Urszula Zurawska, Lisa K. Hicks, Gloria Woo, Chaim M. Bell, Kelvin K. Chan and Jordan J. Feld, University of Toronto; Lisa K. Hicks and Chaim M. Bell, St Michael's Hospital; and Kelvin K. Chan, Princess Margaret Hospital and Sunnybrook Odette Cancer Centre; Lisa K. Hicks and Chaim M. Bell, Keenan Research Centre, Li Ka Shing Knowledge Institute; Gloria Woo and Murray Krahn, Toronto Health Economics and Technology Assessment; Jordan J. Feld, Toronto Western Hospital Sandra Rotman Centre for Global Health, Toronto, Ontario, Canada.
PURPOSE Hepatitis B virus (HBV) reactivation is a potentially fatal complication of chemotherapy that can be largely prevented with antiviral prophylaxis. It remains unclear whether HBV screening is cost effective. METHODS A decision model was developed to compare the clinical outcomes, costs, and cost effectiveness of three HBV screening strategies for patients with lymphoma before R-CHOP (rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone) chemotherapy: screen all patients for hepatitis B surface antigen (HBsAg; Screen-All), screen patients identified as being at high risk for HBV infection (Screen-HR), and screen no one (Screen-None). Patients testing positive were administered antiviral therapy until 6 months after completion of chemotherapy. Those not screened were initiated on antiviral therapy only if HBV hepatitis occurred. Probabilities of HBV and lymphoma outcomes were derived from systematic literature review. A third-party payer perspective was adopted, costs were expressed in 2011 Canadian dollars, and a 1-year time horizon was used.ResultsScreen-All was the dominant strategy. It was least costly at $32,589, compared with $32,598 for Screen-HR and $32,657 for Screen-None. It was also associated with the highest 1-year survival rate at 84.99%, compared with 84.96% for Screen-HR and 84.86% for Screen-None. The analysis was sensitive to the prevalence of HBsAg positivity in the low-risk population, with Screen-HR becoming least costly when this value was ≤ 0.20%. CONCLUSION In patients receiving R-CHOP for lymphoma, screening all patients for HBV reduces the rate of HBV reactivation (10-fold) and is less costly than screening only high-risk patients or screening no patients.