24 May 2021

Hep B reactivation killing cancer patients


Undiagnosed chronic hepatitis B infections are flaring up during chemo, threatening the lives of patients. But there’s an easy fix.

Cancer patients are dying and driven to liver failure from easily preventable hepatitis B flare-ups during chemotherapy.

Experts were urging all patients undergoing cancer chemotherapy, and other therapies that suppressed the immune system, to be screened for the infection, even if they were not in a high-risk group.

“Every year, liver transplants are performed in Australia for hepatitis B reactivation, but other patients die,” said Associate Professor Simone Strasser, president of the Gastroenterological Society of Australia.

She told The Medical Republic about a recent patient who was undergoing adjuvant chemotherapy for her potentially curative breast cancer. The patient’s hepatitis B wasn’t diagnosed, and the cancer treatment caused it to flare up, causing liver failure.

Fortunately for her, she was given approval for a liver transplant because her cancer was potentially curable, said Professor Strasser. “But the vast majority of people would not be eligible for transplantation because of their underlying malignancy.”

It was a “tragic” situation, she added. Not only were patients getting liver failure from an easily avoidable condition, but their chance of survival was also “significantly” reduced by the hepatitis reactivation and so they were less likely to be chosen for a transplant.

Each year, major liver units might see several cases of liver failure from chronic hepatitis B, and its subsequent reactivation, said Professor Strasser, senior staff specialist at the Royal Prince Alfred Hospital.

One of the reasons was that one out of every three people with chronic hepatitis B infection had not been diagnosed.

“The issue is that you cannot pick who has hepatitis B based on risk profiling,” said Professor Strasser. “There are 239,000 Australians living with chronic hepatitis B, not all of whom are from clearly identifiable migrant or Indigenous populations.”

Australian guidelines strongly recommended that all patients undergoing cancer therapy had a screening test for hepatitis B with a hepatitis B surface antigen at a minimum.

Such recommendations for patients undergoing chemotherapy for cancer had existed for around a decade, but a national consensus statement was published in the Medical Journal of Australia only in 2019.

Patients with haematological malignancies in particular needed to be tested for hepatitis B core antibody before undergoing cancer treatment.

This is because some patients who had cleared hepatitis B could have it reactivated under intense immunosuppression, particularly with drugs such as rituximab, said Professor Strasser.

“Individuals with chronic HBV infection (HBsAg positive) or past exposure (HBsAg negative and anti-HBc positive) receiving higher risk chemotherapy require antiviral prophylaxis using entecavir or tenofovir,” said the MJA paper that Professor Strasser co-authored.

These daily antiviral pills did not interact with chemotherapeutic agents, nor did they delay the cancer treatment. In contrast, a hepatitis B flare up might force clinicians to use less-effective doses of chemotherapy to treat the cancer.

The most important thing was for all private and public settings nationwide to have protocols in place to ensure a hepatitis B screen had been done before chemotherapy drugs were dispensed, said Professor Strasser. At the moment, not all cancer treatment guidelines included recommendations to screen, and it might be left to individual clinicians to decide.

“We don’t want to do liver transplants for preventable conditions,” she added. “And this is entirely preventable.”

“Every person that has a transplant means that somebody else doesn’t have a liver transplant. Someone else is dying on a liver transplant waiting list, for a situation that was preventable.”

Read more: Hepatitis B: unnoticed, unmonitored, undertreated