Receiving Cancer Chemotherapy Research Articles

Propensity score matched assessment of treatment patterns and cost of erythropoiesis stimulating agent treatment in patients with cancer receiving myelosuppressive chemotherapy

To examine epoetin alfa (EPO) and darbepoetin alfa (DARB) treatment patterns and erythropoiesis stimulating agent (ESA) costs in patients with cancer receiving chemotherapy (CRC), and to compare the results observed in the pre-matched total study population (TSP) with a propensity score matched population (PSMP). A medical claims analysis was conducted from 1 January 2004 through 31 July 2009 using the HealthCore Integrated Research Database. Patients were at least 18 years old, newly initiated on EPO or DARB, received ≥ 2 ESA doses, and had ≥ 1 claim for cancer and chemotherapy proximate to ESA treatment. Patients were matched using propensity scores. January 2010 Wholesale Acquisition Cost was used to calculate drug cost. Mean cumulative ESA dose and drug costs were evaluated in the TSP and PSMP. 4921 EPO and 9173 DARB patients with CRC were identified. In the TSP, mean cumulative ESA doses were EPO: 398,770 units and DARB: 1508 mcg, with similar treatment durations for each. Mean cumulative drug costs were EPO: $6041 and DARB: $7861 (30% higher for DARB). The cumulative dose ratio (EPO units: DARB mcg) was 264:1. The PSMP analysis identified 4831 ESA treated CRC patients in each group. Mean drug costs were EPO: $6055 and DARB: $7863 (30% higher for DARB). The observed dose ratio (EPO units: DARB mcg) was 265:1. In both analyses, the costs of DARB were higher, even after accounting for baseline differences in the PSMP. Similar trends in dose ratios were also observed in both groups.

The impact of RSV, adenovirus, influenza, and parainfluenza infection in pediatric patients receiving stem cell transplant, solid organ transplant, or cancer chemotherapy

RVIs are a significant cause of morbidity and mortality in immunocompromised children. We analyzed the characteristics and outcomes of infection by four respiratory viruses (RSV, adenovirus, influenza, and parainfluenza) treated at a pediatric tertiary care hospital in a retrospective cohort of patients who had received cancer chemotherapy, hematopoietic stem cell, or SOT. A total of 208 infections were studied among 166 unique patients over a time period of 1993-2006 for transplant recipients, and 2000-2005 for patients with cancer. RSV was the most common respiratory virus identified. There were 17 (10% of all patients) deaths overall, of which 12 were at least partly attributed to the presence of a RVI. In multivariate models, LRT symptoms in the absence of upper respiratory symptoms on presentation (OR 10.2 [2.3, 45.7], p = 0.002) and adenoviral infection (OR 3.7 [1.1, 12.6], p = 0.034) were significantly associated with poor outcome, defined as death or disability related to RVI. All of the deaths occurred in patients who had received either solid organ or HSCT. There were no infections resulting in death or disability in the cancer chemotherapy group.

O2-048 - Current Practices and Future Prospects of a Medical Team in Cancer Chemotherapy in Terms of the Role of a Board-Certified Specialist Oncology Pharmacist

ABSTRACT Background With the recent remarkable developments in anti-cancer agents such as targeted molecular therapies, treating patients with malignancies while keeping a balance among effect, safety, and QOL has become complicated. Methods From the perspective of the role of a board-certified specialist oncology pharmacist, we analyzed the future prospects of medical teams in cancer chemotherapy by examining the current practices of the medical team at our hospital. Results In 2011, our hospital became an authorized base hospital for lung cancer therapy in Osaka Prefecture. The medical team for cancer chemotherapy and supportive therapy at this hospital consists of two medical oncologists, two oncology pharmacists, one certified specialist cancer nurse, one certified cancer chemotherapy nurse, two certified palliative care nurses, and one psychologist. Three departments—thoracic oncology, outpatient chemotherapy, and gynecology—perform cancer chemotherapy. The total number of cancer chemotherapies carried out in 2011 was1433 (thoracic malignancies: 88.4%; breast cancer: 5.1%; gastrointestinal cancer: 6.5%) in outpatients and 1572 (thoracic malignancy: 83.3%; gynecological cancer: 11.8%; gastrointestinal cancer: 4.3%; breast cancer: 0.6%) in inpatients. In 2011, the oncology pharmacist carried out the following important functions in medical team: (i) sitting on a review board four times a year for approval of cancer chemotherapy; (ii) daily management of the ordering system for cancer chemotherapeutic agents; (iii) holding meetings four times a year to educate other specialists about new regimens or anti-cancer agents; (iv) monitoring the dose, schedule and patient's information about cancer chemotherapy to prevent severe toxic effects or treatment death; (v) each day, instructing patients who are receiving cancer chemotherapy; and (vi) consulting daily about side-effects and supportive therapy. Conclusions The oncology pharmacist currently plays an important role in the medical team and will become more important in the future.

