Screening all patients for hepatitis B surface antigen (HBsAg) before initiating chemotherapy for lymphoma is associated with improved clinical outcomes and is economically favorable, according to an analysis presented by researchers at the University of Toronto and St Michael’s Hospital, Toronto, Ontario.
Reactivation of the hepatitis B virus (HBV) during chemotherapy may lead to disruption of chemotherapy, hospitalization for HBV infection, and even death. Screening for HBV is often recommended but is not always performed, although effective prophylactic therapy in the form of lamivudine (Epivir) is available. Whether screening justifies the additional cost has not been investigated.
The researchers developed a decision- analytic model for patients with lymphoma undergoing chemotherapy with R-CHOP (rituximab [Rituxan], cyclophosphamide, hydroxydauno - rubicin [Adriamycin], vincristine [Oncovin], prednisone). Three HBV screening strategies were evaluated: screen all patients, screen only those at high risk, and screen nobody. Patients who tested positive for HBsAg received lamivudine until 6 months after the completion of chemotherapy. Unscreened patients received lamivudine only if they developed HBVrelated hepatitis.
The risks of HBV-related hepatitis recovery, HBV-related death, and lymphoma outcomes were derived from a systematic literature review.
The following cost estimates (in Canadian dollars) were used in the model: HBV DNA test, $133; HBsAg test, $13; lamivudine, $180 per month; R-CHOP, $35,704 per cycle; end-of-life care, $46,465 hepatitis-related and $42,632 lymphoma-related.
Screening all patients was the dominant strategy. It was both the least costly and the most effective in increasing the 1-year survival rate. One-year survival was 85.0% with the screen-all strategy versus 84.96% with the highrisk patient–only strategy and 84.86% with the screen-nobody strategy. The number of HBV-related hepatitis hospitalizations per 1000 patients was 0.1 with the screen-all strategy, 0.9 with the high-risk patient–only strategy, and 3.0 with the screen-nobody strategy.
Screening all patients resulted in a net savings of $62 per patient versus not screening and of $8 per patient versus screening only high-risk patients, presuming that all high-risk patients were correctly identified.
A second analysis presented at the meeting by researchers from the University of Texas M.D. Anderson Cancer Center showed that HBV screening before chemotherapy for nonhematologic tumors is not costeffective.