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Reactivation of hepatitis B virus and hepatitis C virus in patients with cancer

Abstract

Infections with hepatitis B virus (HBV) or hepatitis C virus (HCV) are associated with significant morbidity and mortality among patients with cancer, especially in patients with hematologic malignancies and those who undergo hematopoietic stem-cell transplantation. Reported rates of HBV reactivation in HBV carriers who undergo chemotherapy range from 14–72%. In these patients, mortality rates range from 5–52%. HCV reactivation seems to be less common than HBV reactivation and is usually associated with a good outcome and low mortality. However, once severe hepatitis develops, as a result of viral reactivation, mortality rates seem to be similar among patients infected with HBV or HCV. Liver damage owing to viral reactivation frequently leads to modifications or interruptions of chemotherapy, which can negatively affect patients' clinical outcome. Risk factors for the development of severe HBV or HCV reactivation need to be better defined to permit identification of patients who may benefit from preventive measures, early diagnosis, and therapy. In this article, we review the epidemiology, pathogenesis, risk factors, and clinical and laboratory manifestations associated with reactivation of HBV and HCV during immunosuppressive therapy. We also discuss strategies for the prevention and treatment of viral reactivation, including the management of reactivation with new antiviral agents.

Key Points

  • Patients with cancer who are at risk of infection with hepatitis B virus (HBV) or hepatitis C virus (HCV) should undergo standard viral screening before initiation of cancer therapy

  • HBV-DNA levels and HCV-RNA levels should be measured in patients who are at high risk of viral reactivation

  • A substantial proportion of cancer patients with HBV or HCV infection develop liver dysfunction during chemotherapy, which often leads to discontinuation of potentially life-saving chemotherapy

  • Treatment with antiviral agents can effectively prevent HBV reactivation, should be initiated before cancer therapy, and maintained during as well as for 6–12 months after discontinuation of immunosuppressive therapy

  • HCV reactivation seems to be less frequent and less severe than HBV reactivation, but if severe hepatitis develops, mortality rates seem to be similar to those of HBV-infected patients

  • Treatment of HCV reactivation is mainly supportive and new agents for the treatment of patients with HCV reactivation are urgently needed

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Figure 1: The three stages in the pathogenesis of HBV and HCV reactivation.
Figure 2: Algorithm for the management of patients with possible HBV infection who undergo immunosuppressive therapy.
Figure 3: Approach to management of HCV-positive patients with cancer who undergo chemotherapy or immunosuppressive therapy.

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Acknowledgements

We thank Stephanie P. Deming, scientific editor at the Department of Scientific Publications at the MD Anderson Cancer Center, for editorial assistance. No funding sources were involved in the writing of this Review or the decision to submit the Review for publication.

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Correspondence to Marta Davila.

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H. A. Torres declares he is a consultant for Astellas, Merck, Vertex. M. Davila declares no competing interests.

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Torres, H., Davila, M. Reactivation of hepatitis B virus and hepatitis C virus in patients with cancer. Nat Rev Clin Oncol 9, 156–166 (2012). https://doi.org/10.1038/nrclinonc.2012.1

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