JS2-4 - End-of-Life Care Discussion Based on Advanced Care Planning (ACP) for Outpatients Receiving Cancer Chemotherapy

ABSTRACT Anti-cancer therapies including chemotherapy, molecular target therapy, and radiotherapy for outpatients become standard treatments for patients with advanced cancer because less toxic anti-cancer drugs and better supportive drugs to reduce side-effects have been developed. In the most advanced cancer patients, the purpose of anti-cancer therapy is both improving survival and maintenance of quality of life. Treatments for outpatients with advanced cancer have the advantage of continuing work or relaxing with the family compared with inpatient treatment. On the other hand, they also provide patients disadvantages such as delay of discovery of adverse events. Recently, the project of ‘advanced care planning’ (ACP) has been developed in the field of cancer patient care. ACP is the process by which patients, in conjunction with their physicians and loved ones, establish goals and preferences for future care and codify these preferences. To make better ACP, we should give patients sufficient and enough information about end-of-life care or prognosis. End-of-life care discussion between patients and their physician should be set up if the patients have incurable cancer and a life expectancy of Here, I show my experiences about end-of-life care discussion, and try to clarify a considerable best way to do for cancer patients receiving chemotherapy.

O1-061 - Significance of the Institutional Antiemetic Guidelines for Chemotherapy Induced Nausea and Vomiting: Evaluation of Efficacy and Costs

ABSTRACT Purpose Chemotherapy-induced nausea and vomiting (CINV) is one of the major adverse events in patients receiving cancer chemotherapy. Preventing CINV is the key to maintaining a patient's quality of life. At Oita University Hospital, the antiemetic regimen was standardized based on the antiemetic guidelines for CINV published by the Japanese of Society Clinical Oncology (JSCO) in May 2010. In the present study, we retrospectively evaluated the clinical and economic effects of standardizing the antiemetic regimen. Methods Palonosetoron, dexamethasone aprepitant, was administered as antiemetics according to the newly standardized regime. The efficacy and costs of antiemetic treatment of chemotherapy before and after standardization of the antiemetic regimen between July 2010 and December 2010 were compared between patients receiving high-grade emetogenic chemotherapy (HEC) and those receiving moderate-grade emetogenic chemotherapy (MEC). The efficacy was evaluated by the proportion of patients without nausea ( Results A total of 50 and 38 patients were treated by the HEC and MEC regimens, respectively. In the HEC group, the proportion of patients without nausea (90.0% versus 92.0%) and complete response (89.0% versus 92.0%) were not significantly different between before and after the standardization. In the MEC group, the proportion of patients without nausea after the standardization was significantly higher than that before the standardization (94.7% and 76.7%, respectively, P Conclusion Using the standardized antiemetic treatment may help reduce the nausea or vomiting suffered by patients receiving cancer chemotherapy and will be less of a financial burden to these patients.

1705 - Prospective Evaluation of the Effect of a Manual for Diabetic Patients who Receive Cancer Chemotherapy

ABSTRACT Background How to safely administer cancer chemotherapy to patients with diabetes mellitus is an important issue. Our institution is a general core hospital in Japan. In 2010, we surveyed the current status of diabetic patients given cancer chemotherapy. Adequate medical examinations were not performed. In 2011, we designed a manual for diabetic patients who receive cancer chemotherapy. We now report an improvement in medical examinations of diabetic patients who receive cancer chemotherapy since introducing our manual. Methods We decided that adequate medical examinations should include the following: adequate measurement of blood sugar levels; evaluation of the patient by a diabetologist; making standards for decreasing the dose of steroids given before cancer chemotherapy; and making standards for nutritional guidance. We compared the present status (as of March 2012) with that before the introducing our manual for diabetic patients receiving cancer chemotherapy. Results The proportion of diabetic patients increased from 12% to 19%. The rate of measuring blood sugar levels at the start of new regimens of chemotherapy increased from 69% to 72%. The rate of adequate continuous monitoring of blood sugar levels increased from 48% to 81%. The rate of evaluation by a diabetologist increased from 36% to 50%. The rate of decreased premedication with steroids increased from 55% to 66%. The rate of providing nutritional guidance was unchanged (23% to 24%). Conclusions The rates of adequate continuous monitoring of blood sugar levels, decreasing premedication with steroids, and evaluation by a diabetologist improved. The increase in the proportion of diabetic patients was attributed to adequate blood sugar examinations. However, the low rate of providing of nutritional guidance remains an unsolved problem. Disclosure All authors have declared no conflicts of interest.

