SUMMARYBackground: Chronic hepatitis B virus carriers receiving chemotherapy develop a high hepatitis B virus reactivation rate (38-53%) with a high mortality (37-60%). Few studies have characterized the efficacy of lamivudine in the treatment of chemotherapy-induced hepatitis B virus reactivation. Aim: To determine whether lamivudine prophylaxis reduces chemotherapy-induced hepatitis B virus reactivation and mortality. Methods: The medical records of all hepatitis B surface antigen-positive patients with malignancy treated with chemotherapy since 1995 at the National University Hospital of Singapore were identified, and divided into those who received lamivudine prophylaxis before chemotherapy (P) and those who did not (NP).The parameters examined included gender, age, malignancy type, steroid usage, number of chemotherapy courses and

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We read with interest the articles by Shimakawa et al. outlining a new score to determine treatment eligibility in Africans living with chronic hepatitis B (CHB) 1,2 and by Johannessen et al. 3 validating this score in a hospital-based Ethiopian cohort. The TREAT-B algorithm is a simple score using widely-available alanine aminotransferase (ALT) and HBeAg tests to determine CHB treatment eligibility and to overcome barriers to treatment assessment arising from limited access to HBV DNA nucleic acid testing and transient elastography. 4 Johannessen and colleagues found the TREAT-B algorithm did not perform as well as described previously. 2,5 Both groups found WHO guidelines performed poorly for treatment eligibility. Given the high CHB prevalence in the Asia-Pacific (>115 million people affected) 6 and urgent need for simplified treatment algorithms in lowresource countries within this region, we validated the TREAT-B algorithm in a large Asian-Pacific cohort of patients with CHB. Complete clinical data for 1,358 treatment-naïve patients with CHB from 2 prospective clinical studies conducted in Melbourne, Australia were analysed; 976 (72%) were recruited from a single large metropolitan hospital and 382 (28%) were recruited from primary practice sites. Patients with HIV, HCV or HDV coinfection, hepatocellular carcinoma, decompensated cirrhosis or pregnancy were excluded. We validated the TREAT-B algorithm against the gold standard EASL 2017 guidelines, 7 which replaced the previous EASL 2012 guidelines against which TREAT-B was originally validated. 1 EASL 2017 guidelines recommend treatment in patients with a) cirrhosis and a detectable viral load; b) F2 or greater fibrosis stage and viral load >2,000 IU/L; c) ALT greater than 80 IU/L and viral load >20,000 IU/L; d) Metavir score (liver biopsy) > − A2 and viral load >2,000 IU/ml; e) HBeAg-positive, age >30 years-old and viral load >2,000 IU/L; and f) family history of hepatocellular carcinoma. 1 To define severe fibrosis/ cirrhosis for the purposes of treatment eligibility, we used a transient elastography (TE) cutoff of >12 kPa (Fibroscan®, Echosens, France) for those with elevated ALT and >9 kPa if normal ALT, in accordance with EASL guidelines (2017) 7,8 or cirrhosis confirmed on liver histology. The TREAT-B score was derived by addition of HBeAg status (positive 1 point, negative 0 points) to ALT level (<20 IU/L, 0 points; 20-39 IU/L, 1 point; 40-79 IU/L, 2 points; > − 80 IU/L, 3 points) 1 ; an overall score > − 2 was deemed eligible for treatment. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of TREAT-B was compared to EASL 2017 guidelines. 7

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Most patients in Melbourne with HBV-associated HCC have cirrhosis. HCC characteristics in non-cirrhotic and cirrhotic patients were similar. The large number of patients detected through symptoms and with large tumours reinforces the need for vigilance in screening.