ASCO: No evidence to support routine hepatitis B virus screening before chemotherapy

An American Society of Clinical Oncology ad hoc panel of experts concluded that there is no evidence to support the CDC’s call for routine screening for hepatitis B in all patients undergoing cytotoxic or immunosuppressive therapy.

The CDC issued this recommendation in MMWR: Recommendations and Reports in 2008. ASCO published its opinion last month in the Journal of Clinical Oncology.

At the request of ASCO’s practice guidelines committee, a team from McMaster University used the Rigour of Development subscale of the Appraisal of Guidelines for Research and Evaluation II instrument to assess the quality of the processes the CDC used to gather and synthesize data and the methods used to formulate the guideline. A perfect score is 100%, and a score of 86% is an example of an ASCO-endorsed guideline based on a systematic review of the literature.

Researchers from McMaster gave the guideline an overall score of 24% in terms of methodological quality, with “several serious deviations from the ideal,” such as a lack of systematic methods used to search for evidence and lack of clarity in the description of the criteria for selecting the evidence reviewed. The Rigour of Development score for the guidelines pertaining to testing for hepatitis B among patients receiving cytotoxic or immunosuppressive therapy was only 18%. ASCO said the guideline scored especially low on the item linking the recommendations to the supporting evidence for the cancer-specific section.

“There was little agreement between the published evidence and the recommendation made by the CDC,” said Sandra Wong, MD, assistant professor in the division of surgical oncology with the University of Michigan Health Systems. Wong was co-chair of the practice guidelines committee and one of the authors of the ASCO opinion. “We felt it was our responsibility to point out to ASCO members — practicing clinical oncologists — that while the CDC recommendations are out there, there is little evidence upon which to base those recommendations.”

The CDC recommendation has the potential to change the day-to-day operations for every oncology practice in the country. Considering the potential effect on clinical practice, Wong said panel members were “underwhelmed” by the CDC’s professional outreach efforts.

She said some patients should be screened for hepatitis B surface antigen, antibodies to hepatitis B surface antigen and anti-hepatitis B core antigen. Patients undergoing bone marrow transplantation, those already at-risk for hepatitis B or those assigned to immunosuppressive drugs such as rituximab (Rituxan, Genentech) should be screened before undergoing chemotherapy. However, Wong said the CDC recommendation went too far, especially in light of the scant evidence supporting such a blanket comprehensive program.

“The evidence was insufficient to say that routine screening should be done,” she said. “Physicians have to use clinical decision-making. If the patient may be at risk for hepatitis B de novo, they should be screened. Or if the patient is undergoing immunosuppressive therapy, bone marrow transplant or treatment with rituximab, physicians should consider screening for hepatitis B. However, we don’t think every patient needs screening.” – by Jason Harris

Artz AS. J Clin Oncol. 2010;doi:10.1200/JCO.2010.30.0673.