1643 - Analysis of the Association Between the Number of Regimens and the Frequency of Side Effects in Outpatients Receiving Cancer Chemotherapy. Can Progression-Free Survival be the Primary End Point?

1643 - Analysis of the Association Between the Number of Regimens and the Frequency of Side Effects in Outpatients Receiving Cancer Chemotherapy. Can Progression-Free Survival be the Primary End Point?

Semuloparin reduced venous thromboembolism in patients receiving chemotherapy for cancer

Source Citation Agnelli G, George DJ, Kakkar AK, et al. Semuloparin for thromboprophylaxis in patients receiving chemotherapy for cancer. N Engl J Med. 2012;366:601-9. 22335737

Management of hepatitis B reactivation in patients receiving cancer chemotherapy

Hepatitis B virus (HBV) reactivation is well documented in previously resolved or inactive HBV carriers who receive cancer chemotherapy. The consequences of HBV reactivation range from self-limited conditions to fulminant hepatic failure and death. HBV reactivation also leads to premature termination of chemotherapy or delay in treatment schedules. This review summarizes current knowledge of management of HBV reactivation in patients receiving cancer chemotherapy. HBV surface antigen (HBsAg) testing should be performed in patients who require cancer chemotherapy. Four meta-analyses support lamivudine prophylaxis for HBV reactivation during chemotherapy in HBsAg-positive patients. Randomized controlled trials to compare different HBV antiviral agents are needed to define optimal regimens for the prevention and treatment of HBV reactivation in patients receiving cancer chemotherapy.

Pharmacoeconomics of the Myeloid Growth Factors

The pharmacoeconomics of the myeloid growth factors (MGFs) is an important topic that has received substantial attention in recent years. The use of the MGFs as primary prophylaxis to prevent febrile neutropenia (FN) has grown considerably over the past decade and professional guidelines regarding their use have broadened the settings in which these agents are indicated. Recent data also suggest a potential role for them in reducing infection-related and all-cause mortality. The cost and effectiveness of these agents will continue to gain visibility as companies pursue approval for biosimilar agents in the US, similar to their recent approval in Europe. The objective of this paper is to review the available pharmacoeconomic literature on the MGFs, which is particularly timely in light of the recent passage of healthcare reform and the increasing focus on cost control. The cost of treating cancer in the US is rising faster than the already rapid increase in overall medical expenditure. The clinical utility and cost effectiveness of supportive care measures in oncology must therefore be weighed carefully. This review focuses on the use of different formulations of MGFs for primary and secondary prophylaxis of chemotherapy-induced neutropenia. A MEDLINE search was performed to find studies that became available since the prior review of this topic was published in Pharmacoeconomics in 2003. Acceptable cost-minimization estimates for primary prophylaxis with the MGFs in patients receiving cancer chemotherapy have been provided by several studies in the US. Of the commonly used agents in the US, pegfilgrastim appears to be superior to the currently recommended dose and schedule of filgrastim in terms of cost minimization, and primary prophylaxis appears to be less costly than secondary prophylaxis. However, the cost benefits of primary prophylaxis in Europe are not as pronounced as in the US, due to the lower costs of medical care. Data continue to emerge suggesting a decreased risk of early mortality from averted infections as well as the possibility of a disease-specific mortality benefit through maintaining the relative dose intensity of chemotherapy with MGF support. This evidence will prove valuable in assessing the overall cost effectiveness and cost utility of the MGFs in patients receiving cancer chemotherapy.

Efficacy and safety of balugrastim compared with pegfilgrastim in patients with breast cancer who are receiving chemotherapy.

