Avoid hep B reactivation during cancer therapy

Cancer care

22 May 2018

The need for more consistency around the management of hepatitis B during immunosuppression with cancer treatment was one of the drivers for new guidelines soon to be endorsed by five professional societies.

Speaking at the Australasian Society for Infectious Diseases (ASID) Annual Scientific Meeting on the Gold Coast, Dr Joseph Doyle said a second reason was to strengthen advocacy for better access to PBS-funded hepatitis B prophylaxis in this patient group.

International guidelines were ‘pretty good’ but ‘we just wanted to look at it with the Australian lens’.

“The reason we thought we need this for Australia was because Australia has its own funding rules about who can get tested and which tests you can do and it’s also got its own PBS rules about who can be prescribed drugs and getting hepatitis B tablets just for prevention of reactivation of HBV in cancer is not funded.”

“We hope with these Australian guidelines, we can say the five societies involved are all really advocating for this approach and we would like the PBS to look at specific items so that people getting cancer therapies with hep B serology that says they should be prophylaxed, should be able to get the drugs.”

Dr Doyle, from Monash University and the Alfred Hospital, told the limbic the guidelines were currently in draft form and would be circulated to members of MOGA, HSANZ, GESA, ASHM and ASID.

“The main purpose is to make sure people are tested adequately and then if they need preventive therapy, that they get that before they get their chemotherapy.”

He said there were currently slight differences in practice between the disciplines.

“Haematological diseases themselves make people more immunosuppressed than solid cancers, so if you’ve got no white blood cells with a haematological cancer, that in itself can be a risk.”

“It’s probably fair to say haematologists generally test everybody for hep B. Hopefully through this process, oncologists will see their craft group have been involved and they will also recognise indications for testing,” he said.

He added that some drugs used by oncologists were not as potent in causing hep B re-activation as haematology drugs; while oncologists also had factors they needed to consider regarding treatment for solid organ cancers.

“Palliation versus cure – sometimes the purpose of the cancer therapy comes into play a little bit too.”

He said anti-CD20s such as rituximab and other agents that deplete B cells were particularly problematic because they removed one of the key mechanisms for containing hepatitis B.

“So when you lose that, with current or old hepatitis B, the disease can flare up. And we know that when hep B flares during cancer it can be a very nasty liver flare with rapid fibrosis progression and occasionally people can die.”

“But probably the main reason to optimise treatment, and this is very important for oncologists, is that when hep B does flare, it interrupts cancer treatment.

“So whilst it is really rare for people to get a full-on hep B flare, changes in liver function tests actually happen much more often and can interrupt cancer treatment which has an impact on the patient’s health and their survival.”

The guidelines are expected to be published and presented at relevant meetings in the second half of the year.


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