CME Author: Zeena Nackerdien
Study Authors: Scott D. Ramsey, Joseph M. Unger, et al.
Target Audience and Goal Statement: Infectious disease specialists and oncologists
The goal was to estimate the prevalence of hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV infection among patients with newly diagnosed cancer.
- What was the estimated prevalence of HBV, HCV, and HIV infection among this group of patients with newly diagnosed cancer?
- Was the viral infection diagnosed before or at the time of testing?
- What are the recommendations, if any, for screening?
Study Synopsis and Perspective:
Population studies have suggested that the prevalence rates of HBV, HCV, and HIV among people old enough to have higher rates of cancer exceed prevalence rates in the general population. Estimated prevalence rates of HCV, HIV, previous HBV, and chronic HBV are 1.3%, 0.3%, 4.7%, and 0.3%, respectively.
In a new study, Scott Ramsey, MD, PhD, of Fred Hutchinson Cancer Research Center in Seattle, and colleagues noted that because the true risk of severe adverse events linked with most cancer treatments with latent infections remains unknown, the presumed benefits from delaying or modifying cancer treatments are only hypothetical.
There is also very little evidence-based data behind the various oncology practice guidelines on viral screening for cancer patients. “There is some evidence, however, that anti-CD20 therapies, such as the drug rituximab, as well as hematopoietic cell transplantation, both treatments for lymphomas and leukemias, can cause some infection-causing viruses to reactivate and multiply,” the researchers added.
The study by Ramsey and co-authors included 3,092 patients recruited from 18 institutions affiliated with the SWOG network (2013-2017). A total of 3,051 patients were found to be eligible and evaluable (median age of 60.6). Most participants were female (60.4%), and minority enrollment was also high. Black and Hispanic participants represented 18.1% and 18.3% of the eligible participants, respectively. Breast, blood, bone marrow, colorectal, and lung cancers were the most common tumors among the study participants.
The primary study endpoint in this multicenter, prospective cohort study was the presence of HBV infection (previous or chronic), HCV infection, or HIV infection at enrollment. Both patients with unknown and known viral status were evaluated in the trial.
Key findings were as follows:
- Infection rates in the cancer patients were similar to those in the general U.S. population (6.5% for previous HBV, 0.6% for chronic HBV, 2.4% for HCV, and 1.1% for HIV)
- Many patients with HBV or HCV infections were unaware of their viral status prior to the screening (42.1% for chronic HBV; 87.3% for past HBV infection; 31% for HCV)
- Only 5.9% of patients with HIV were newly diagnosed through the study
- Some of the patients with infections had no identifiable risk factors (27.4% for past HBV infection; 21.1% for chronic HBV; 32.4% for HCV; 20.6% for HIV)
- Cancers that had the highest prevalence of infection included liver, gastrointestinal tract other than liver or colorectal, head and neck, lung, and prostate
- About 8% of patients with any viral infection changed cancer treatments because of viral-positive status
Study limitations, Ramsey and co-authors said, included the influence of variable screening approaches, a possible under-estimation of HCV prevalence, and possible selection bias.
Source Reference: JAMA Oncology, online, Jan. 17, 2019; DOI: 10.1001/jamaoncol.2018.6437
Study Highlights: Explanation of Findings
In this prospective cohort study of 3,051 patients with newly diagnosed cancer, the infection rates were 6.5% for previous HBV, 0.6% for chronic HBV, 2.4% for HCV, and 1.1% for HIV. Notably, 42.1% of patients with chronic HBV, 31% of those with chronic HCV, and 5.9% of patients with HIV were newly diagnosed with the infections through the study.
Study strengths, the researchers said, included a large sample size and an ethnically, racially, and geographically diverse population.
“The results of this study showed that a substantial proportion of patients with newly diagnosed cancer and concurrent HBV or HCV are unaware of their viral infection at the time of cancer diagnosis,” the team wrote. “Screening patients with cancer to identify HBV and HCV infection before starting treatment may be warranted to prevent viral reactivation and adverse clinical outcomes.”
The low rate of undiagnosed HIV infection, however, may not support universal screening of newly diagnosed cancer patients, the team said.
Clinical practice guidelines vary as to how to implement such screening in clinical practice. For example, while others have called for universal HBV screening, the American Society of Clinical Oncology and the National Comprehensive Cancer Network (NCCN) recommend limiting screening for HBV infection only before starting anti-CD20 therapy or hematopoietic cell transplantation. The NCCN also recommends that patients with risk factors for HBV infection should also be screened, although universal screening should occur for centers where risk-based screening cannot be effectively performed.
Ramsey et al. pointed out that the CDC recommends universal one-time screening for HIV among individuals ages 13 to 64, and one-time screening for HCV among persons born from 1945 to 1965. On the other hand, NCCN recommends HIV screening for persons with newly diagnosed lymphomas.
What is beyond question, however, is that the viral status is unknown for many individuals.
Asked for his perspective, Harrys Torres, MD, of the University of Texas MD Anderson Cancer Center in Houston, noted that his institution started screening all patients with hematologic malignancies for HBV and HCV about 10 years ago; the rationale, he said, was that patients could be at risk for complications related to reactivation of either virus, which in some cases can even be fatal.
A study led by his colleague Jessica Hwang, MD, also of MD Anderson, found that the majority of a large cohort of patients with solid and hematologic malignancies still required HBV testing if the goal is to achieve a false-negative rate of zero.
Similarly, another 2018 study by the group found that if HCV screening of newly diagnosed cancer patients is limited to the high-risk baby boomer birth cohort, many patients would be left with undiagnosed HCV infection, since many of the affected patients in the current study were not baby boomers, nor did they have risk factors for HCV.
“For me, this important study is a prospective validation of our initial observations,” Torres told MedPage Today.
“Patients with HBV or HCV can present with any type of cancer — not just liver cancer but also breast, prostate, and head and neck cancers — and we have to identify these patients when they present, because not only might they receive bone marrow transplantation or even rituximab, both of which can reactivate HBV and even HCV, but also we don’t yet know what any of the new cancer drugs are going to do in patients with HBV or HCV, and these drugs could lead to other complications,” he suggested.
Lastly, the presence of either viral infection could prompt oncologists to err on the side of caution and offer patients a less effective treatment plan out of concern that concurrent HBV or HCV might lead to unwanted complications. This is particularly concerning, Torres noted, because HBV is treatable and HCV is potentially curable — and once the viral infections are treated, oncologists can proceed to treat patients as they optimally should be.
“Even if patients do have a viral infection, if we can eliminate that from the picture, patients can move on and receive the cancer treatment they need,” Torres emphasized.
“While our results don’t suggest that universal HIV screening is necessary for cancer patients, they do provide new evidence to inform a discussion in the oncology community about whether we should require hepatitis screenings,” Ramsey said in a SWOG news release. “Screening may be especially important now that we’ve entered the age of immunotherapies for cancer — treatments that may affect cancer patients’ immune systems and alter the course of their viral infections.”
“While we don’t know much about the impact of immunotherapies on patients with cancer and hepatitis and other viral infections, oncologists should know as much as possible about the overall health of the people they treat.”