9125 Background: Patients receiving cancer chemotherapy are at an increased risk of neutropenia. Recombinant granulocyte colony stimulating factors (G-CSFs) have been developed to stimulate proliferation and differentiation of neutrophils. Pegfilgrastim is a pegylated recombinant G-CSF that allows for once-per-cycle dosing. Balugrastim is a long-acting G-CSF composed of a genetic fusion between recombinant human serum albumin and G-CSF. The objective of this study was to compare the efficacy and safety of balugrastim and pegfilgrastim in patients with histologically or cytologically confirmed breast cancer who were scheduled to receive doxorubicin and docetaxel. Methods: In this double-blind, randomized, active-comparator, noninferiority trial, patients with ≥1.5x109 neutrophils/L, and ≥100x109 platelets/L were randomly assigned to subcutaneous injections of balugrastim 40 mg (n=153) or pegfilgrastim 6 mg (n=151) with stratifications for weight, prior chemotherapy exposure, and global location. The primary efficacy endpoint was the duration of severe neutropenia (days with an absolute neutrophil count <0.5x109 cells/L) during the cycle 1 for the population of patients who did not have major protocol violations. Results: Mean duration of severe neutropenia in cycle 1 was 1.1 days in the balugrastim group and 1.0 days in the pegfilgrastim group (95% CI for difference between groups -0.13 to 0.37). Fifty-eight percent of patients in the balugrastim group and 59% in the pegfilgrastim group had severe neutropenia during cycle 1 (95% CI for difference between groups -11.98% to 10.41%). Two and 4 patients, respectively, had febrile neutropenia during cycle 1; no patients in either group had febrile neutropenia during cycles 2-4. Twenty percent of patients in the balugrastim group and 19% in the pegfilgrastim group had adverse events that the investigator considered to be related to study medication. Six and 7 patients, respectively, had serious adverse events. Conclusions: The results of this study support the noninferiority of balugrastim versus pegfilgrastim, demonstrating that both compounds have comparable efficacy. There were no unexpected safety events.

Reactivation of Hepatitis B During Immunosuppressive Therapy: Potentially Fatal Yet Preventable

Reactivation of Hepatitis B During Immunosuppressive Therapy: Potentially Fatal Yet Preventable

Yoga Breathing for Cancer Chemotherapy–Associated Symptoms and Quality of Life: Results of a Pilot Randomized Controlled Trial

Many debilitating symptoms arise from cancer and its treatment that are often unrelieved by established methods. Pranayama, a series of yogic breathing techniques, may improve cancer-related symptoms and quality of life, but it has not been studied for this purpose. A pilot study was performed to evaluate feasibility and to test the effects of pranayama on cancer-associated symptoms and quality of life. This was a randomized controlled clinical trial comparing pranayama to usual care. The study was conducted at a university medical center. Patients receiving cancer chemotherapy were randomized to receive pranayama immediately or after a waiting period (control group). The pranayama intervention consisted of four breathing techniques taught in weekly classes and practiced at home. The treatment group received pranayama during two consecutive cycles of chemotherapy. The control group received usual care during their first cycle, and received pranayama during their second cycle of chemotherapy. Feasibility, cancer-associated symptoms (fatigue, sleep disturbance, anxiety, depression, stress), and quality of life were the outcomes. Class attendance was nearly 100% in both groups. Sixteen (16) participants were included in the final intent-to-treat analyses. The repeated-measures analyses demonstrated that any increase in pranayama dose, with dose measured in the number of hours practiced in class or at home, resulted in improved symptom and quality-of-life scores. Several of these associations--sleep disturbance (p=0.04), anxiety (p=0.04), and mental quality of life (p=0.05)--reached or approached statistical significance. Yoga breathing was a feasible intervention among patients with cancer receiving chemotherapy. Pranayama may improve sleep disturbance, anxiety, and mental quality of life. A dose-response relationship was found between pranayama use and improvements in chemotherapy-associated symptoms and quality of life. These findings need to be confirmed in a larger study.

Weight-Based Chemotherapy Dosing in Obese Patients With Cancer: Back to the Future

Weight-Based Chemotherapy Dosing in Obese Patients With Cancer: Back to the Future

Fosaprepitant for the prevention of chemotherapy-induced nausea and vomiting

For patients receiving cancer chemotherapy, the ongoing development of antiemetic treatment is of significant importance. Patients consider nausea and vomiting among the most distressing symptoms of chemotherapy, and as new antiemetics have been very successful in prevention of vomiting, agents effective against nausea have become one of the major unmet needs. The neurokinin (NK)1 receptor antagonist aprepitant potentiates the antiemetic efficacy of the combination of a serotonin receptor antagonist and a corticosteroid. Fosaprepitant (intravenous prodrug of aprepitant) given as a single intravenous dose of 150 mg can replace the aprepitant 3-day oral regimen. This article focuses on the development and clinical application of fosaprepitant.

