Poor recognition of risk factors for hepatitis B by physicians prescribing immunosuppressive therapy: a call for universal rather than risk-based screening.

Reactivation of hepatitis B virus (HBV) during immunosuppressive therapy (IST) can lead to severe and even fatal hepatitis but can be largely prevented with prophylactic antiviral therapy. Screening for HBV prior to starting IST is recommended. Both risk-based and universal screening have been recommended by different societies. For effective risk-based screening, physicians must be aware of risk factors for chronic HBV infection.The HBV screening practices prior to starting IST of rheumatologists, medical and hematological oncologists were evaluated by survey and chart review. Country of origin, the primary risk factor for HBV exposure, was determined in all patients.Of 140 rheumatology, 79 medical oncology and 53 hematology patients reviewed, 81%, 11% and 81% were deemed to be at high risk of HBV reactivation by their physicians respectively, however only 27%, 6% and 62% (p<0.0001) were actually screened for HBV prior to starting IST. For patients from HBV-endemic regions, more hematology patients (53%) were correctly identified by their physicians as being at high risk of reactivation than rheumatology patients (2.4%, p=0.0001) or medical oncology patients (15%, p=0.009). However actual screening rates were not increased in patients from endemic regions. A total of 81 patients were screened for HBsAg; 2 were positive. Of the 33 patients screened for anti-HBc, 10 (30%) were positive.Hematologists, rheumatologists and medical oncologists had low rates of screening for HBV prior to prescribing IST, largely due to poor identification of those at risk for infection. Risk-based screening strategies are unlikely to be effective and should be replaced by universal screening

Physician ability to identify patients at high risk of chronic HBV infection based on country of origin.

<p>Patients originating from areas with greater than an intermediate rate (≥2) of chronic HBV infection, as determined by the CDC [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0120749#pone.0120749.ref016" target="_blank">16</a>], were identified through the patient questionnaire. This figure illustrates the proportion of these patients who were correctly identified by their treating physician as being at high risk of HBV reactivation due to their country of origin.</p

Summary of current guidelines regarding HBV screening.

<p>*As per the AASLD guidelines, patients can be tested with anti-HBc alone provided that patients who test positive are further tested for HBsAg and anti-HBs to differentiate infection from immunity.</p><p>Summary of current guidelines regarding HBV screening.</p

Summary of Screening Patterns.

<p>IST—immunosuppressive therapy</p><p>Summary of Screening Patterns.</p

Demographics of Physician Respondents.

<p>Demographics of Physician Respondents.</p

Screening practices of physicians prior to immunosuppressive therapy.

<p>A) The proportion of patients identified to merit screening for HBV prior to immunosuppressive therapy in each specialty are shown. This is contrasted with the proportion of patients requiring TB screening before biologic DMARDs (rheumatology) and cardiac testing prior to anthracycline-based chemotherapy (hematologists/oncologists). B) The rates of planned screening are contrasted with the actual rate of HBV screening for HBV prior to immunosuppressive therapy for all patients and for the sub-group of patients from HBV-endemic countries.</p

Carfilzomib usage patterns and outcomes in patients with relapsed multiple myeloma: A multi‐institutional report from the Canadian Myeloma Research Group (CMRG) Database

Abstract Carfilzomib is an active and commonly used treatment in patients with multiple myeloma (MM). Using the Canadian Myeloma Research Group Database, we performed a retrospective observational study of patients treated with carfilzomib for relapse of MM in a real‐world setting in Canada between years 2007 and 2020. A total of 445 patients were included in this study: the doublet (Kd/p, n = 218) and triplets (KCd, n = 88; KRd, n = 99; KPd/p, n = 40). One hundred and twenty‐two (27%) received carfilzomib‐based treatment in line 2, 133 (30%) in line 3, 90 (20%) in line 4, and 100 (23%) in line 5 or higher. Carfilzomib was dosed weekly in 40% of patients and twice weekly in 60%. The overall response rate of the entire cohort was 57.7%, with 33.6% of patients achieving very good partial response or better. Median progression‐free survival for the overall cohort was 6.3 months with overall survival 19.7 months. This study provides a benchmark for carfilzomib‐based regimens in the real world, demonstrating that these regimens are effective in treating patients with relapsed MM

Redefining attrition in multiple myeloma (MM): a Canadian Myeloma Research Group (CMRG) analysis

Abstract While most patients diagnosed with multiple myeloma (MM) receive initial therapy, reported attrition rates are high. Understanding attrition rates and characteristics of patients not receiving subsequent therapy is useful for MM stakeholders. We performed an analysis of attrition rates in a large disease-specific database of patients with newly diagnosed MM who received at least one line of therapy between Jan 1/10-Dec 31/20. Attrition was defined as failure to receive a subsequent line of therapy despite progression of MM or due to death. A total of 5548 patients were identified, 3111 autologous stem cell transplant (ASCT) patients and 2437 non-ASCT. In the ASCT cohort, the attrition rate was 7% after line 1, 12% after line 2, and 23% after line 3. In non-ASCT patients, the attrition rate was 19% after line 1, 26% after line 2, and 40% after line 3. Death was the dominant contributor to attrition across all cohorts, with a minority of patients alive with progressive disease in the absence of further therapy at each line. Multivariable analysis identified older age, shorter time to progression, and inferior response as independent risk factors for attrition. Our data show that attrition rates increase with each line of therapy and are higher in non-ASCT patients but are appreciably lower than previously reported. This study supports a revision of the previous definition of attrition, demonstrating that most patients who do not receive subsequent therapy are either continuing their current therapy and/or are in remission off-treatment rather than being irreversibly lost to attrition