Gaps in Pre-rituximab Hepatitis B Screening An Institutional Experience

SUMMARY:The Centers for Disease Control and Prevention (CDC) estimates that there are 800,000 -1.4 million individuals with Chronic Hepatitis B infection in the United States. Reactivation of HBV is a major concern in cancer patients who may be on chemotherapy or other immunosuppressive therapies, with the incidence of HBV reactivation ranging from 40%-60% in those who are positive for Hepatitis B surface antigen (HBsAg). HBV reactivation is preventable with prophylactic antiviral therapy, failing which it can result in delays in cancer treatment as well as potentially fatal outcomes. The CDC updated their recommendations in 2008 and recommended HBV screening for patients receiving cytotoxic chemotherapy or immunotherapy. The American Society of Clinical Oncology in 2010 rendered a Provisional Clinical Opinion (PCO) suggesting that there was insufficient evidence to recommend routine screening for HBV in cancer patients,but screening may be considered for patient populations at high risk or for those who are to receive highly immunosuppressive therapies including anti-CD20 monoclonal antibody therapy such as Rituximab (RITUXAN®). To evaluate compliance with these recommendations, the authors in this study retrospectively reviewed charts of patients with Low grade Non Hodgkins Lymphoma at a teritiary care center and documented the various studies performed, as a part of the pretreatment workup, between January 2005 and December 2011. They noted that only 19% of the total patients and 25% of the patients who received RITUXAN® had HBV screening done. The authors concluded that this was a significant deviation from the recommended guidelines and these findings resulted in the implementation of stricter measures for HBV screening at this teritiary care center. Screening for HBV should include testing for Hepatitis B surface antigen (HBsAg), Antibody to Hepatitis B core antigen (anti-HBc) and Antibody to Hepatitis B surface antigen (Anti-HBs). Patients positive for HBsAg and anti-HBc as well as those who are negative for HBsAg and positive for anti-HBc, should have testing for HBV viral load using serum HBV DNA and those without active disease should receive prophylactic antiviral therapy and be closely monitored for HBV reactivation. Prophylaxis is usually started one week before initiating chemotherapy and continued for at least 6 months after completion of chemotherapy, although the actual duration of prophylactic antiviral therapy remains unclear. If HBV reactivation is noted, chemotherapy should be immediately discontinued. Given the prevalence of chronic Hepatitis B in the United States, screening for HBV should become a routine part of pretreatment evaluation in cancer patients. Abbi KK, Gorris M, Skeel RT. Am J Ther. 2013;June 28.