Reactivation of chronic hepatitis B virus in cancer patients receiving immunosuppression: The case for screening.

Abstract

9088 Background: Reactivation of hepatitis B virus (HBV) infection following immunosuppressive therapy can cause significant morbidity and mortality. This study aims to estimate the frequency and clinical consequences of reactivation of HBV in a diverse group of cancer patients (pts) receiving immunosuppression. Methods: We retrospectively reviewed all pts at Memorial Sloan-Kettering Cancer Center between 2003 and 2009 who had an HBV DNA PCR>1000 to identify cases of reactivation of HBV. The medical record was used to distinguish between reactivation and de novo infection. Pt demographics, type of malignancy, immunosuppressive agent, and clinical outcome were recorded. Results: Between 2003 and 2009, 241 pts had HBV PCR>1000 copies including 23 with associated abrupt increase in serum ALT. Twenty-two of these pts (median age: 53; 45% Asian descent) had no risk factors for acute HBV, suggesting reactivation. Immunosuppressive therapy began a median of 21 days (range 1-175) prior to reactivation. Varied chemotherapeutic agents were used; 1 pt received high dose steroids only. Seven (32%) patients had lymphoma, and 15 (68%) had other tumors: hepatocellular carcinoma (2), glioblastoma (2), leukemia (2), multiple myeloma (1), esophageal ca (1), sarcoma (1), breast ca (1), lung ca (1), jejunal ca (1), pancreatic ca (1), ovarian ca (1), and neuroendocrine tumor (1). Four (21%) pts died from liver failure; 19 (86%) required hospitalization (median LOS 5 days (range 2-33)). Four pts had clinically significant delays in cancer treatment due to HBV reactivation. Three pts were transferred for liver transplant evaluation; 1 pt underwent transplant. Conclusions: Reactivation of HBV during chemotherapy-induced immunosuppression is a completely preventable disease with substantial morbidity and mortality. Our 3 cases per year of clinically significant HBV reactivation occurred in patients of various nationalities without association with a particular malignancy or medication. Because of these findings, we now screen all patients initiating immunosuppressive therapy for HBV; subsequent use of antiviral prophylaxis is based on planned treatment and HBV risk group. No significant financial relationships to disclose.