Hwang Jessica P, Somerfield Mark R, Alston-Johnson Devena E, Cryer Donna R, Feld Jordan J, Kramer Barnett S, Sabichi Anita L, Wong Sandra L, Artz Andrew S
Jessica P. Hwang, University of Texas MD Anderson Cancer Center; Anita L. Sabichi, Baylor College of Medicine, Houston, TX; Mark R. Somerfield, American Society of Clinical Oncology, Alexandria, VA; Devena E. Alston-Johnson, Upstate Oncology Associates, Greenville, SC; Donna R. Cryer, Global Liver Institute, Washington, DC; Jordan J. Feld, Toronto Western Hospital Liver Centre, Toronto, Ontario, Canada; Barnett S. Kramer, National Cancer Institute, Bethesda, MD; Sandra L. Wong, University of Michigan, Ann Arbor, MI; and Andrew S. Artz, University of Chicago, Chicago, IL.
J Clin Oncol. 2015 Jul 1;33(19):2212-20. doi: 10.1200/JCO.2015.61.3745. Epub 2015 May 11.
This updated provisional clinical opinion presents a revised opinion based on American Society of Clinical Oncology panel consensus in the context of an evolving database.
Despite the 2010 provisional clinical opinion recommendation, there is still evidence of suboptimal hepatitis B virus (HBV) screening among patients at high risk for HBV infection or HBV reactivation after chemotherapy. This updated provisional clinical opinion introduces a risk-adaptive strategy to identify and treat patients with HBV infection to reduce their risk of HBV reactivation.
Medical providers should screen by testing patients for HBV infection before starting anti-CD20 therapy or hematopoietic cell transplantation. Providers should also screen patients with risk factors for HBV infection. Screening should include both hepatitis B surface antigen (HBsAg) and hepatitis B core antibody (anti-HBc), because reactivation can occur in patients who are HBsAg positive/anti-HBc positive or HBsAg negative/anti-HBc positive. Either total anti-HBc or anti-HBc immunoglobulin G (not immunoglobulin M) test should be used. Clinicians should start antiviral therapy for HBsAg-positive/anti-HBc-positive patients before or contemporaneously with cancer therapy and monitor HBsAg-negative/anti-HBc-positive patients for reactivation with HBV DNA and ALT levels, promptly starting antivirals if reactivation occurs. Clinicians can initiate antivirals for HBsAg-negative/anti-HBc-positive patients anticipating cancer therapies associated with a high risk of reactivation, or they can monitor HBV DNA and ALT levels and initiate on-demand antivirals. For patients who neither have HBV risk factors nor anticipate cancer therapy associated with a high risk of reactivation, current evidence does not support HBV screening before initiation of cancer therapy. Two panel members provided a minority viewpoint, involving a strategy of universal HBsAg and selective anti-HBc testing.
本更新后的临时临床意见基于美国临床肿瘤学会专家小组在不断发展的数据库背景下达成的共识，提出了修订后的意见。
尽管有2010年临时临床意见的建议，但仍有证据表明，在乙肝病毒（HBV）感染高危患者或化疗后HBV再激活高危患者中，HBV筛查仍未达到最佳状态。本更新后的临时临床意见引入了一种风险适应性策略，以识别和治疗HBV感染患者，降低其HBV再激活风险。
医疗服务提供者应在开始抗CD20治疗或造血细胞移植前，通过检测患者是否感染HBV进行筛查。提供者还应筛查有HBV感染风险因素的患者。筛查应包括乙肝表面抗原（HBsAg）和乙肝核心抗体（抗-HBc），因为HBsAg阳性/抗-HBc阳性或HBsAg阴性/抗-HBc阳性的患者都可能发生再激活。应使用总抗-HBc或抗-HBc免疫球蛋白G（而非免疫球蛋白M）检测。临床医生应在癌症治疗前或同时为HBsAg阳性/抗-HBc阳性患者开始抗病毒治疗，并监测HBsAg阴性/抗-HBc阳性患者的HBV DNA和ALT水平，一旦发生再激活应立即开始抗病毒治疗。对于预期进行与再激活高风险相关的癌症治疗的HBsAg阴性/抗-HBc阳性患者，临床医生可以开始抗病毒治疗，或者他们可以监测HBV DNA和ALT水平并按需启动抗病毒治疗。对于既无HBV风险因素，也未预期进行与再激活高风险相关的癌症治疗的患者，目前的证据不支持在开始癌症治疗前进行HBV筛查。两名专家小组成员提出了少数观点，涉及普遍检测HBsAg和选择性检测抗-HBc的策略。
