

1. Khokhar OS, et al. Chemotherapy. 2009;55:69-75. 2. Lee R, et al. Curr Oncol. 2010;17:32-38.

is screening only of high risk populations effective
Is Screening Only of High-Risk Populations Effective?

Knowledge About HBV ScreeningAmong Oncologists

100

80

60

Proportion of Oncologists (%)

40

20

0

Recognize Country of Origin as No. 1 Risk Factor

Aware of HBVGuidelines

High-risk screening requires recognition of high-risk population

Lee R, et al. ASCO 2010. Abstract 6147.

what is the optimal screening strategy
What Is the Optimal Screening Strategy?
  • Screening all patients is most cost-effective and easiest to implement
  • HBsAg should be tested in all individuals, with follow-up HBV DNA in HBsAg-positive patients
  • Role of anti-HBc testing less clear; recommendations from various societies mixed
    • EASL: HBsAg and anti-HBc[1]
    • AASLD: HBsAg and anti-HBc[2]
    • CDC: HBsAg and anti-HBc and anti-HBs[3]
    • ASCO: Consider HBsAg alone[4]

1. EASL. J Hepatol. 2012;57:167-185. 2. Lok AS, et al. Hepatology. 2009;50:661-662. 3. Weinbaum CM, et al. Hepatology. 2009:49(suppl 5):S35-S44. 4. Artz AS, et al. J Clin Oncol. 2010;28:3199-3202.

use of preemptive lamivudine reduces risk of hbv related hepatitis
Use of Preemptive Lamivudine Reduces Risk of HBV-Related Hepatitis
  • HBsAg-positive patients with lymphoma treated with high-dose chemotherapy randomized to “preemptive” vs “on-demand” lamivudine

100

Preemptive LAM

75

Survival Free From Hepatitis Due to HBV Reactivation

50

P = .002 by log-rank test

On-demand LAM

(if HBV DNA increased)

25

0

0

10

20

30

40

Wk

Pts at Risk, nPreemptive LAM

On-demand LAM

1515

1213

1010

94

62

Lau GK, et al. Gastroenterology. 2003;125:1742-1749.

value of preemptive antivirals
Value of Preemptive Antivirals
  • HBsAg-positive patients with NHL treated with CHOP randomized to “preemptive” vs “on-demand” lamivudine

100

On-demand group: start LAM if ALT > 1.5 x ULN

Preemptive group: start LAM on Day 1 of CHOP

80

60

48

HBsAg Patients (%)

36

40

20

20

8

8

0

0

0

0

HBV Reactivation and Hepatitis Flare

HBV Reactivation and ALT >10 x ULN

HBV Reactivationand Jaundice

Death

(After ChemoTx)

Preemptive antivirals decrease HBV reactivation

Hsu C, et al. Hepatology. 2008;47:844-853.

choice of antiviral therapy and monitoring
Choice of Antiviral Therapy and Monitoring
  • Choice of therapy affected by HBV DNA level
    • HBV DNA < 2000 IU/mL: any therapy can be used (including lamivudine)
    • HBV DNA > 2000 IU/mL: entecavir or tenofovir
  • Choice of therapy affected by duration of therapy
    • > 12 mos: entecavir or tenofovir
  • HBV DNA and ALT should be monitored every 3 mos

EASL. J Hepatol. 2012;57:167-185. Lok AS, et al. Hepatology. 2009;50:661-662.

timing of antiviral therapy
Timing of Antiviral Therapy
  • When to start
    • Ideally before or together with chemotherapy
    • Do not delay start of chemotherapy
  • When to stop
    • If baseline HBV DNA > 2000 IU/mL: high risk of withdrawal flare
      • Continue therapy as for chronic HBV infection
    • If baseline HBV DNA < 2000 IU/mL
      • 6-12 mos after end of chemotherapy
  • Monitor for withdrawal flares with monthly HBV DNA and ALT

EASL. J Hepatol. 2012;57:167-185. Lok AS, et al. Hepatology. 2009;50:661-662.

significance of isolated anti hbc positive marker
Significance of Isolated Anti-HBc Positive Marker
  • Indicates exposure to HBV
  • Usually persists lifelong but may lose after yrs
  • May be false positive if truly no HBV risk factors
  • No guidelines for management
  • Risk for reactivation
    • Low risk for most standard solid tumor regimens
    • Consider preemptive HBV therapy if cirrhosis is present
    • Consider preemptive HBV therapy if the following treatment strategies are used
      • Rituximab
      • Bone marrow/stem cell transplantation

Manzano-Alonso ML, et al. World J Gastroenterol. 2011;17:1531-1537.