Use and Helpfulness of Self-Administered Stress Management Therapy in Patients Undergoing Cancer Chemotherapy in Community Clinical Settings

The purpose of this multicenter longitudinal randomized controlled trial was to examine the efficacy of self-administered stress management training (SSMT) in improving quality of life and reducing psychological distress among patients receiving cancer chemotherapy. Participants were randomized to SSMT (n = 111) or usual psychosocial care only (n = 109). Mixed linear modeling demonstrated no significant improvements in primary outcome measures; however, participants assigned to SSMT reported using significantly more relaxation techniques (p < 0.0001), showed improvements on emotional adjustment scores, and demonstrated a stabilizing effect on the functional adjustment scores. Findings highlight the usefulness of SSMT in community clinical settings.

Personalizing Cancer Supportive Care: Predicting Neutropenic Complications in Patients Receiving Intermediate Risk Cancer Chemotherapy

Abstract 1022 Background:Neutropenic complications represent important dose-limiting toxicities of cancer chemotherapy. We recently developed and validated a risk model for neutropenic complications in patients with solid tumors or lymphoma receiving cancer chemotherapy (Lyman et al. Cancer 2011). While practice guidelines recommend primary colony-stimulating factor (CSF) prophylaxis for patients at >20% risk of febrile neutropenia (FN), many patients receive chemotherapy regimens associated with an intermediate risk (10–20%) of FN. For these patients, the decision to give or withhold primary CSF prophylaxis is based on clinical judgment. We report here the ability of the risk model to identify patients with individual characteristics placing them at high risk for neutropenic complications among patients receiving intermediate risk chemotherapy regimens. Methods:A prospective cohort study was conducted of consenting patients initiating a new chemotherapy regimen at 115 randomly selected US oncology practices between 2002–2006. The risk of cycle 1 severe or febrile neutropenia was estimated [95% CI] utilizing logistic regression analysis adjusting for key clinical factors including: planned chemotherapy, prior chemotherapy, age, abnormal hepatic or renal function, low pretreatment white blood count, and immunosuppressive medications. The cumulative incidence of severe neutropenia and FN across 4 cycles was estimated by the product limit method of Kaplan and Meier. Results:Among 3,760 patients with cancers of breast, lung, ovary, colon, or lymphoma, 2,270 received an intermediate risk chemotherapy regimen based on NCCN guidelines. Overall, in the subpopulation receiving intermediate risk regimens, severe or febrile neutropenia occurred in cycle 1 in 21.4% while FN over 4 cycles was observed in 11%, and primary CSF prophylaxis was utilized in 16.4%. The performance of the risk model was good in this subgroup with a c-statistic of 0.82 [0.80–0.84]. Among the half of patients classified as high risk based on the model despite receiving an intermediate risk chemotherapy regimen, cycle 1 severe or febrile neutropenia occurred in 38% [35%–41%] compared to 5% [4%–6%] of patients classified as low risk based on the model receiving such regimens. Model sensitivity and specificity were 89% and 61%, respectively. The cumulative risk of FN over 4 cycles of chemotherapy was 20% in predicted high risk group versus 5% in the low risk group (Figure). The majority of severe or febrile neutropenia events (67%) and FN events (55%) were observed in cycle 1. One-half of high risk patients who did not receive primary CSF prophylaxis in cycle 1 received CSF during subsequent cycles following a neutropenic event. Conclusions:Our model for predicting neutropenic complications can identify patients at high individual risk for severe neutropenia in cycle 1 or FN in the first 4 cycles of chemotherapy when receiving intermediate risk chemotherapy. This analysis emphasizes the potential value of determining an individual patient's risk of chemotherapy complications based on a validated risk model. [Display omitted] Disclosures:Lyman:Amgen: Research Funding. Crawford:Amgen: Consultancy, Honoraria, Research Funding. Dale:Amgen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. Kuderer:Amgen: Research Funding.

