1. PI project: Hepatitis B prophylaxis in patients with malignancies
Natasha Banerjee

2. The problem Estimated 240 million people have chronic HBV infection
Patients with CHRONIC Hep B infection OR prior Hep B infection are at risk for REACTIVATION when exposed to immunosuppressive therapy
REACTIVATION can lead to acute hepatitis  liver function impairment  liver failure  DEATH
REACTIVATION can lead to hepatitis  DELAY or termination of curative cancer treatment
20-50% of patients with HepBsAg positivity and 3-45% with HBcAb positivity develop reactivation with cytotoxic chemotherapy

3. Who should be screened?
Most guidelines recommend universal screening of ALL patients before cancer therapy
NCCN and the CDC recommend “any patient who is expected to receive IST or chemotherapy should be screened for HBV, HCV, and HIV prior to treatment.”
Who should especially be screened?
Patients undergoing intensive immunosuppressive therapy, including HSCT or therapy for leukemia or lymphoma
All patients who will receive rituximab/B cell depleting therapies

4. How to screen?

5. Labs to order HBsAg HBcAb (TOTAL, NOT IgM!!)
WARNING: acute Hepatitis panel checks HBc IgM ONLY
IF positive for HBsAg or HBcAb
HBV DNA PCR (viral load)

6. Chronic Hep B infection
Chronic Hep B Pattern:
POSITIVE HBsAg (negative indicates cleared/resolved infection)
POSITIVE total HBcAb
Vaccinated against Hep B
NEGATIVE HBsAg
POSITIVE HBsAb
NEGATIVE HBcAb

7. WHO receives prophylaxis?
HBsAg positive or detectable HBV viral load
HBsAg NEGATIVE, HBcAb positive
More important if going to receive rituximab or undergo HSCT
Can also monitor viral load q3mos and initiate if VL becomes detectable

8. How to prophylax Approved nucleoside analogues:
Lamivudine (high rates of resistance, 80%)
Tenofovir (nephrotoxicity)
Entecavir (low resistance, 1.2%, no significant side effects)
0.5 mg daily

9. How to monitor
During chemo, monitor HBV viral load monthly, then q3 mos after treatment completed
Continue prophylaxis at least 6 months and up to 12 months after completion of therapy

10. How do we do?
Chart checked all fellow patients seen in 2 Monday clinics in Jan 2016
4/5 CML patients never had hepatitis labs checked
Two PV/MF patients never had hepatitis labs checked
1/4 myeloma patients never had hepatitis labs checked
One T cell lymphoma patient had labs done correctly
1/3 follicular lymphoma patients had labs done correctly
One Hodgkins lymphoma patient had labs done correctly
One T-ALL patient had acute panel done only
One DLBCL patient had acute panel done and was negative, then HBcAb total done and was positive, VL not checked, was not started on ppx