Hepatitis and liver cancer
A report encourages clinicians to increase screening of adults at high risk, provide better patient education about HBV serologic results, and strengthen efforts toward patient access to treatment and monitoring services.
By Maria Perno Goldie, RDH, MS
According to the report by the Institute of Medicine titled Hepatitis and Liver Cancer: Information for Health Care Providers, chronic infection with hepatitis B virus (HBV) is a major public health problem.1 Primary care clinicians can play a vital role in dealing with this dilemma. The report encourages clinicians to increase screening of adults at high risk, provide better patient education about HBV serologic results, and strengthen efforts toward patient access to treatment and monitoring services.
Clinicians are encouraged to identify resources that can be used to assist in making local effective referrals of patients infected with hepatitis B virus to specialist care. As well, they should be aware of the therapeutic goals of hepatitis treatment according to American Association for the Study of Liver Diseases (AASLD) guidelines.2
The medical primary care setting is ideal for integrated HBV care. However, as oral health care providers treating individuals with a variety of medical conditions, it is incumbent on us to be familiar with HBV. As with many other diseases, primary prevention is vaccination. After screening and diagnosis, if infected, secondary prevention cirrhosis or liver cancer is important. Continued risk assessment and counseling should be performed, along with the necessary treatment, monitoring, and referral prevention, diagnosis, treatment, and side effects.
A variety of tests should be done to assess for liver function and HBV replication and to exclude viral co-infections with hepatitis C virus (HCV) and human immunodeficiency virus (HIV).3
Hepatocellular carcinoma (HCC, also called malignant hepatoma) surveillance recommendations for chronic hepatitis B include: Asian men older than 40 years of age; Asian women older than 50 years of age; patients with cirrhosis; patients with family history of HCC; African/North American blacks; and those with other risk factors such as high HBV DNA, co-infection with HCV or HIV, or presence of other liver diseases.4 There are four phases of chronic HBV infection:
- Immune Tolerant, minimal inflammation and fibrosis
- Immune Clearance, chronic active inflammation
- Inactive Carrier State, mild hepatitis and minimal fibrosis
- Reactivation, with active inflammation.
Optimal treatment times are during the Immune Clearance and Reactivation phases.5
Hepatitis B is a family disease and sexual partners and household contacts of the infected patients should be included in risk assessment, vaccination, education, and counseling. HBV Reactivation risk factors are: solid tumors and lymphoma, chemotherapy, HBV DNA, and the male sex.6 Agents reported to cause HBV reactivation are: Corticosteroids, prednisone, and budesonide; anti-TNF, infliximab, adalimumab, and etanercept; antimetabolite, methotrexate; purine analogues, azathioprine and 6-MP; and other drugs like rituximab and cyclosporine.7
The AASLD Guidelines for Prophylactic Antiviral Therapy to Prevent HBV Reactivation include:
- Recommendation 39 - HBsAg and anti-HBc testing should be performed in patients who are at high risk of HBV infection, prior to initiation of chemotherapy or immunosuppressive therapy
- Recommendation 40 - Prophylactic antiviral therapy is recommended for HBV carriers at the onset of cancer chemotherapy or of a finite course of immunosuppressive therapy3
The primary goal is prevention of long-term negative clinical outcomes, such as cirrhosis, hepatocellular carcinoma, and even death. This is possible by robust suppression of HBV DNA to low or undetectable levels. Secondary goals are to decrease or normalize serum alanine transaminase (ALT), seroconversion from hepatitis B e antigen (HBeAg+) to HBeAg-, and seroconversion from hepatitis B surface antigen (HBsAg+) to HBsAg-. (3)
HBV infection is prevalent, is associated with significant morbidity and mortality, is a public health problem, and is underdiagnosed and undertreated. Globally, 2 billion have been exposed, and 350-400 million have chronic infection.8,9 HBV is a leading cause of hepatocellular carcinoma (HCC). There are U.S. Food and Drug Administration (FDA) approved therapies for hepatitis B infections.8 For more information, visit the FDA website.
- Hepatitis and Liver Cancer: Information for Health Care Providers. Report Brief April 2010. http://www.iom.edu/~/media/files/report%20files/2010/hepatitis-and-liver-cancer-a-national-strategy-for-prevention-and-control-of-hepatitis-b-and-c/hepatitis%20and%20liver%20cancer%202010%20%20report%20brief%20for%20providers.pdf.
- Lok AS, et al. Hepatology. 2009;50(3):661-662. PMID: 19714720.
- Bruix J, et al. Hepatology. 2011;53(3):1020-1022.
- Yim HJ, Lok AS. Hepatology. 2006;43(2 Suppl 1):S173-181.
- Yeo W, et al. Hepatology. 2006;43:209-220.
- Roche B, et al. Liver Int. 2011;31(suppl 1):104-110.
- World Health Organization. 2012. http://www.who.int/mediacentre/factsheets/fs204/ en/index.html.
- CDC Division of Viral Hepatitis. 2012. http://www.cdc.gov/hepatitis/hbv/hbvfaq.htm.
Maria Perno Goldie, RDH, MS