rituximab a particular problem
Rituximab: A Particular Problem
  • Monoclonal antibody against CD20 (B-cell marker)
  • Reduces B-cell numbers and antibody levels
  • Increasingly used as part of CHOP-R, EPOCH-R
  • Increased risk of HBV reactivation, including HBsAg-negative patients
  • Reverse seroconversion: reappearance of HBsAg in previously HBsAg-negative patient due to loss of immune control

Yeo W, et al. Hepatology. 2006;43:209-220. Papamichalis P, et al. Clin Res Hepatol Gastroenterol. 2012;36:84-93.

hbv reactivation with rituximab in hbsag negative individuals
HBV Reactivation With Rituximab in HBsAg-Negative Individuals
  • Patients with diffuse large B-cell lymphoma
    • HBsAg-negative, anti-HBc–positive individuals treated with CHOP or CHOP-R

40

CHOP (n = 25)

CHOP-R (n = 21)

30

24

Proportion of Anti-HBc Positive, HBsAg-Negative Patients (%)

20

10

5

0

0

0

HBV-Related

Death

HBV Reverse

Seroconversion

Risk of reactivation with rituximab significant in anti-HBc positive

Yeo W, et al. J Clin Oncol. 2009;27:605-611.

hbv reactivation associated with rituximab typically late and severe
HBV Reactivation Associated With Rituximab: Typically Late and Severe
  • Reverse HBV seroconversion[1]
    • Among 5 patients who reactivated, 1 during fifth cycle of chemotherapy; 3 median of 98 days AFTER last rituximab cycle; can occur early as well
    • Median peak ALT: 809 U/L (362-3499)
    • Median peak bilirubin: 65 µmol/L (19-249)
  • Additional cases reported in literature
    • Including instances of liver failure and liver-related deaths
  • Risk Factors for reactivation
  • Men >> women (almost all cases)
  • Anti-HBs negative (or low titer)
  • ? increased age (> 50 yrs)

Yeo W, et al. J Clin Oncol. 2009;27:605-611.

bone marrow transplantation increased risk of reactivation
Bone Marrow Transplantation: Increased Risk of Reactivation
  • Markedly high rate of reactivation (HBsAg positive)
    • Up to 54%[1]→ need preemptive antiviral therapy!
    • Long-term complications: cirrhosis in 10%[2]
  • Reverse seroconversion common if anti-HBc positive[3]
    • Up to 50% become HBsAg positive → use preemptive antivirals
    • May occur very late
  • HBV status of donor important[1,4]
    • If natural immunity (anti-HBs, anti-HBc): may clear HBsAg
    • If vaccinated (anti-HBs): possibly some protection

1. Lau GK, et al. Bone Marrow Transplant. 1997;19:795-799. 2. Hui CK, et al. Blood. 2005;106:464-469.3. Onozawa M, et al. Transplantation. 2005;79:616-619. 4. Lau GK, et al. J Infect Dis. 1998;178:1585-1591.

what does aasld 2009 say about isolated hbcab positivity
What Does AASLD 2009 Say About Isolated HBcAb Positivity?
  • “While HBV reactivation can occur in persons who are HBsAg negative but … with isolated anti-HBc, this is infrequent, and there is not enough information to recommend routine prophylaxis for these individuals”
what does easl 2012 say about isolated hbcab positivity
What Does EASL 2012 Say About Isolated HBcAb Positivity?
  • Should be tested for HBV DNA
    • Patients with detectable serum HBV DNA should be treated similarly to HBsAg positive patients
    • Patients with undetectable serum HBV DNA undetectable serum HBV DNA who receive chemotherapy and/or immunosuppression should be followed carefully by means of ALT and HBV DNA testing q1-3 months and treated with NA therapy upon confirmation of HBV reactivation before ALT elevation
    • HOWEVER… some experts recommend preemptive NA therapy in all who receive rituximab and/or combined regimens for hematological malignancies, bone marrow and stem cell transplants
so who dropped the ball in our case
So Who Dropped the Ball in Our Case?
  • No one in particular
  • BUT the guidelines are outdated (esp the oncology guidelines) and non-committal in regards to isolated HBcAb
  • March 2013 there will be a combined AASLD/NIH sponsored conference on this topic
  • Until then…
recommendations
Recommendations
  • Preemptive therapy requires preemptive screening, which is highly cost-effective
  • Screening recommended by CDC, EASL, AASLD, and IOM
    • Patients to receive Standard chemotherapy
      • Screen HBsAg (± anti-HBc)
    • Patients to receive Complex chemotherapy (eg, rituximab/ BMT)
      • Screen HBsAg, anti-HBc, anti-HBs
summary screening tests and results
Summary: Screening Tests and Results

**If observation is chosen, monitor liver tests, HBsAg and HBV DNA q1-3 months