Prevalence of symptoms, with a focus on fatigue, and changes of symptoms over three months in outpatients receiving cancer chemotherapy

Prevalence of symptoms, with a focus on fatigue, and changes of symptoms were explored over three months in outpatients with lymphoma, lung, breast or colorectal cancer, receiving chemotherapy in the oncology outpatient clinic of a Swiss tertiary care hospital. Prospective, descriptive design; symptom prevalence was measured at start of chemotherapy (T1), and one week prior to the third and fourth cycle (T2, T3). Included were patients starting chemotherapy, with expected survival of >3 months, irrespective of stage of disease. The Memorial Symptom Assessment Scale was used to assess 32 symptoms; fatigue was measured with the FACIT-Fatigue Scale (negative scale). Data were analysed using descriptive statistics and random-intercept regression models. 77 patients participated at T1, 58 and 50 at T2 and T3. Patients experienced on average 9.8, 14.4, and 13.7 symptoms, showing a significant increase over time. Lack of energy and feeling drowsy were most frequent. Symptom scores for lack of energy, changes in skin, pain, and feeling drowsy remained >2 over time (scale 0-4, higher scores = more symptoms). Fatigue mean scores were 36.3, 30.2, and 31.3, showing a significant increase of fatigue over time. Individual symptom trajectories varied widely within and among patients. High symptom prevalence at start of chemotherapy as well as over time and great variability in symptom experience call for an individual, systematic symptom assessment and management that does not focus solely on side-effects of therapy but includes disease-related symptoms to achieve satisfactory control of symptoms in outpatients receiving chemotherapy.

Assessment of hepatitis B immunization status after antineoplastic therapy in children with cancer

BACKGROUND AND OBJECTIVES:Hepatitis B is a disease that is preventable with vaccination. Antibody levels after vaccination may be affected by suppression of the immune system due to cancer therapy. Children with cancer have a high risk of hepatitis B virus (HBV) infection. We aimed to assess the pretreatment immunization status against HBV infection and the rate of continuity of immunization after therapy in children with cancer.DESIGN AND SETTING:Retrospective case review of patients treated from 2004 to 2008.PATIENTS AND METHODS:We reviewed the medical records of patients treated in the departments of pediatric hematology and oncology and collected data on immunization history and hepatitis B serology. Anti-HBs antibody titers were compared before and after treatment.RESULTS:This study included 159 (99 males, 60 females) children who had a serologic examination. Antineoplastic therapy had been given for acute leukemia (n=66), non-Hodgkin lymphoma (n=27), Hodgkin lymphoma (n=20), and solid tumors (n=46). Fifty-one patients had not been immunized against HBV prior to the therapy; HBV serology was negative in 49 of these patients and HBsAg was positive in 2 patients. Anti-HBs antibody positivity was present in 99 of 108 patients with an immunization history, whereas no vaccination response was present in 9 patients. The titer of anti-HBs antibody was decreased below the protection level in 33 (33%) patients with positive anti-HBs antibody, whereas the protection level was found to be maintained in 66 (67%) patients. The most significant decrease (63.6%) was observed in leukemia patients. Posttreatment HBsAg and HBV DNA positivity was detected in two of the patients with negative pretreatment serology, whereas no HBV infection developed in the group with positive anti-HBs antibody.CONCLUSIONS:This study demonstrated the importance of routine childhood vaccination in reducing the risk of HBV infection in patients with cancer.

Hepatitis B virus reactivation in patients receiving cancer chemotherapy: natural history, pathogenesis, and management

Chronic hepatitis B virus (HBV) infection is endemic in the Asian-Pacific region, and reactivation of HBV post-cancer chemotherapy has become an emerging clinical challenge. Patients with detectable serum HBV DNA before chemotherapy and those receiving intensive chemotherapy are particularly at a risk of HBV reactivation. Most patients with HBV reactivation are positive for hepatitis B surface antigen (HBsAg) and are, therefore, easily identified by recommended serological screening before chemotherapy. However, a small, but significant proportion of subjects who have apparently recovered from HBV infection as reflected by HBsAg negativity and hepatitis B core antibody positivity in HBV endemic areas may also experience reactivation when host immunity is severely compromised by cancer chemotherapy. Serum alanine aminotransferase, HBsAg, and/or HBV DNA should be monitored closely in these subjects and antiviral therapy should be administered immediately when any evidence of HBV reactivation is detected during chemotherapy. The prophylactic use of nucleos(t)ide analogs before chemotherapy and its continuation until reconstitution of host immunity remain the mainstay of effective prevention of hepatitis B reactivation in this special clinical entity.