Presejanje na okužbo z virusom hepatitisa B in preprečevanje reaktivacije hepatitisa B
Screening for hepatitis b infection and prevention of its reactivation in cancer patients under systemic therapy

current clinical recommendations

  • Tanja Čufer
  • Tanja Južnič Šetina Onkološki inštitut, Ljubljana
  • Boštjan Šeruga Onkološki inštitut, Ljubljana
  • Nina Turnšek Hitij
  • Brigita Gregorič Onkološki inštitut, Ljubljana
Keywords: screening, hepatitis B

Abstract

Septembra 2010 so bile v Zdravniškem vestniku objavljene slovenske nacionalne usmeritve za preprečevanje reaktivacije hepatitisa B pri bolnikih, ki potrebujejo imunosupresivno zdravljenje. Te smernice temeljijo na usmeritvi dveh mednarodnih združenj za preučevanje bolezni jeter, evropskega EASL in ameriškega AASLD in predlagajo presejanje na okužbo z virusom hepatitis B (HBV) pri vseh bolnikih, pri katerih je predvideno imunosupresivno zdravljenje, med katere spada tudi sistemsko zdravljenje raka. Če se pri teh bolnikih ugotovi latentna okužba, se priporoča uvedba protivirusne učinkovine. Protivirusno zdravljenje po podatkih posameznih raziskav in metaanalize 11 raziskav zmanjša tveganje za reaktivacijo hepatitisa B in umrljivost zaradi reaktivacije hepatitisa B, medtem ko značilnega vpliva na skupno umrljivost ni bilo zaznati. Skoraj istočasno je ameriško združenje za klinično onkologijo ASCO objavilo začasna klinična priporočila za presejanje in preprečevanje reaktivacije hepatitisa B pri rakavih bolnikih na citostatskem zdravljenju. V njih je priporočeno presejanje na okužbo s HBV samo pri rakavih bolnikih z velikim tveganjem za kronično okužbo s HBV ter pri vseh bolnikih, pri katerih je predvideno zdravljenje z močno imunosupresivnim sistemskim zdravljenjem, kot je visokodozna kemoterapija s presaditvijo matičnih krvotvornih celic ali zdravljenje limfomskih bolnikov z rituksimabom. Profilaktičnega zdravljenja z lamivudinom ta skupina ne priporoča pri vseh bolnikih z latentno okužbo, ampak svetuje individualni razmislek o zdravljenju, ki naj temelji na tehtanju koristi in slabosti zdravljenja z lamivudinom pri vsakem posameznem bolniku. Ti dve objavi in njuna ne povsem enoznačna priporočila postavljajo pred slovenske onkologe vprašanje o najprimernejši oskrbi bolnikov v trenutni vsakodnevni klinični praksi. Zato smo v okviru ozke skupine strokovnjakov internistične onkologije in infektologije novembra 2010 pripravili okroglo mizo, katere sklepe objavljamo v tem prispevku. Za jasne sklepe o tem, ali je smiselno presejanje na okužbo s HBV pri vseh rakavih bolnikih na sistemskem zdravljenju, ter o varnosti in učinkovitosti protivirusnega zdravljenja pri kroničnih nosilcih HBV potrebujemo dodatne podatke, pridobljene v okviru prospektivnih kliničnih raziskav. Tudi v Sloveniji bomo izvedli prospektivno klinično raziskavo, ki nam bo odgovorila na vprašanje o pojavnosti kroničnih nosilcev HBV med našimi bolniki z limfomi in solidnimi raki ter nam dala podatke o učinkovitosti in varnosti protivirusnega predčasnega zdravljenja oz. kemoprofilakse pri naših bolnikih. Samo na lastnih izsledkih, pridobljenih v okviru načrtovane prospektivne študije, in ob upoštevanju izsledkov dodatnih, že potekajočih mednarodnih kliničnih raziskav bo mogoče oblikovati jasna in dokončna priporočila o presejanju in preprečevanju reaktivacije hepatitisa B pri slovenskih bolnikih z rakom, ki se sistemsko zdravijo.

Abstract (Eng)

As a supplement to the September 2010 issue, the Slovenian Medical Journal published Slovenian national guidelines for prevention of hepatitis B reactivation in the patients undergoing immunosuppressive treatment. These guidelines, based on the orientations provided by two international organizations for liver cancer prevention, the European EASL and the American AASLD, suggest screening for hepatitis B infection (HBV) in all patients to whom immunosuppressive treatment, including also systemic cancer treatment, is indicated. In cases where a latent infection is determined, application of antiviral therapy is suggested. In several individual studies as well as in a meta-analysis of 11 studies, antiviral therapy reduced the risk of hepatitis B reactivation and mortality due to it, while there is no proof of a significant impact on the overall survival. Within almost the same timeframe, several provisional clinical opinions on screening and prevention of reactivation of hepatitis B in cancer patients receiving cytostatic treatment were published by the American Society for Clinical Oncology (ASCO); they all promote the use of screening for HBV infection only in the group of cancer patients who show a high risk for chronic HBV infection and in all patients to whom highly immunosuppressive therapies, such as high-dose chemotherapy with bone marrow transplantation or treatment of lymphoma patients with rituximab, are indicated. ASCO does not suggest prophylactic treatment with lamivudin in all patients with latent infection, but promotes an individual approach to treatment based on cost-benefit analysis in each individual patient. These two publications and their not entirely unanimous guidelines are confronting the present Slovenian oncologists with the dilemma which of the current approaches to patient treatment is optimal in everyday clinical practice. To resolve these issues, a group of specialists in the field of medical oncology and infectology conducted a round table discussion in November 2010. The conclusions and proposals derived from this meeting are presented in this article. In order to obtain an even more clear statement on whether screening for HBV infection should be used in all cancer patients receiving systemic therapy as well as on the safety and efficiency of antivirus treatment in latent HBV carriers, additional data gathered in the frame of prospective clinical trials are needed. The decision was made to plan and conduct a prospective clinical trial in Slovenia, which will provide us with the data on the occurrence of chronic HBV carriers in the current population of patients with lymphoma and solid cancer patients as well as with the answers on the safety and efficiency of preemptive antivirus treatment or chemoprophylaxis in our patients. On the basis of the findings of this widely set out prospective trial and taking into account additional data obtained in the frame of international trials already under way, we will be able to define more precise and clear guidelines on screening and prevention of hepatitis B reactivation in Slovenian cancer patients receiving systemic therapy
Published
2011-06-15
How to Cite
Čufer, T., Južnič Šetina, T., Šeruga, B., Turnšek Hitij, N., & Gregorič, B. (2011). Screening for hepatitis b infection and prevention of its reactivation in cancer patients under systemic therapy. Onkologija : A Medical-Scientific Journal, 15(1), 26-29. Retrieved from https://revijaonkologija.si/Onkologija/article/view/247
Section
Guidelines
Page
26-29